Registered Nurse Fvr-5

ASSESSMENT: 1. Interviews patient, family, significant others to formulate a nursing history.

2.Observes, identifies and collects data to identify nursing care needs of the patient and family.

3.Correlates the medical plan of care with the nursing plan of care.

4.Identifies and reports to the appropriate person(s) abnormal diagnostic data and clinical changes in the patient's condition.

PLANNING:

5.Develops and/or updates individualized nursing care plan on each patient.

6.Documents patient problems and nursing care needs of the patient and family/significant others.

7.Actively involves patient and family/significant others in planning patient's care.

8.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.

9.Initiates discharge planning upon admission.

IMPLEMENTATION:

10. Performs common nursing procedures as defined in Policy and Procedure Manual.

11. Implements changes in physicians' orders in a timely manner.

12. Explains treatments and procedures to patient and family/significant others.

13. Provides patient and family teaching.

14. Provides for the safety, cleanliness and comfort of the patient.

15. Initiates emergency procedures as needed within the scope of practice and hospital policy.

EVALUATION:

16. Evaluates the patient's response to nursing care.

17. Updates and revises care to be delivered as patients' needs change.

18. Appropriately communicates changes and care given to other members of the health care team