1. ASSESSES THE PHYSICAL, PSYCHO-SOCIAL, SPIRITUAL, CULTURAL, FUNCTIONAL, HIGH RISK AND DISCHARGE NEEDS OF THE PATIENT AND FAMILY.2. Performs, reassessments/care at intervals as required or appropriate to the patient’s needs.3. Ensures physical assessment/care includes all major body systems. 4. Ensures spiritual assessment/care includes actual/expressed needs. 5. Incorporates cultural and ethnic factors into assessment/care. 6. Correctly differentiates between normal and abnormal findings. 7. DEMONSTRATES THE ABILITY TO ACCURATELY ACCESS AND DOCUMENT PATIENT CARE ACTIVITIES AND HOSPITAL PROCESSES .8. Uses computer system(s) appropriately. 9. Documents in the medical record according to policy/procedure. 10. Complies with incident reporting and notification requirements. 11. Attends/reviews department staff meetings for information.
- OBTAINS KNOWLEDGE OF, AND DEMONSTRATES COMPLIANCE WITH INFECTION CONTROL POLICIES AND PROCEDURES.
- Practices Standard Precautions in patient care activities.
14. Practices appropriate disease specific isolation as required. 15. Appropriately handles and disposes of sharps.
- PROVIDES FOR THE EDUCATION/TRAINING OF THE PATIENT/FAMILY
17. Identifies and documents patient/family educational needs upon initial assessment and thereafter.18. Identifies barriers to learning. 19. Provides teaching based on identified needs. 20. Evaluates the effectiveness of instruction provided. 21. Assessment and teaching incorporates cultural and ethnic actors. 22. Assessment and teaching incorporates functional needs.23. COLLABORATES WITH RN ON IMPLEMENTATION OF A NURSING PLAN OF CARE FOR THE PATIENT/FAMILY24. Re-evaluates and modifies the plan of care, based on the patient’s response to the interventions. 25. Communicates the plan of care to members of the nursing team. 26. Prioritizes and delegates patient care activities based on patient assessment and staff capabilities.27. Demonstrates sound clinical judgement in decision-making regarding patient care.28. Assists RN in management of emergencies
- INCORPORATES THE PLAN FOR NURSING CARE INTO THE MULTIDISCIPLINARY CARE AND MANAGEMENT OF THE PATIENT/FAMILY.
30. Reports significant changes in patient condition to RN promptly. 31. Communicates effectively with physicians and health team.
- Coordinates nursing care with other disciplines involved.
- Actively participates in multidisciplinary care conferences
34. ASSURES THE RIGHTS OF THE PATIENT/FAMILY ARE RESPECTED AND MAINTAINED.35. Allows for privacy and modesty in the provision of care. 36. Identifies self by name and title to patient/family 37. Reports suspected cases of abuse/neglect, if identified. 38. Understands role of, and how to access, the Ethics Committee. 39. Establishes presence of consent prior to treatment/procedure. DEMONSTRATES THE ABILITY TO SAFELY AND COMPETENTLY ADMINISTER MEDICATIONS, INTRAVENOUS THERAPY AND BASIC FLUID MANAGEMENT.40. Understands actions, side-effects, contra-indications of drugs.
- Follows five “rights” of medication administration.
- Adheres to medication policies, practices and standards.
- Administers medication, intravenous therapy and fluid management only under physician order and guidance.
- Assists RN with IV medication administration.
45. DEMONSTRATES KNOWLEDGE OF UNIT SPECIFIC POLICIES AND PROCEDURES AND THE ABILITY TO SAFELY AND COMPETENTLY USE UNIT SPECIFIC PATIENT CARE EQUIPMENT IN THE DELIVERY OF QUALITY PATIENT CARE.
- Obtains necessary training prior to initial equipment use.
- Assures equipment is in operating order prior to use.
48. Uses medical equipment in accordance with manufacturer’s operating guidelines.49. Reports potential equipment/user error incidents to RN.