Completes initial assessment on new patients within one (1) hour of admission, including functional assessment, psychosocial, pain assessment, discharge planning, referrals to interdisciplinary team and code status.
Initiates and updates patient care plan, assess patient educational needs and barriers to learning. Reviews and transcribes all telephone orders. Monitors all telephone orders for signature and validation by physicians within 24 hours.
Explains all procedures to patients maintaining privacy and allowing patients to express emotional needs. Demonstrates knowledge of IV medications , adverse drug reactions ADR and blood components
Documents evidence of nursing care on the patient’s record. Observes for reactions and/or complications and report to the physician in a timely manner. Participates in the PI data collection regarding core measures and pain management.
Knowledgeable about National Patient Safety Goals.
Recognizes signs of abuse and reports appropriately to the hospital social worker and/or Adult / Child Protective Services. Familiar with the EMTALA Regulations.
Responsible for the observation and direction of patient lifts, mobilization, and shall participate as needed in patient handling.
Attends and maintains mandatory training in safe patient handling, trained in safe lifting techniques, includes but not limited to 1) Appropriate use of lifting devices and equipment, 2) Five areas of body exposure: vertical, lateral, bariatric repositioning and ambulation, 3) Use of lifting devices to handle patients safely.
Uses professional judgment and clinical assessment in safe patient handling that are consistent with Safe Patient Handling policies.
Uses two patient identifiers consistently when drawing lab, administering medications and performing procedures.
Does not use unacceptable abbreviations in documentation and uses read back on all telephone orders. Monitors authentication and validation of telephone orders within 24 hours by the physician.
Follows medication reconciliation policy consistently.
Ensures Crash Cart, defibrillation function have been checked per protocol and after each code, appropriate items are immediately replaced and indicated by signature on crash cart checklist.
Is in compliance with information contained in the Infection Manual (i.e. OSHA blood borne pathogen standards, CDC Guidelines), and demonstrates appropriate use of personal protective equipment (i.e. gloves, gowns, masks, goggles) and hand hygiene techniques.
Ensures consistently that all clinical alarms i.e. cardiac monitor alarms are set with the appropriate parameters for the patient and are audible at all times.
Gives thorough, detailed efficient change of shift report or upon patient intra-department transfer to ensure consistency in the plan of care. Uses the SBAR communication methodology in all reporting.
Assists physicians with special tests and procedures in the ICU. Uses universal protocol “time out” on all patients for any bedside procedures.
Avoids and prevents injury to self and patients by applying the principles of body mechanics. Maintains a safe environment, functioning with an awareness and application of safety issues identified within the unit/facility, i.e., suction and oxygen immediately available at all ICU bedsides.
Completes pain assessment and reassessment consistently with the time frame after giving pain medications and upon discharge or transfer of patients.
Completes documentation of medications given to the patient on the medication administration record (MAR).
Initiates discharge and patient / family education planning with proper documentation on the patient record or electronic medical record (EMR).
Establishes priorities of patient care based on essential needs and available resources of time, equipment, personnel and supplies.
Formulates, maintains and updates a goal directed plan of care on patients which is prioritized and based on patient outcomes.
Complies with all regulatory requirements for clinical pathways, clinical assessments, interventions and documentation
Initiates, titrates and safely monitors all IV medications and blood components. Uses two patient identifiers consistently when drawing lab, medicating, or performing any procedure on a patient and blood components
Performs all other duties as assigned or required.