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This position assesses, plans, implements, evaluates and documents nursing care of patients in accordance with organizational policies and in accordance with standards of professional nursing practice utilizing the framework for professional nursing practice and development.
This position is accountable for the quality of nursing services delivered by self or others who are under their direction.
This position utilizes specialized knowledge, judgment, and nursing skills necessary to assess data and plan, provide and evaluate care appropriate to the physical and developmental age of assigned patients.
Responsibilities- Assesses patient physical, psychological, social, spiritual, educational, developmental, cultural and discharge planning needs.
- Reviews patient history and physical with patient/family and assures completion within appropriate timeframe.
- Reviews available information obtained by other health care team members.
- Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers.
- Completes assessment and reassessments according to patient need and as outlined in policy.
- Formulates a plan of care, including the discharge plan, utilizing assessment data and patient, family and health team input.
- Implements the plan of care through direct patient care, coordination, delegation and supervision of the activities of the health care team.
- Provides care based on physician orders and the nursing plan of care, in compliance with policies and procedures, standards of care, and regulatory agency requirements.
- Delegates appropriately, and provides nursing supervision in the provision of care to patients by other licensed nurses and other personnel.
- Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided.
- Evaluates the patient's and family's response to care and teaching, and revises the plan of care as needed.
- Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members.
- Evaluates patient's response and the effectiveness of patient teaching.
- Documents assessment, planning, implementation and evaluation in the patient record.
- Graduate of an accredited nursing program.
- Must possess a current, valid RN license in state of practice, temporary RN license in state of practice, or compact RN licensure for current state of practice.
- BLS certification is required.
- Additional certifications required: Completion of CPI training.
- Additional certification or continuing education may be required based on area of practice.
Able to stand, walk, bend, squat, reach, and stretch frequently.
Possess physical agility and adequate reaction time to respond quickly and appropriately to unexpected patient care needs.
Needs adequate hearing and visual acuity, including adequate color vision.
Requires fine motor skills, adequate eye-hand coordination, and ability to grasp and handle objects.
Able to use proper body mechanics to assist patients in ambulating, transferring in and out of bed, chair or wheelchair.
May be required to lift up to 50 pounds.
Must use standard precautions due to threat of exposure to blood and bodily fluids.
Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
May require periodic use of personal computer.
