Assessment
- Performs appropriate nursing history and physical upon admission and on an ongoing basis.
- Collects and documents patient data.
- Interviews patients and significant others and completes a history documentation.
- Documents signs and symptoms that indicate actual and potential problems.
- Incorporates information in the written assessment from families/significant others and members of the health care team.
- Assesses safety of the patient care environment.
- Documents patient/family teaching needs in the patient care plan.
Planning
- In conjunction with the patient and family, develops individualized patient care plan.
- Identifies short and long-term goals, including discharge planning consistent with established patient care.
- 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 through the shift report, in accordance with the unit's guidelines.
- Involves family members and other health care team members in the development of the plan of care as able and appropriate.
- Revises the initial patient care plan to the changing needs of the patient.
Implementation
- Provides direct nursing care based on the plan of care and established priorities.
- Sets priorities and gives nursing care based on the patient's needs.
- Implements the medical care plan as delegated.
- Follows through with care plan established by other health team members (i.e., P.T., O.T., Speech, etc.).
- Writes patient discharge plan and makes appropriate referrals.
- Delegates and guides aspects of care to appropriate personnel based on level of acuity and individual patient needs.
- Coordinates the activities of other disciplines of the health team to implement the individual care plan.
Evaluation
- Evaluates and documents the patient/family response to nursing interventions related to the stated goals and the overall effectiveness of the care plan.
- Revises plan of care based on evaluation.
- Documents the response of the patient to the medical care plan.
- Documents the response of the patient to nursing interventions.
- Recognizes alterations in physiological and psychosocial status.
- Collaborates with other members of health care team to revise the patient care plan according to changing needs of the patient.
- Documents revision of the goals and plan of care to meet the changing needs of the patient.
Customer Service
- Consistently strives to implement the unit's customer service standards and to exceed the expectations of patients, families, physicians and visitors.
- Unit surveys consistently meet or exceed hospital benchmark.
- Demonstrates customer service commitment to patients by maintaining flexibility in relation to patient assignment, shift assignment and work schedule.
- All interactions are conducted in a professional manner.
- Verbal and written feedback from patients, family members/significant others, medical staff visitors and co-workers indicates behavior conducive to positive guest relations.
- Consistently exhibits appropriate phone protocol, e.g., answers phones promptly and professionally, is courteous and helpful.
- Interacts with other departments for problem resolution and quality patient care.
- Maintains a quiet, therapeutic environment in the immediate patient care areas, including at the nursing station.
- Makes rounds to assigned patients; anticipates patients' needs and answers/responds to the patients' call lights or paging promptly.
Professional Conduct
- Employee has the willingness and ability to perform additional duties and responsibilities in different areas of the department or on an as-needed basis or as determined by managment.
- Follows attendance and all other established hospital and department policies.
- Demonstrates the philosophy of the team concept.
- Participates in staff meetings with suggestions that enhance the work environment and increase productivity.
- Communicates well with supervisor, reporting problems with equipment, supplies or procedures.
- Requests assistance as appropriate.
- Complies with all safety and infection control standards.
- Maintains confidentiality as related to job responsibilities. Exhibits willingness to resolve problems as they arise.
- Consistently project positive professional image through appearance and behavior.
- Attends 75% of staff meetings or reads and initials minutes.
- Completes assigned work within shift.
- Complies with time and attendance policy (i.e., Kronos).
Performance Improvement
- Demonstrates WHMC's commitment to quality through the maximum individual effort of each employee.
- Completes Annual Updates and Ethics Training within established time frames.
- Completes general and departmental orientation within established time frames.
- Attends 80% of in-service programs.
- Maintains licensure/certification as appropriate.
Professional Growth and Development
- Completes Annual Updates and Ethics Training within established time frames.
- Completes general and departmental orientation within established time frames.
- Attends 80% of in-service programs.
- Maintains licensure/certification as appropriate.
Knowledge of Growth and Development
- Adolescent: Demonstrates ability to obtain and interpret information according to developmental age, e.g., sensitive to body changes (need for privacy); non-judgmental and accepting of behavior.
- Early to Middle Adulthood: Demonstrates ability to obtain and interpret information according to developmental stage, e.g., sensitive to need for control over own environment and need for explanation education regarding condition and treatment.
- Geriatric: Demonstrates ability to obtain information and recognize multiple disease entities associated with the aging process, e.g., increased need for personal possessions and personal safety maintained.
Range of Treatment
- Adolescent: Demonstrates ability to effectively care for patients with UTI, respiratory distress, trauma, toxic substance abuse/overdose, potential life-threatening medical/surgical conditions, suspected abuse, fluid/electrolyte imbalance.
- Early to Middle Adulthood: Demonstrates ability to effectively care for patients with UTI, acute neurological deficit, chest pain/MI, cardiac arrest, respiratory distress, trauma, potential life-threatening medical/surgical conditions, suspected abuse, fluid/electrolyte imbalance.
- Geriatric: Demonstrates ability to effectively care for patients with UTI, acute neurological deficit, chest pain/MI, cardiac arrest, respiratory distress, trauma, potential life-threatening medical/surgical conditions, suspected abuse, fluid/electrolyte imbalance.
Assessment
- Adolescent: Demonstrates ability to identify normal physiological parameters of the adolescent and assess for deviation, e.g., V/S, breath sounds, neurological deficit (reflexes), urinary output, nutritional status.
- Early to Middle Adulthood: Demonstrates ability to identify normal physiological parameters of the adult and assess for deviation, e.g., V/S, breath sounds, neurological deficit (reflexes), urinary output, nutritional status, cardiac arrhythmias.
- Geriatric: Demonstrates ability to identify normal physiological parameters of the geriatric patient and assess for deviation, e.g., decreased cognitive behavior and sensory perception, nutritional status, decreased skin integrity, fluid/electrolyte status.
Unit-Specific Competencies
- Procedural Sedation
- Discharge from Outpatient Anesthesia
- Malignant Hyperthermia
- H. Pylori
Cultural-Specific Competencies
- Exhibits culturally responsive attitude, including flexibility, empathy, respect and awareness of communication needs.