Interviews patient and/or family to obtain data for nursing assessment, records and reports data;
Utilizes assessment data to formulate nursing diagnosis;
Applies knowledge of normal parameters; identifies deviation from normal, obvious patient problems, symptoms, and/or behavioral changes. Reports these to the appropriate authority;
Makes observations about physical, psycho-social, cultural, learning needs and response of patient and families; documents in a clear, concise manner.
Planning
Identifies patient care problems and establishes priorities for care based on nursing and medical diagnosis;
Understands goals and plans of care, for the usual patient population;
Initiates a patient care plan and collaborates when appropriate;
Contributes to the revision of the initial patient care plan dependent upon the changing needs of the patient;
Contributes to the development of unit standards of care;
Plans patient teaching activities.
Implementation
Establishes priorities and gives nursing care based on the patient care plan;
Implements the patient care plan;
Seeks supervision and guidance in further developing nursing skills, in performing procedures not yet mastered and/or in functioning in unfamiliar situations;
Accepts accountability for all nursing care provided;
Monitors compliance with safety standards and care protocols for self and others;
Records nursing care given and patient's response to care;
Assists in coordinating the activities needed to implement the patient care plan;
Participates in implementation of patient discharge plan;
Teaches patient and families;
Compiles with external and internal regulations pertaining to nursing practice; recognizes legal and ethical duties and responsibilities of registered nurses.
May participate in research projects.
Evaluation
Evaluates the patient's response to care provided;