Works under the direction of the physician and the Arizona State Nurse Practice Act to provide nursing care to patients in compliance with nursing standards and regulations. Utilizes the nursing process to make continuing assessments of the patient’s total health needs; implements nursing interventions based on assessment data; develops and implements the nursing plan of care and evaluates the patient’s response. Strives to provide excellent patient care with compassion, tact, cheerfulness, accuracy, patience, flexibility in scheduling, calmness in emergency, and ability to work well with team members, receiving and applying feedback from peers and superiors. Assists with orientation of new staff to the unit as requested. Quality of Care and Nursing Process
- The nurse provides evidence-based care to prevent the development of a Healthcare Acquired Condition and hospital readmissions.
- The nurse practices standard precautions during patient contact and while handling contaminated materials.
- The nurse complies with CDC hand hygiene guidelines and works to reduce hospital acquired infections and other conditions. Assessment : The nurse collects patient health data.
- Nursing assessments are completed according to hospital and unit specific policies, procedures, and standards of nursing care.
- Collects pertinent data from the patient, significant others, and health care providers.
- A comprehensive patient history and physical is completed in a timely manner and includes biophysical, psychosocial, environmental, self-care abilities, educational, age specific, cultural, and discharge planning needs. Diagnosis / Care Needs : The nurse analyzes the assessment data to identify care needs.
- Nursing diagnoses / care needs are derived from the assessment data. 5449 (Init : 8 / 17ms Rev : 2 / 18sn (Please refer to electronic document management system for the most current revision) 4 / 18sn; 12 / 4 / 18sn)
- Involving the patient and significant other as appropriate, the nurse formulates a plan to provide appropriate care based on identified patient needs. Implementation : The patient’s nursing care is based on identified nursing diagnoses / care needs and patient care standards, and is consistent with the therapies of other disciplines.
- Nursing care is based on identified nursing diagnoses / care needs.
- Nursing care is based on standards of patient care.
- Nursing care is prioritized based on assessment of patient’s immediate condition or needs.
- The patient and / or significant other(s) is involved in the patient’s care as appropriate.
- The nurse collaborates with the patient, family, physician, and other clinical disciplines in making decisions regarding each patient’s need for nursing care.
- The nurse implements patient education and involves the patient, family and / or significant other(s) as appropriate to the age of the patient. Evaluation : The nurse evaluates the patient’s progress towards attainment of desired outcomes.
- Evaluation of the patient’s response to nursing care is evident in the ongoing assessment data.
- Nursing diagnoses / care needs are revised based on reassessment data. Documentation : Documents patient care management in clear, concise manner.
- Completes nursing admission and assessment form. All blanks completely filled in or “N / A”.
- Initiates the Nursing Care Plan with identified patient problems considering age specific variations, nursing diagnosis, expected outcomes and nursing interventions.
- Records patient’s response to hospitalization, treatments, and nursing intervention on the patient care record.
- Documents medications, treatments, and nursing intervention on appropriate chart forms.
- Provides thorough discharge instructions and sends patient home with a discharge folder as appropriate. Patient Satisfaction Regularly updates patient “communication” boards, is skilled at providing bedside shift report, performs hourly rounds on patients, and applies AIDET as well as other evidence-based behaviors. Unit goal for Patient Satisfaction met.