Lvn - Weatherford, United States - Hilltop Park Rehabilitation and Care Center

Description

• Works under direct supervision in accordance with the statespecific Nurse Practice Act, facility Policies and Procedures and nursing judgment.
• Delivers nursing care to patients/residents requiring longterm or rehabilitative care.
• Collects patient/resident data, makes observations, and reports pertinent information related to the care of the patient/resident.
• According to statespecific regulations, implements the patient/resident plan of care and evaluates the patient/resident response.
• In accordance with statespecific regulations, directs and supervises care given by other nursing personnel in selected situations.
• Maintains knowledge of necessary documentation requirements.
• Maintains knowledge of equipment setup, maintenance and use, i.e., monitors, infusion devices, drain devices, etc.
• Maintains confidentiality and patient/resident rights, regarding all patient/resident/personnel information.
• Provides patient/resident/family/caregiver education as directed.
• Conducts self in a professional manner in compliance with unit and facility policies.
• Works rotating shifts, holiday and weekends as scheduled.
• Initiates emergency support measures (i.e. CPR, protects patients/residents from injury).
• Data Collection
• Admission and routine patient/resident observations/transfer notes are complete and accurately reflect the patient's/resident's status.
• Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures.
• Nursing history is present in the medical record for all patients/ residents.
• Changes in a patient's/resident's physical/psychological condition (i.e., changes in lab data, vital signs, mental status), are reported appropriately.
• Planning of Care: Contributions to the formulation/review of nursing care plans are made as appropriate, under the direct supervision or delegation of an RN.
• Pertinent nursing problems are identified.
• Goals are stated.
• Appropriate nursing orders are recommended.
• Evaluation of Care
• Observations related to the effectiveness of nursing interventions, medications, etc., are reported as appropriate and documented in the progress notes.
• Care Plans:
• Evaluation of care plan is noted monthly or as indicated.
• Contributions to care plan revision are made as indicated by the patient's/resident's status.
• General Patient/Resident Care
• Patient/resident is approached in a kind/gentle and friendly manner. Respect for the patient's/resident's dignity and privacy is consistently provided.
• Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided.
• Independence by the patient/resident in activities of daily living is fully encouraged possible.
• Treatments are completed as indicated.
• Safety concerns are identified, and appropriate actions are taken to maintain a safe environment.
• Siderails and height of bed are adjusted.
• Patient/resident call light and equipment is within reach.
• Rooms are neat and orderly.
• Functional assignments are completed.
• Emergency situations are recognized, and appropriate action is instituted.
• All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, AED, crash cart, fire extinguisher, etc.)
• Patient/Resident Education/Discharge Panning
• Patient/Resident/Family teaching is conducted according to the nursing care plan.
• Explanations are given to the patient/resident prior to interventions.
• Discharge/death summaries are complete and accurate.
• Transfer forms are complete and accurate.
• Active participation in patient/resident care management is evident.
• Adherence to Facility Procedures
• Facility Policy and Procedure Manual or reference materials are utilized as needed.
• Procedures are performed according to the method outlined in the procedure manual.
• Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions.
• Safety guidelines established by the facility (i.e., proper needle disposal) are followed.
• Documentation
• Only approved abbreviations are utilized.
• Vital signs are properly and timely recorded.
• I&O summaries are recorded and added correctly.
• Progress notes are timed, dated and signed.
• Unit flow sheets are completed properly (i.e. wound care records, treatment records, weight sheets, etc.).
• Medication Administrations/Parenteral Therapy Record
• Adheres to statespecific Nurse Practice Act for administration of medication and parenteral therapy.
• Dates that medications are started or discontinued are documented.
• Medications are charted correctly with name, dose, route, site, time, and initials of nurse administering.
• Pulse and blood pressure and obtained and recorded when appropriate.
• Medications not giv