Performs the duties of a Professional Nurse in assessing, planning, implementing and evaluating the care of all assigned patients. Records comprehensive documentation of patient care and demonstrates professional competence according to established Southside Hospital Standards of Care.
- * Assessment:
- Collects and organizes, systematically, patient data using all possible resources.
- Examines patient to determine physical status including interview, observation, and inspection.
- Identifies and records patient’s physical, psycho-social condition including history, health habits and patient perception
- * Planning:
- Formulates a care plan which identifies patient needs in priority order, including patient and/or family participation, and expected outcomes
- Collaborates with health team.
- Identifies patient’s educational needs and coping mechanisms.
- Anticipates work-flow, and completes tasks.
- Responds to schedule changes and/or emergencies.
- * Implementation:
- Delivers care that communicates the worth and dignity of patient.
- Adapts nursing procedures when possible to meeting individual needs of patients.
- Meets patient’s needs for daily hygiene and acceptable appearance
- Involves patient and family in the care when it is therapeutic to do so.
- Identifies physical symptoms and changes; and takes appropriate action.
- Administers medications and treatments according to established policies and procedures.
- Observes behavioral and physiological changes due to medications and takes appropriate action.
- Uses good medical and surgical asepsis in delivery of care.
- Demonstrates skill using equipment necessary to delivery of patient care.
- Helps patient accept dependence/independence appropriate to condition.
- Protects patients from environmental hazards.
- Takes action to meet patient’s needs for adequate hydration and elimination.
- Takes action in response to anticipated or manifest patient anxiety or distress.
- Provides for mental and social stimulation in appropriate amounts on the basis of patient’s potential.
- Implements teaching plan using principles of teaching and learning.
- * Evaluation:
- Uses current data to measure progress toward goal achievement.
- Initiates Nursing actions if patient fails to progress toward pre-set goals
- Evaluates teaching done by obtaining patient or “significant other” verbalization of instructions
- Refers patient’s needs which cannot be met to appropriate personnel and obtains feedback.
- * Documentation:
- Writes admission notes which reflect a clear picture of the patient’s physical and psychological status.
- Records patient data on the Nursing Care Plan.
- Writes Nurse’s Notes demonstrating progress or lack of progress toward patient goals; presenting a clear and current picture of the patient’s status; indicating a knowledge of and appreciation for legal and ethical aspects of charting; and reflecting Nursing Intervention and Patient Response.
- Uses graphic/flow sheets correctly when pertinent to patient’s condition.
- Writes discharge notes which clearly reflect the patient’s status with regard to health, activity, and knowledge at the time of discharge.
- * Professional Implications:
- Makes decisions which reflect sound judgment based upon knowledge of facts
- Suggests constructive changes in delivery or monitoring of patient care.
- Participates in review and revision of Policies and Procedures as directed by Head Nurse, Supervisor or Assistant Director of Nursing.
- Serves on committees.
- Utilizes and enforces Universal Precautions.
- Performs related duties, as required.
*ADA Essential Functions
- Graduate from an accredited School of Nursing. Bachelor’s Degree in Nursing, preferred. Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010 and obtain a BSN degree within five (5) years of employment date.
- Current license to practice as a Registered Professional Nurse in New York State.
- ACLS/BLS required.
- At least one year of ICU experience required.
- Neuro ICU experience required.