1. Obtain and records initial assessment and establishes priorities according to patient age, symptoms and psychosocial needs.
2. Re – assess patients systematically to identify progress and trends that require intervention.
3. Develops and implements a measurable individualized plan of care for the patient within the time frame established by the Nursing Standards of Care.
4. Makes comprehensive nursing decisions based on the interpretation of facts and evaluations of patient outcome; modifies the plan of care based on changing patient condition and outcome.
5. Participate in patient / significant others during health education and discharge planning.
6. Implements and document appropriate interventions of patient needs.
7. Demonstrates accountability for ongoing awareness of the status of patients by collecting and documenting data appropriate to the nature and severity of the illness and communicating this data to the attending physician and other healthcare team members.
8. Collaborates with other for patient care planning.
9. Interprets and implement physician’s orders for treatment in accordance to accepted standards of patient care and departmental policies and evaluates and documents effectiveness of treatments to appropriate forms in the patient medical record.
10. Documents patient responses to interventions.
11. Consult, re-evaluates and supplements a multidisciplinary plan of care for each shift. Documents resolution of patient problems in the nurses’ progress notes.
12. Follows 10 Golden Rules in Medication Administration thereby reducing potential medication errors.
13. Assess, and evaluates effectiveness of medications administered to patients.
14. Prepare and administer IV Fluids to patients and monitor & assess IV site.
15. Discontinue IV Medications / Fluids upon the order of the Attending Physician.
16. Assist physicians in bedside procedures.
17. Assess, and evaluates effectiveness of medications administered to patients.
18. Prepare and administer IV Fluids to patients and monitor & assess IV site.
19. Discontinue IV Medications / Fluids upon the order of the Attending Physician.
20. Assist physicians in bedside procedures.
21. Treat patients and their families with respect and dignity by acknowledging their psycho social, cultural, ethnic and religious beliefs / needs.
22. Serve as a liaison between patients, physicians, administration and other members of the healthcare team.
23. Interacts professionally with patient and family and involve them in formulating patient care plan.