Assess and Diagnose Nursing Care Needs
- The priority of data collection is determined by the patient’s immediate condition of needs.
- The pertinent assessment data is collected using appropriate assessment techniques (interview, observation, inspection palpation, and review of reports and records).
- Validation of patient problems and data collection involves the client significant others, family and health care providers as appropriate.
Prescribes, Delegates, Supervises, and Evaluates Patient Care
- Nursing interventions reflect current nursing practice and are based on scientific knowledge and documented on the record.
- Delegates responsibility for nursing interventions according to the support staff level of education, orientation experience and scope of practice as mandated by the Nurse Practice Act.
- Frequency of reassessments is appropriate to the condition of the patient. Documents patients’ response to the nursing interventions on the surgical records. The medical record.
- Gives a concise report to receiving unit providing necessary information relative to patient care and their progress toward resolution of identified problems when the patient is transferred to a unit.
- Accurately transcribes and implements medical orders and assures that medical orders are communicated to all affected ancillary staff.
- Demonstrates knowledge of sterile/aseptic techniques.
- Recognizes cardiac arrhythmias and follows appropriate treatment protocol.
- Demonstrates knowledge and skills of all patient procedures.
- Pain management
Teaching
- Identifies learning needs of self and assist in the development and implementation of learning opportunities.
- Provides “on the spot coaching” to personnel observed in unacceptable behavior. Coaching is done in a constructive manner and in privacy.
- Determines patient learning needs and provides teaching or makes an appropriate referral. Appropriate teaching methods and supporting materials are used for patient instruction.
- Documentation in the medical record reflects content and type of instruction and the patients’ response to the instruction.
Maintains Safe and Therapeutic Environment for Patient Care
- Accounts for all drugs including schedule II drugs according to hospital policy and procedures.
- Demonstrates knowledge of location, care and use of all equipment/supplies pertaining to the unit.
- Seeks to reduce waste in the workplace.
- Follow procedure for removal of faulty equipment from service.
- Assist in evaluation of patient care products.
- Correctly fills out incident reports with assistance.
- Knows and responds appropriately to all emergency codes.
- Knows and uses good body mechanics.
- Properly reports any safety or infection hazards.
- Checks emergency equipment after each use and at least once a shift.
- Accountable for ensuring patient safety during the course of performing his/her duties.
Upholds Standards of Nursing Practice and Code of Ethics
- Code of Ethics and Standards of Nursing practice are continuously met.
- Performs all nursing procedures according to the established policy and procedure of Ohio County Healthcare nursing department.
- Meets licensure requirements and maintains CE licensure.
- Recognizes and supports the patients’ bill of rights and maintains confidentiality in all hospital manners.
- Adheres to Blood and Body Fluid Precautions and knows where to locate personal protective equipment and uses equipment appropriately.
- Adheres to other infection control policies, to include the exposure control plan and employee health protocols.
- Follows and upholds hospital wide personnel policies.
- Committed to Quality Insurance and actively participates in and supports the hospital improvement efforts.
- Is always available and accessible when on duty or on call.
- Frequently accesses email to stay up to date on information within the organization and provides a way of communication between staff members.
- Performs all procedures according to established policies and procedures of OCH and adheres to legal compliance policies and other regulatory issues.
Professional Self Development
- Attends CE and in-services that pertain to assigned areas and are mandatory.
- Attends 80% of staff meetings per year.
- Maintains clinical skills as evidenced through competency review.
- Accepts supervision and guidance in a non-defensive manner as needed.