Lvn

**Summary Description**:
To deliver nursing care to patients requiring long-term acute care and/or rehab care.

**Essential Functions and Responsibilities**:

- Works under direct supervision in accordance with the state-specific Nurse Practice Act, facility Policies and Procedures and nursing judgment.
- Delivers nursing care to patients/residents requiring long-term or rehabilitative care.
- Collects patient/resident data, makes observations, and reports pertinent information related to the care of the patient/resident.
- According to state-specific regulations, implements the patient/resident plan of care and evaluates the patient/resident response.
- In accordance with state-specific regulations, directs and supervises care given by other nursing personnel in selected situations.
- Maintains knowledge of necessary documentation requirements.
- Maintains knowledge of equipment set-up, maintenance and use, i.e., monitors, infusion devices, drain devices, etc.
- Maintains confidentiality and patient/resident rights, regarding all patient/resident/personnel information.
- Provides patient/resident/family/caregiver education as directed.
- Conducts self in a professional manner in compliance with unit and facility policies.
- Works rotating shifts, holiday and weekends as scheduled.
- Initiates emergency support measures (i.e. CPR, protects patients/residents from injury).
- Data Collection
- Admission and routine patient/resident observations/transfer notes are complete and accurately reflect the patient’s/resident’s status.
- Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.
- Nursing history is present in the medical record for all patients/ residents.
- Changes in a patient’s/resident’s physical/psychological condition (i.e., changes in lab data, vital signs, mental status), are reported appropriately.
- Planning of Care: Contributions to the formulation/review of nursing care plans are made as appropriate, under the direct supervision or delegation of an RN.
- Pertinent nursing problems are identified.
- Goals are stated.
- Appropriate nursing orders are recommended.
- Evaluation of Care
- Observations related to the effectiveness of nursing interventions, medications, etc., are reported as appropriate and documented in the progress notes.
- Care Plans:

- Evaluation of care plan is noted monthly or as indicated.
- Contributions to care plan revision are made as indicated by the patient’s/resident’s status.
- General Patient/Resident Care
- Patient/resident is approached in a kind/gentle and friendly manner. Respect for the patient’s/resident’s dignity and privacy is consistently provided.
- Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
- Independence by the patient/resident in activities of daily living is fully encouraged possible.
- Treatments are completed as indicated.
- Safety concerns are identified, and appropriate actions are taken to maintain a safe environment.
- Side-rails and height of bed are adjusted.
- Patient/resident call light and equipment is within reach.
- Rooms are neat and orderly.
- Functional assignments are completed.
- Emergency situations are recognized, and appropriate action is instituted.
- All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, AED, crash cart, fire extinguisher, etc.)
- Patient/Resident Education/Discharge Panning
- Patient/Resident/Family teaching is conducted according to the nursing care plan.
- Explanations are given to the patient/resident prior to interventions.
- Discharge/death summaries are complete and accurate.
- Transfer forms are complete and accurate.
- Active participation in patient/resident care management is evident.
- Adherence to Facility Procedures
- Facility Policy and Procedure Manual or reference materials are utilized as needed.
- Procedures are performed according to the method outlined in the procedure manual.
- Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
- Safety guidelines established by the facility (i.e., proper needle disposal) are followed.
- Documentation
- Only approved abbreviations are utilized.
- Vital signs are properly and timely recorded.
- I&O summaries are recorded and added correctly.
- Progress notes are timed, dated and signed.
- Unit flow sheets are completed properly (i.e. wound care records, treatment records, weight sheets, etc.).
- Medication Administrations/Parenteral Therapy Record
- Adheres to state-specific Nurse Practice Act for administration of medication and parenteral therapy.
- Dates that medications are started or discontinued are documented.
- Medications are charted correctly with name, dose, route, site, time, and initials of nurse administering.
- Pulse and blood pressure and obtained and recorded when appropriate.
- Medications not giv