Performs initial assessment appropriate to the patientâ€™s clinical presentation/diagnosis, care setting, age, development level, and cultural and religious orientation in a timely manner.
Performs completely and accurately including, but not limited to, physical (i.e. assessment for pain, skin breakdown, risk for falls), psychological (i.e. cognitive and communicative skills or development), social status and other patient needs.
Identifies and prioritizes the need for further assessment based on the patientâ€™s clinical presentation/diagnosis, care setting, desire for care and responses to any previous care.
Initiates discharge planning for each patient upon admission as appropriate.
Is individualized for each patient based on assessment of needs that include input from the patient, family and other multi-disciplinary health care team members.
Identifies specific nursing diagnosis is relevant to assessment findings.
Identifies interventions, for each nursing diagnosis, specific to identified patient needs
Performs interventions identified for each nursing diagnosis on the Interdisciplinary Plan of Care.
Demonstrates the ability to effectively communicate patient care needs to all members of the multidisciplinary health care team.
Documents nursing intervention and patient teaching on designated forms.
Evaluates and documents the patientâ€™s response to the Plan of Care and to interventions.
Revises and updates the Plan of Care as evidenced by documentation.
Documents patientâ€™s response to teaching on designated form.
Accountable for own conduct and independent decisions made in the course of job performance.
Participates in unit activities designed for improvement of services.
Acts as preceptor for new health care team members and student nurses when asked.
Effectively delegates tasks to appropriate health care team members.
Provides input for policy/procedure development.
Demonstrates sound judgment and effective decision-making in following the nursing process.