Completes an assessment for each patient by performing a thorough mental, physical, nutritional and functional assessment on admission, and as needed, based upon patient's condition.
Assesses patient's psychosocial status, and patient/family learning needs and discharge criteria.
Assesses for pain, utilizes pain scale documents accordingly.
Utilizes appropriate observation level for patient: q15 minute checks, visual observation, and/or 1:1 or elopement precautions.
Completes plan of care formulates a nursing diagnosis based upon assessment findings. Reviews plan of care daily and modifies as patient's condition changes.
Organizes and directs care of patients, setting priorities and assigning most skilled staff to care for most acutely ill patients.
Provides/coordinates education of patients based on assessment of learning needs and readiness.
Provides care for patient's with: Depression/Suicidal impulses, Mania, Delusions/Hallucinations, Paranoia, Anxiety, Aggressive/Assaultive Behavior, Chemical Dependency Issues/Detox, Personality Disorders, i.e. Borderline/Sociopathic, Eating Disorders, Dissociate Identity Disorder/PTSD, Dementia/Alzheimer's, and medical problems such as hypertension, headache, diabetes, URI, UTI, heart disease, thyroid disorders, and acute or chronic infection.
Intervenes in managing complex patient care situations utilizing departmental policies and procedures that promote most facilitative alternatives. Prioritizes interventions in rapidly changing patient situations.
Assesses patient's response to interventions communicates these findings to other team members.
Sets priorities appropriately utilizing data from Nursing Assessment. Adapts procedures to individual patient needs while maintaining the integrity of the principles involved.
Documents education about medications, disease symptom identification, social skills, stress management, and impulse control regulation.