Performs initial assessment and documents appropriately for the level of care appropriate to the patientâ€™s clinical presentation/diagnosis, care setting, age development level, and cultural and religious orientation in a timely manner.
Performs ICU standard level of care, 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 response 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.
Prioritizes the shift based on patientâ€™s needs coordinating with the multidisciplinary team to manage the care of the patient.
Includes plan for discharge/transfer.
Identifies specific nursing diagnoses that are relevant to assessment findings.
Identifies interventions, for each nursing diagnosis, specific to identified patient needs and documents in the EMR.
Attends and actively participates in the Interdisciplinary Team meetings for assigned patients.
Performs intervention 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.
Conducts patient/family education that:
-Is appropriate to the patientâ€™s age, learning needs, level of understanding, and readiness to learn.
-Includes the family/significant others when appropriate.
Documents nursing intervention and patient teaching in the EMR.
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.
Accountable for own personal conduct and independent decisions related to patient and family
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.