Clinical Practice: Nursing

1

Assesses, collects and documents health assessment data focusing on the physical, emotional, spiritual, psychosocial and educational needs of the patient.

a) Interviews the patient/family/significant other to complete Triage information.

b) Identifies actual and potential needs and determines priority.

c) Identifies barriers to learning.

After initial triage evaluation, completes and documents an assessment, focusing on abnormal systems and actual and potential problems.  Performs ongoing assessment as indicated.

2

Plans nursing care, based on priority of physical and psychosocial-emotional needs.

a) Develops realistic short-term goals for each problem, involving the patient, family or significant others.

b) Plan demonstrates understanding of age-related needs of the patient.

c) Negotiates with patient, family, significant other and health care team members in              planning for education and discharge needs.              

3

Implements the plan of care including prescribed procedures and treatments.

a)    Organizes and prioritizes care based on individual needs and unit activity.

b)    Assesses for changes in patient’s condition and appropriateness of the plan. 

c)     Initiates interventions using appropriate clinical expertise and knowledge.

d)    As Primary Nurse, coordinates the activities of health care team members in completing diagnostic and therapeutic interventions. 

4

Evaluates the effectiveness of nursing care delivered to reach the expected outcome.

a) Evaluates the plan of care according to the current condition and changing needs of the     patient.

b) Accurately and concisely documents the patient’s status and response to the care               delivered.

Clinical Practice: Emergency Nursing

6

Utilizing professional nursing knowledge and skills. Appropriately assesses for:

a)    Physical and psychosocial-emotional needs.

b)    Barriers to learning.

c)     Educational/learning needs.

d)    Discharge needs.

e)    Age-related needs.

f)      Issues related to assault or abuse.

7

Analyzes patient related data, such as vital signs, past medical history, physical exam findings, laboratory values and other information, including age-specific criteria, to determine appropriate care.

8

Utilizes advanced, specialized knowledge and skills to implement interventions for all Emergency Services patients, by prioritizing needs, and using a patient centered approach.

9

Provides health education and teaching to patient’s, family members and/or significant others, that is age specific, providing for any barriers to learning.  Clearly communicates health, treatment and discharge information, ensuring the patient, family member or significant other understands all discharge and follow-up instructions. 

10

Effectively performs procedures, such as initiation of IV catheters and fluids, medication administration, dressings, patient teaching, etc., within their scope of practice, and unit, department and Medical Center policies and procedures.

11

Effectively performs other nursing procedures/skills, such as cardiac monitoring, rhythm interpretation, defibrillation, monitoring of conscious sedation, ABGs etc., based completed specialty training and their scope of practice, and unit, department and Medical Center policies and procedures.

12

Appropriately recognizes and quickly responds to emergency medical situations.

a) Accurately assesses “A-B-Cs.”

b) Initiates appropriate emergency treatment, i.e., CPR, O2, etc.

c) Communicates critical information to other team members.

13

Maintains all required credentials and training (CA RN license, BLS, ACLS, PALS, NIHSS).

14

Remains current on emergency treatments/practices/procedures through attendance at staff meetings, continuing education events, in-services and the review of professional literature.

15

Integrates/applies new knowledge from education and research into clinical practice.

16

Demonstrates knowledge of and competence in age-related patient care.

17

Consistently demonstrates knowledge of state and federal regulations, such as Title XXII and COBRA/EMTALA.  Follows all JCAHO guidelines. 

18

Advocates for public health and safety through patient and family education.

19

Consistently completes required documentation of the Emergency Services visit.

20

Consistently demonstrates caring and compassion through behaviors and interactions in performance of all duties, recognizing the inherent worth and dignity of patients, families, other staff and physicians.

21

Will perform duties of Relief Charge RN if called upon to do so.

22

Adheres to departmental and medical center policies on scheduling, overtime, sick time and time off.

23

Arrives punctually, takes appropriate time for breaks, use sick time appropriately.