o Performs a systematic initial and on going assessment of the patient’s physical and psychosocial status, specific to the age of the patient.
o Assesses patient/family educational needs and readiness to learn utilizing appropriate resources.
o Assesses patient/family discharge planning needs utilizing appropriate resources.
o Collaborates with the patient/family and other members of the health care team to develop and update a plan of care that is consistent with the medical diagnosis and based on the patient’s changing physical, psychosocial and age related requirements.
o Establishes realistic and measurable goals that are culturally sensitive, and identifies nursing interventions to achieve the goals.
o Plans and organizes patient care activities on a daily basis.
o Provides total, direct nursing care consistent with the plan of care and needs of the patients with respect for the patient’s privacy, dignity, personal preference and culture.
o Carries out physician’s orders and reviews nursing and medical orders for accuracy and appropriateness.
o Prepares, administers, and documents the administration of oral, parental and topical medications as prescribed by the physician.
o Is knowledgeable of therapeutic effects, usual dosages, contraindications, side effects and adverse reactions for all drugs and parental fluids administered.
o Maintains accountability for narcotics and controlled drugs.
o Intervenes appropriately in clinical emergency situations, initiates emergency resuscitative measures and assists with codes.
o Sets up equipment for and assists physicians with diagnostic and therapeutic procedures.
o Performs a wide range of nursing procedures with attention to accuracy, patient safety and comfort, including those requiring strict aseptic technique.
o Assists with transfer of patients within the health care facilities.
o Serves as transport nurse for patients during ambulance or aircraft transport.
o Teaches patients and their families with emphasis on compliance with prescribed therapeutic regimen. Supports families in meeting the patient’s psychosocial needs.
o Maintains a safe, clean and organized environment for the patient/family/visitors and staff.
o Demonstrates priority setting skills and timeliness in responding to patient needs.
o Evaluates quality of nursing care being delivered and identifies opportunities for improvement.
o Evaluates on an ongoing basis the patient’s progress and the appropriateness of the plan of care involving the patient/family and other health team members.
o Updates the plan of care to reflect patient’s current health status and needs.
o Evaluates and documents the patient/family’s understanding of and response to the plan of care including teaching and discharge plans.
o Participates in presenting patient care conferences.
6.3.5 Professional Expectations:
o Practices within the established standards, policies and procedures.
o Recognizes when patient care needs extend beyond the limits of personal ability and consults appropriate resources.
o Provides input during development and review of patient care standards, policies and procedures and participates in the Interdisciplinary Quality Assessment & Improvement Program.
o Assumes responsibility for professional development and maintains currency in nursing for area of practice.
o Uses computer technology as required.
o Maintains infection control and safety awareness, functions accordingly and initiates corrective action when indicated.
o Participates in fire and disaster drills and mock codes.
o Demonstrates acceptance, caring and empathy to patients and families.
o Maintains the confidentiality of patient/family information.
o Acts as a patient advocate and develops supportive relationships with patient/family maintaining a professional role.
o Uses verbal and nonverbal communication that conveys respect for the patient/family/visitor/staff.
o Communicates verbal information in an accurate concise and timely manner.
o Communicates written information in a legible accurate, concise and timely manner
o Documents in a manner that is consistent with the nursing documentation guidelines.
o Establishes and maintains effective working relationships with other members of the health care team.
o Complies with department dress code.
o Maintains an acceptable standard of attendance and reports to work on time.
o Demonstrates support for Nursing Department Philosophy and Objectives.