Mass RN license required
Systematically and continually collects data regarding the health status of the patient. Interviews and collects specific information and data from patients and families, contributes to the identification of specific physical, emotional, educational and cultural needs of those patients. Completes an admission assessment, to include appropriate documentation, within the time frames established by policy. Utilizes assessment skills to continually gather information about the health status of the individual and family. Accurately assess all critical care patients for pain, intervenes and reassesses patient’s response to interventions. Assesses all patients for safety in the unit and follows established policies to provide a safe environment for all patients.
DEVELOPMENT OF PLAN OF CARE (PROBLEM LIST) :
Analyzes assessment data in determining patient’s Plan of Care. Identifies individual patient problems using the assessment data. Documents and analyzes assessment data, and develops the Plan of Care for the individual patient. Continues to document and analyze assessment data and revises the Plan of Care for the individual patient. Collaborates with physician, healthcare team and the patient/family in developing a Plan of Care. Develops a plan of care that includes interventions and goals. Reassesses interventions and goals. Contributes to an effective team environment by working with others in a way that promotes and encourages each person’s contribution.
Identifies expected outcomes individualized to the patient. Identifies appropriate nursing outcomes, interventions, and communicates this data verbally and in writing. Regularly perceives potential problem situations and intervenes to offset adverse impact, demonstrates proactive attitude. Collaborates with physician, healthcare team and the patient/family in decision making and planning of care during hospitalization and in anticipation of discharge. PLANNING:
Develops an individualized and holistic plan of care that prescribes interventions to attain expected outcomes. Collaborates with physicians, healthcare team, and the patient/family in planning care to meet individual needs. Assigns nursing care to team members in accordance with the patient’s needs and the personnel’s capabilities and qualifications, and assigns other duties as needed. Collaborates with interdisciplinary team in identifying appropriate resources and other agencies within the health care delivery system. Reflects current evidence based nursing practice in implementing the Plan of Care. Follows established policy and procedure for safe transportation of critical care patient within hospital and to other facilities.
Implements the plan of care to achieve the identified expected outcomes for the patient.
A. Implements nursing interventions and evaluates based on outcomes.
B. Develops a therapeutic and supportive relationship with the patients/families and maintains a proper perspective between personal and professional affairs.
C. Utilizes established protocols and collaborates with health team to facilitate therapeutic interventions and attainment of desired patient outcomes.
D. Provides an appropriate safe, comfortable physical and emotional environment for patients and families.
E. Performs technical aspects of patient care (medications, treatments, etc.) safely, according to the established policies and procedures.
F. Reviews/educates the discharged patient and family to ADL’s, medications, treatments, and provides appropriate discharge instruction sheet(s).
G. Cares for patients with compromised respiratory function by assessment of patients and clinical status and Arterial Blood Gases.
H. Cares for patients with vasoactive and antiarrythmic medications. Titrates medications and assesses patient response. Accurately documents vital signs, doses of medications and patient response.
I. Cares for patient with neurological impairment. Assesses neuro status of patient using glascow coma scale. Intervenes appropriately and reassesses patients repsonse
J. Provides education for the patients and families and documents according to policy.
K. Participates in chart reviews and unit based PI by reviewing a minimum of three charts per year.
L. P rovides care to the post cardiac Cath patient with arterial sheath.
M. Delivers care in a manner that meets the diverse needs and strengths of the patient and preserves patient autonomy, dignity and rights uses available resources in formulating ethical decisions.
Systematically and regularly evaluates the patient’s response to interventions in order to determine progress towards achievement of expected outcomes.
A. Utilizes ongoing assessment data to revise interventions, outcomes and Plan of Care and documents accordingly.
B. Documents patient’s responses to interventions.
C. Reports pertinent observations and reactions regarding patients to the appropriate person (i.e., physicians, clinical manager, or charge nurse) and records those observations accurately and concisely.
D. Provides teaching and counseling for patients/families according to their needs and ability to understand. Documents teaching on the appropriate teaching tool.
E. Actively participates in interdisciplinary rounds and collaborates with other health professionals.
Demonstrates through work performed, a thorough knowledge of and adherence to the standards of nursing care, and the policies and procedures of the hospital and nursing division.
A. Assists in the orientation of new staff.
B. Seeks guidance and resources when necessary in the management of patient care from the healthcare team.
C. Maintains knowledge of contemporary, evidence based professional nursing practice.
D. Supervises care given by ancillary personnel.
E. Assumes shift charge responsibility.
F. The Staff Nurse evaluates his/her own nursing practice in relation to professional practice standards and relevant statutes and regulations
G. The Staff Nurse acquires and maintains current knowledge in practice
H. Attends all mandatory educational programs: skills day, BCLS, ACLS and IABP class. ( IMC excluded from IABP)
I. Provides proof of attendance at two critical care related educational programs each year. These may be online offerings, hospital based, or outside programs.
J. Maintains certification for defibrillation, cardioversion and external pacemaker.
CHARGE NURSE ONLY:
A. Identifies and assigns personnel appropriately for individual patients.
B. Triages all patient admissions, discharges and transfers with the unit.
C. Guides and directs the staff to ensure safe and appropriate care is given.
D. Communicates with Clinical Manager, unit Educator ( CNS ), Administrative Coordinator, and Director effectively.
E. Reviews and assesses staffing needs for the next 8-24 hours and appropriately staffs the unit based on patient acuity and needs.
F. Is responsible for daily code cart checks, med refrigerator temperature checks, and narcotic counts being done.
G. Completes condition and supervisors report prior to end of shift.
H. Seeks learning opportunities for new staff and encourages participation in educational programs.
I. Works with nursing instructors to appropriately assign nursing students.
HR Use Only:
Lowell General Hospital - 2 years ago