NURSING ADMISSION ASSESSMENT
- Perform comprehensive nursing assessment on admission patients within 30 Minutes with consideration to clinical condition, pain, activities of daily living, allergies, integrity, valuables, safety needs, age, mental, social and physical status etc.
- Identify patient problems based upon data collected through nursing assessment as well as information obtained through the family. Take measures to address any vital concerns compromising the haemodynamic stability and safety issues.
- Follow all aspects of the hospital policy in terms of safety, personal belongings, medico – legal entity and medications.
- Assess vital signs, important information and report abnormalities to the doctor and carry out orders as per instructions.
- Document the nursing assessment and patient problems using appropriate clinical terminology.
- Assess and communicate to the concerned about educational, spiritual, pain management, dietary and special needs.
- Involve the family members in decision making andfuture plan of patient care by effective communication and education.
PLAN OF CARE
- Formulate nursing care plan in context to patient needs, safety, PFE, diet and other needs in each shift considering the age, behavior and concerns identified through nursing assessment.
- Ensure that care is provided with a comprehensive approach always ensuring safety and nursing clinical outcome.
- Establish priority for nursing needs based on nursing assessment, problems identified and estimated length of stay.
- Active participation in the development of interdisciplinary plan of care as per policy.
- Ensure timely and continuity of care with adequate communication.
- Ensure accurate documentation.
PROVISION OF NURSING CARE
- Practice within the general policies, philosophy and objectives of the department of nursing and the hospital with focus on safety, quality and infection control
- Provide nursing care in a therapeutically efficient manner by adapting current practices demonstrating social, clinical and professional judgment and competency.
- Participate in the implementation of the treatment plan utilizing intervention appropriate to the needs of the patient.
- Demonstrate knowledge and skills related to treatment, procedures, precautions, seclusions and restraints .
- Provide supportive counseling of patient and family for current patient concerns.
- Assess unit milieu and maintains a safe, therapeutic environment for patients, family members and staff.
- Assess and meet daily living needs of patients in dressing, bathing, grooming, toileting, eating and sleeping.
- Identify all vulnerable patients and ensure that the safety measures are followed at all time.