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Performs an age specific plan of care for a designated group of patients using the nursing process of assessment, diagnosis, outcome identification, planning, implementation and evaluation of patient care. Collaborates with physicians and other health team members in coordinating and implementing procedures and treatments. Uses leadership skills/clinical judgment in coordinating patient care and directing/delegating activities of the patient care unit team.

Responsibilities:

1. Assesses the patient's physiologic health status

• Conducts patient interview, explains policies and procedures to patient/significant others, reviews patient's chart and answers questions correctly and courteously;
• Assesses gastrointestinal, cardiovascular, respiratory, renal and neurological health status;
• Determines mobility, sensory deficits, prostheses use, and skin condition and adjusts plan of care, as appropriate;
• Assesses level of pain and pain management;
• Communicates/documents patient's physiologic health status and plan of care.

2. Assesses patient's psychosocial health status

• Elicits perception of medical/nursing care and the expectation of care;
• Determines coping mechanism, knowledge level, and ability to comprehend;
• Identifies cultural/ethnic requirements to reduce anxiety and ensure patient satisfaction;
• Communicates and documents psychological status and care plan; support group, counseling services, social services.

3. Identifies patient outcome

• Develops criteria for measurement of patient outcomes;
• Identifies actual/potential patient problems;
• Identifies patient's need for teaching based on psychosocial and developmental assessment;
• Develops patient outcome statement (s) and establishes individualized patient goals.

4. Formulates the plan of care and establishes the priorities necessary to achieve expected outcome

• Identifies care activities and establishes the priorities necessary to achieve expected outcome;
• Coordinates the cost-effective use of supplies, equipment and medication to achieve expected outcome;
• Documents the plan of care and collaborates with physicians and other health team members.

5. Implements the plan of care

• Maintains constant vigilance over patients care to ensure that safety precautions/needs are followed. (Side rails up, call lights and bedside stand within reach, etc.);
• Exercises professional skills related to the plan of care;
• Reassesses patients as needed and appropriately revises plan of care;
• Correctly administers prescribed treatments;
• Correctly uses equipment necessary for patient care;
• Provides emotional support to patient and significant other;
• Applies scientific principles in performing procedures; carries them out safely, timely and efficiently;
• Makes accurate observations of patient's conditions during treatments/procedures.Reports and records same as appropriate;
• Keeps accurate documentation of patient's treatment, activity and condition, as well as patient's responses to medical and nursing interventions;
• Uses appropriate methods of documentation according to departmental policy;
• Acts rapidly and effectively during any emergency situation, managing self, patients and other employees;
• Provides a calm, quiet, restful atmosphere. Communicates effectively with the patient's family or caretakers;
• Participates in planning for discharge and coordinates referrals, as appropriate;
• Provides discharge instructions to patient and significant other.

6. Evaluates care provided for patient outcome

• Demonstrates ability to measure effectiveness of care provided and documents same;
• Performs variance analysis related to outcome data for performance improvement;
• Designs, implements, and evaluates systems to improve care in Unit;
• Keeps accurate documentation of patient's treatment, activity and condition;
• Uses appropriate methods of documentation according to departmental policy.

7. Collaborates with other care team members in planning and carrying out treatment regimen; provides direction to other members of the care team

• Collaborates with the appropriate physician on patient's plan of care;
• Accurately interprets and implements treatment regimen as prescribed by the Physician;
• Assists the Physician during treatments and/or diagnostic procedures;
• Keeps the Patient Care Manager/designee and/or physician, abreast of changes in patient's condition and/or treatments, as appropriate;
• Uses clinical judgment in delegating assignments to the Patient Care Associate, Support Care Associate and Clerical Service Associate in providing patient care, and ensures that assignments are completed in a timely fashion.

8. Performs grade I-IV Decubitus Care

• Performs preventive skin care measures
• Applies simple dressings, maintaining principles of aseptic technique;
• Applies warm & cold compresses, consistent with facility procedure;
• Performs irrigations, consistent with Facility procedure;
• Performs other procedures related to skin care, as necessary.

9. Administers medications correctly and safely

• Correctly identifies medication: action; dosage; side effects and implications for the patient;
• Meets standard on medication administration examination;
• Demonstrates preparation of local solutions;
• Demonstrates preparation of I.V. drips;
• Administers and documents medication correctly;
• Administers IVP medication as per department policy and procedure;
• Educates patients and significant others related to drug and food interactions.

10. Participates in patient and family education

• Provides the patient with an explanation of his/her condition as indicated;
• Communicates assessment data in an orderly fashion by recording, updating and verbalizing pertinent information to care team members and to appropriate agencies;
• Recognizes and utilizes health teaching opportunities and resources /materials available for this teaching;
• Provides for early discharge planning and appropriate referrals for post-hospital care;
• Evaluates the effectiveness of teaching by feedback from patient/family and documents same.
• 11.Performs related duties, as required.

Qualifications:

• Graduate from an accredited School of Nursing. Associate's Degree in Nursing, required. Bachelor's Degree in Nursing, preferred.
• Minimum 1-2 years of professional nursing experience in the related specialty.
• Current license to practice as a Registered Professional Nurse in New York State, required.
• BLS required, plus specialized certifications as needed.