Registered professional nurse who assesses, implements or delegates, plans, and evaluates total nursing care and functions in accordance with established philosophy, providing and directing patient care for a group of patients. Relates effectively with other shifts/departments for optimal continuity of care. Provides clinical supervision for entry level nurses and assists in their development.
1. Uses critical thinking skills to assess the basic physical, psychological, social, cultural, spiritual, and developmental needs of patients and families. Communicates findings to appropriate healthcare team members.
a. Collects data from all applicable resources; organizes assessment data so that it is complete and accessible; and then documents findings (legibly) in the medical record or other appropriate documents.
b. Recognizes alterations in health status, anticipates onset of patient care crisis situation and communicates findings appropriately.
c. Assesses, reassesses, and manages pain.
2. Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practices. Implements patient care and therapeutic procedures. Monitors and documents progression of treatment and teaching goals.
a. Identifies and prioritizes the patient’s present/potential problems.
b. Plans appropriate nursing interventions specific to the patient’s problems, incorporating the patient’s cultural, age-specific, and developmental needs.
c. Competently performs nursing interventions and procedures for the patient population (s) served consistent with scientific principles of nursing and policy and procedure.
d. Provides education to patients and family concerning diagnosis, treatment, and hospitalization.
e. Reviews and updates plan of care according to patient’s needs and/or regulatory agency requirements.
f. Documents and involves patient, family, and other healthcare workers in plan of care decisions in accordance with HIPAA requirements.
3. Evaluates the care and treatments provided to the patient and the patient response to the care and treatments. Performs timely re-assessment and documentation:
a. Evaluates patient’s response to treatment/care and modifies plan of care as needed.
b. Evaluates patient and/or significant others ability to perform self care and procedures prior to discharge.
c. Records patient’s response to prescribed treatment and other significant data.
1. Anticipates admission/discharge/transfer needs to facilitate patient flow.
a. Identifies potential/actual discharge/transfer needs of patients upon admission and as patients’ conditions change.
b. Identifies need for and/or follows-up on referrals to ensure identified problems are addressed.
c. Incorporates other disciplines into plan of care according to patient’s needs.
d. Evaluates patients and/or significant other’s understanding of discharge instructions based on ability to verbalize and/or give return demonstration.
e. Expedites admission/discharges/transfers.
f. Participates in a process of communication with the multi-disciplinary team to facilitate the progress of the patient through the continuum of care.