Description
- Department: NTICU - Schedule: PT Days 7a - 7:30p Monday - Friday & EOWE - Hospital: Genesys - Location: Grand Blanc, MI Use independent professional judgment, analytical skills, and the nursing process to provide a full range of delegated, interdependent, and independent nursing services to patients. Within the framework of the Seven Dimensions of Patient Care and Benner's Domains of Nursing Practice, demonstrates clinical competence; compassion and customer service orientation; focus on process and outcomes; and cost-consciousness when assessing, planning, implementing, and evaluating nursing care provided to patients. - Seven Dimensions of Patient Care: Coordinate development of a multi-disciplinary plan of care in accordance with Nursing Problem Care Sets (Core Outcomes and Core Intervention Sets) and/or clinical practice guidelines, age-specific requirements and professional and regulatory requirements to ensure appropriate length of stay, use of resources, and achievement of quality outcomes. - Provide patient care that reflects a respect for patient's rights, dignity, values, culture, preferences, and expressed needs. Assesses patient/family needs for information and education across the continuum, plans and implements patient teaching using a variety of techniques and methods, and evaluates effectiveness of educational interventions. - Help to alleviate patient fears and anxiety through skillfull application of professional and interpersonal communication. - Utilize a variety of pharmacologic and non-pharmacologic approaches to ensure patient comfort and relief of pain. Involves patient, family, significant others in development of plan of care. Collaborate with patient/family, hospital staff, and community agencies to develop discharge plans that prepare patients for continued care needs. - Orientation Self-Evaluation: (C) Competent (NT) Needs Training or Review. - Standards of Performance: - Seven Domains of Nursing Practice. - Helping/Teaching &Coaching: - Incorporate all elements of Signature Care in Daily interactions with patient: - Introduce self and writes name on whiteboard. - Discuss plan of care with patient/family. - Explain meds and treatments, provide teaching as appropriate. - Ask if patient needs anything else before leaving room. - Assess health status and determines care needs of the patient. Performs ongoing reassessment as required. - Complete Admission Assessment and shift assessment as required. - Complete assessment for Risk Factors; including fall, skin breakdown, VTE, and aspiration. Initiate appropriate initiatives as indicated SKINN Bundle, Fall Prevention Plan, SCD, etc. - Complete Medication Reconciliation upon admission and change in level of care. - Establish, direct, coordinate and document plan of nursing care in conjunction with patient/family. - Initiate Problems and Outcomes list (plan-of-care) based on medical diagnosis and patient needs. - Monitor, document, and report patient response to interventions and progress toward outcomes. - Document nursing interventions (NIC) and progress toward outcomes (NOC); patient education; and evaluation every shift, as required. - Educate patient regarding treatment plan, safety measures, medications, and self-care as indicated. Document education activities on shift assessment flowsheet and plan of care (POC). - Work with Case Manager to ensure appropriate referrals initiated prior to discharge. - Review discharge plans/instructions with patient prior to discharge, including signs/symptoms to watch for after leaving the hospital. Ensures appropriate follow-up arranged. - Ensure that core measures Discharge Instructions are given to all CHF patients. - Document patient care according to established documentation guidelines. - Administration of Therapeutic Regimens: - Demonstrate knowledge and skill application of basic nursing procedures - dressing change, catheterization, NG tube insertion, suctioning. - Implement/complete medical interventions as ordered. - Initiate standing orders appropriately. - Initiate and/or assists with all patient care activities including activities of daily living and provides other services as required for patient comfort, safety, and well-being. - Assess and initiate interventions to prevent/minimize patient skin breakdown. - Follow clinical practice guidelines and procedures as written. - Establish and maintain peripheral IV therapy. - Obtain body fluid specimens, per procedure. Obtains blood specimens if no phlebotomist assigned to area. - Perform blood capillary glucose monitoring. - Administer the following according to established policies and procedures: - Medications. - IVs. - Blood products. - Prepare patients for surgery or other invasive procedures according to established guidelines. - Perform or assist with procedures according to established standards of care and nursing practice. - Utilize equipment based on manufacturers instructions and established nursing procedure. Correctly operates and trouble shoots IV pumps, PCA pumps, epidural pumps, feeding pumps, patient beds, as applicable. - Monitoring Patient Responses/Responding to Changing Patient Situations: - Regularly reviews work in progress to ensure that treatments, medications, and tests ordered are expeditiously carried out and documented. - Review patient medical record/reports and confers with physician regarding treatment plans. Routinely checks chart for new orders. - Monitor patient physiologic parameters including vital signs, lab work, I&O, blood glucose; recognizes and reports meaningful changes and intervenes appropriately. Documents interventions accordingly. - Monitor presence and intensity of patient s pain on admission, after pain producing events, with each new report of pain, and routinely at regular intervals. Informs patient about pain relief and pain relief measures; administers pain medication or alternative interventions as indicated; includes pain management resources in the discharge plan/instructions. - Recognize acute changes in respiratory status - dyspnea, cyanosis, tachypnea, respiratory depression, airway obstruction and responds - appropriately with direct intervention and physician/SWAT notification. - Recognize acute changes in neurologic status/decreased LOC and responds appropriately with direct intervention and physician/SWAT notification. - Recognize acute changes in cardiac status - tachycardia, chest pain and responds appropriately with direct intervention and physician/SWAT notification. - Recognize acute changes in urinary output and responds appropriately with direct action and physician notification. - Utilize SBAR tool or other standardized approach to data collection and information sharing when notifying physician of patient changes/concerns. - Respond appropriately to life-threatening emergencies through initiation of CPR, assembly of emergency equipment, and immediate interventions (as allowable and indicated). - Perform emergency equipment
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