Assessment: Collects and documents patient data.
- The LVN will assist the RN in the Nursing Assessment of each patient by:
- Interviewing patients/family and completing a history documentation.
- Documenting signs and symptoms that indicate actual and potential problems.
- Incorporating information in the written assessment from patient/family and members of the health care team.
- Assessing safety of the patient care environment.
- Documenting patient/family teaching needs in the patient care plan.
Assists in the development of a collaborative, individualized patient care plan.
- Documents patient problems and goals requiring intervention, including teaching needs and discharge planning.
- Provides continuity of care by communicating the plan of care and diagnostic data to the RN.
- Involves family members and other health care team members in the development of the plan of care as able and appropriate.
Implementation: Provides nursing care based on clear and established priorities.
- Implements the delegated portion of the medical care plan.
- Initiates referrals to other members of the health care team and appropriate health care agencies to meet specific learning and care needs of patients and significant others.
- Records and reports all interventions clearly and accurately, in the designated manner, to the appropriate persons.
- Explains tests, procedures, medications and disease processes to patients and families in order to alleviate anxiety.
- Documents teaching provided and response to same in the medical record.
Evaluation: Evaluates patient's response to the plan of care and revises appropriately.
- Evaluates the patient's responses to the plan of care and the attainment of the patient care plan goals.
- Collaborates with other disciplines to evaluate the attainment of the patient care plan goals.
- Assists in the revision of the care plan to meet the patient's changing needs.
Professional Conduct/Growth and Development
- Accepts new responsibilities.
- Sets realistic and measurable goals for own development based on personal, peer and manager's assessment of strengths and learning needs. Achieves goals on a timely basis.
- Recognizes professional responsibility as extending beyond patient assignment to include goals established for unit and Department of Nursing. Upholds established quality standards in overall job performance. Maintains current knowledge of and complies with unit and departmental policies and clinical procedures. Presents cost-effective ideas when appropriate to improve systems and procedures. Consistently manages workload to avoid overtime. Consistently arrives on time. Does not exceed sick time allowance, as established by hospital policy. Completes timecard according to policy and procedure. Maintains professional attire, including visible ID.
- Demonstrates professional commitment to patients and nursing staff. Teaches and assists other nursing personnel for whom he/she is responsible and orients new personnel. Maintains flexibility in relation to patient assignment, shift assignment or work schedule. Uses established systems to document reportable occurrences. Complies with all safety and infection control standards.
Guest/Interdepartmental Relations
- Participates in reports and patient care conferences as assigned.
- Acknowledges requests.
- Promptly and cordially offers assistance.
- Listens to the ideas, opinions and feelings of others.
- Expresses and accepts constructive feedback, with a focus on positive outcomes.
- Participates in one-to-one and group discussions to resolve conflicts that inhibit effective working relationships.
- Interacts with other departments for problem resolution and quality patient care.
- Recognizes and intervenes appropriately in stressful situations that may arise with patients, families and health care team members.
- Maintains a quiet, therapeutic environment in the immediate patient care areas, including nursing stations.
- Communicates any changes in orders to team members.
- Makes rounds to assigned patients, anticipates patients' needs, and answers/responds to patient call lights or paging promptly.
Performance Improvement
- Consistently strives to understand, anticipate and meet the needs, expectations and satisfaction levels of patients and other "customers". Errors, inefficiencies and inaccuracies are brought to management's attention with suggestions for improvement. Demonstrates knowledge of each step of the QI process and participates in the formation and implementation of a quality improvement plan. Participates as a team member in assigned Corrective Action Teams (CATS). Identifies and implements methods of controlling costs or generating revenue while providing maximum value to both the patient/customer and the hospital. Maximizes efficiency in all departmental operations. Measures progress against quality goals.
Unit Specific Job Activities
- Telemetry: maintains LVN license, BLS, ACLS, Cardiac arrhythmia competency, and other unit-based competencies.
- May cover as Monitor tech if unit need arise. Maintains annual Nihon Kohden competency. Monitors telemetry units and alerts primary RN or Charge nurse of changes in underlying rhythms and of any life threatening arrhythmias that may develop, documents any rhythms in the patient clinical record, Notes the name and time nurse notified of rhythm change; documents vital signs when applicable; interprets and posts telemetry strips per unit specification in the patient clinical record, admits and discharges patients with telemetry units as appropriate, presents information to physician as requested, Obtains a 10-second rhythm strip on patients who complain of chest pain; posts the strip and documents the pain in the strip with appropriate measurement of P-r QRS duration; runs continuous strip during cardiopulmonary arrest event unit the EKG Tech is running a strip at the bedside; make notes on the trend recording rhythm strips or profess record which reflect alterations in cardiac activity or change in lead; maintains the Log Book on all patients using telemetry, including name, room #, hospital #, date, time on and time off; maintains telemetry equipment, including Biomed notification of malfunctions. At completion of shift, gives the oncoming Tech report on the patient's rhythm. May perform clerical activity per unit scope of service.