B.Planning:
1.Initiates Nursing Care Plans upon admission which identifies the patient’s present/potential problems from the patient assessment and formulates a nursing diagnosis or problem statement.
2.Individualizes care based on collected data, identified problems, and established goals with patient/family input.
3.Formulates nursing orders that delineate interventions to be taken relating specifically to identified patient/family needs including education, discharge planning, and follow-up care.
C.Implementation:
1.Administers nursing care according to MD’s orders and nursing plan of care within the scope of hospital and nursing department policies and procedures.
2.Demonstrates accurate technical skill and operational knowledge of:
•procedures
•medications
•IV therapy
•chemotherapy / radiation therapy
•telephone triage
•side effect management
•equipment
3.Demonstrates ability to recognize and function appropriately under stress and in a crisis situation.
4.Communicates (verbally and written) the results of the nursing assessment, the plan of care, and the patient’s response to care to all individuals involved in patient care.
5.Organizes and appropriately schedules patients to meet treatment plan. Performs management responsibility when delegated.
6.Facilitates and implements patient and family teaching.
7.Recognizes the needs for additional patient care services, and coordinates these activities with appropriate individuals or outside agency.
8.Anticipates psycho-social and spiritual needs of the patient involving appropriate services as needed.
9.Evaluates patient’s status and interventions and modifies plan as needed with input from care team members and patient/family.
10.Records the evaluation of the patient’s response to nursing intervention.
11.Evaluates patient and family preparedness for discharge.
•Ensures accuracy and relevancy of patient records and other hospital documents
12.Documents accurately in OR Manager or, if weekend nurse, writes legibly on the patient record throughout the shift; is thorough, accurate, and complete.
13.Completes and submits Variance Reports within the shift.
14.Documents errors in charting according to policy.
15.Uses appropriate terminology and approved hospital abbreviations.
16.Satisfactorily completes annual competency review.
•Maintains department specific skill competencies.
17.Consistently demonstrates skills necessary to provide competent care to all patients for which are is assigned.
18.Demonstrates initiative to acquire skills necessary to provide new care treatments or services.