Job Description Summary
Manages individualized, outcome oriented nursing care through the use of the nursing process. Provides care, treatment and services through the successful coordination and completion of a series of processes that include assessment, planning care, providing care, in accordance with departmental and hospital policies and procedures
Job Description
1 - ASSESSMENT/REASSESSMENT
Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients by:
a - Initiating admission assessment within 8 hours of admission, identifies and documents patient/family/significant other teaching needs upon admission anf throughout hospitalization.
2 -PLAN OF CARE
Develops, discusses, and communicates a prioritized problem list/plan of care for each patient, in collaboration with designated support persons in order to address all identified needs.
a - Develop, evaluate and update individualized plan of care for patients and documentsd outcomes.
b - Actively communicates plan of care with the primarynure assigned to care for the patient
c - Facilitates dischasrge/transfers by goal of 12:00 pm, communicating barriers utilizing the Chain of Command.
d - Documents all patient care follwoing the department of nursing policies, unit based standards and nurse sensitive indicators (falls, skin pain).
e - Assessess/re/assesses and documentsd patient's level of comfort utilizong the appropriate pan scale and the patient's response to each intervention both pharmacoligical and non-pharmacological per South Shore Hospital Policy.
f - Works on behalf of patient/family. Seeks help to repersent patient/family when they are unable to represent themselves.
g - Raises ethica questions and concerns with clinica team. Seeks available resources to help formulate and understand ethical decisions.
3 - MEDICATION ADMINISTRATION
a - Demonstrates knowledge of and follows SSH policies and procedures for administering, transcribing, and recording medications.
b - Demonstrates proper porcedure for the documentation of narcotic withdrawal, administration, verifies count, wastes per policy and resolves narcotic discrepency.
c - Initiates and maintains IV access according to SSH policy and procedure.
6 - SAFETY
Fosters a "Culture of Safety" through personal ownership and commitment to a safe environment.
a - Verifies patient identification with two idenitifiers prior to the start og any invasive procedure, including "time out
