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- Observes, identifies and collects data to identify nursing care needs of the patient and family.
- Correlates the medical plan of care with the nursing plan of care.
- Identifies and reports to the appropriate person(s) abnormal diagnostic data and clinical changes in the patient's condition.
- Develops and/or updates individualized nursing care plan on each patient.
- Documents patient problems and nursing care needs of the patient and family/significant others.
- Actively involves patient and family/significant others in planning patient's care.
- Develops short- and long-term goals for the patient and family/significant others. Identifies the need to involve other disciplines in the patient's care.
- Initiates discharge planning upon admission.
- Performs common nursing procedures as defined in Policy and Procedure Manual.
- Implements changes in physicians' orders in a timely manner.
- Explains treatments and procedures to patient and family/significant others.
- Provides patient and family teaching.
- Provides for the safety, cleanliness and comfort of the patient.
- Initiates emergency procedures as needed within the scope of practice and hospital policy.
- Evaluates the patient's response to nursing care.
- Updates and revises care to be delivered as patients' needs change.
- Appropriately communicates changes and care given to other members of the health care team
RN Telemetry Per Diem Nights - Fountain Valley, United States - UC Irvine Health
Description
ASSESSMENT:
1. Interviews patient, family, significant others to formulate a nursing history.
PLANNING:
IMPLEMENTATION:
EVALUATION: