Assessment: Does admission and ongoing assessment of patient’s condition. Provides nursing care to meet the patient’s physical, psychological and spiritual needs. Notifies doctor of changes in assessment that require attention. Planning: Designs, directs, evaluates, and documents the plan of care, patient/family teaching and the transition of care plan to include a safe appropriate level of care discharge. Works with other clinical disciplines to meet specialized patient care and discharge needs. Formulates a plan of care and daily goals that takes into consideration the individualized needs of the patient. Implementation: Prepares patients physically, psychologically, and spiritually for treatments, surgeries and diagnostic studies to help reduce patient anxiety. Knows patients' conditions and reports significant changes to Charge Nurse/Team Leader, and/or physician. Implements patient safety initiative and protocols including medication safety practices, physician orders, consult notifications. Evaluation: Reassesses patients at appropriate intervals following interventions. Notifies physician as necessary to modify interventions. Adjusts nursing care to meet patient's emerging and changing needs. Report Skills: Gives and receives report using Bedside Shift Report including family participation. Provides an accurate and comprehensive report to the oncoming shift to help establish continuity of patient care.
