Performs a comprehensive assessment on all assigned patients as evidenced by completed documentation. Supports patient/family/spiritual/cultural needs when assessing the patient and family needs for teaching; identifies the patient's learning level and readiness, and documents education record. Communicates changes in patient’s condition promptly. Utilizes appropriate nursing diagnosis and data from the assessment to derive realistic outcomes and documents them as measurable goals on the plan of care; modifies care plan, if indicated, in order to identify realistic patient goals. Identifies and prioritizes patient needs and/or nursing diagnosis for patients and documents. Collaborates with patient, family, and other members of the health care team when planning patient care and documents accordingly. Assesses patients with regard to discharge planning and makes the appropriate referrals as necessary. Implements nursing interventions consistent with the established plan of care. Demonstrates safe medication administration. Assesses patients with regard to discharge planning and makes the appropriate referrals as necessary. Evaluates and documents the patient response to nursing interventions and alters the plan of care as necessary. Oversees and directs the work of patient care or support techs; maintains overall accountability for the care of assigned patients. Demonstrates effective interpersonal skills in leading and directing others; deals with conflict directly and appropriately. Demonstrates proficiency in the charge nurse/preceptor role when assigned; assumes responsibility for coordinating patient care for the entire unit. EOE Minorities/Women/Disabled/Veterans. VEVRAA Federal Contractor.
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