Assesses, plans, implements, evaluates, and supervises individual patient care on a nursing unit according to unit policies and procedures. Supports and upholds the Patient Bill of Rights. Practices under the supervision of the Manager/Director.
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- Communicates the patient’s progress including critical findings, changes in the patients’ condition to the physician and/or disciplines involved in the care of the child.
- Plans, implements, and documents the plan of care in collaboration with other disciplines and services to assure safe and efficient care.
- Completes all nursing assessment of patients. Performs reassessments as per policy when there is a change in the plan of care or an intervention is performed.
- Provides basic nursing care such as feeding, bathing, changing diapers, may start IV, suctioning and repositioning for neonates. Responds to medical equipment in a timely manner.
- Completes patient admission history (spiritual, cultural, developmental, educational/learning, and psychosocial needs) and discharge planning thoroughly and accurately as per policy .
- Accesses electronic health record independently according to hospital policy and completes accurate and timely documentation.
- Provides education and documents on patient/family teachings on health related needs (i.e. disease, medications, treatments, pain, discharge, safety, nutrition, skin care etc.).
- Follows physician’s orders and administers medications as directed. Adheres to the six rights of medication administration.
- Promotes a safe “error free” working environment by consistently performing thorough hand-offs and infection prevention measures.
- Assesses all body systems, ensures safe, effective, efficient care delivery with emphasis on the absence of medication errors, avoidance of falls from surface, ouch-free procedural pain, reduction of pain, absence of blood borne infections and surgical site infections.
- Secures Endotracheal tubes when applicable per competency and observes of skin integrity for prevention of skin breakdown.
- Provides beside report and patient information at shift change. F: Daily/ T: 10 minutes per patient R:
- Responsible for specimen collection.
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