• | The Registered Nurse systematically and continuously collects and assesses data in collaboration with the multidisciplinary team to provide therapeutic care for the patient and family. |
• | Establishes an in-depth database by assessing the behavioral and physiologic status of the patient utilizing interview, observation, physical examination, and other available data. |
• | Integrates nursing interventions into the multidisciplinary plan of care, incorporating appropriate standards of care and practice and patient outcomes. |
• | Incorporates discharge/home care planning into the multidisciplinary plan of care on an ongoing basis. |
• | Implements safe, competent, and efficient patient care within policies, procedures and standards, and interventions as noted on the multidisciplinary plan of care. |
• | Sets priorities adapting to changing patient and unit/clinic situations. Initiates action to reduce or correct risk in response to data indicating urgent and/or emergent risk to the patient. |
• | Documents the nursing process to reflect a comprehensive and integrated approach to patient care. |
• | Evaluates patient’s responses to care based on effectiveness of nursing interventions/actions in relationship to established outcomes and consults with medical staff, Care Team Leader, Case Manager, and/or Nurse Practitioner regarding clinical variances and recommended changes to the plan of care. |
• | Identifies learning needs of patients/families and teaches by adapting standard information to provide individualized and comprehensive teaching-learning. |
• | Performs systematic nursing assessment, recognizes abnormalities, and integrates findings into the plan of care. Critical elements include telephone triage, physical examination, assessment of readiness to learn, psychosocial assessment, functional assessment, and (depending on setting) utilization of specific assessment scales including the Braden scale, pain and functional assessment, and developmental level scales. |
• | Possesses knowledge of the principles of growth and development for the appropriate age group(s). Establishes each patient’s nursing care requirements relative to his/her age specific needs. |
• | Initiates the multidisciplinary plan of care by establishing individualized, measurable patient goals and outcomes in consultation with the patient, family and health care team and in collaboration with the Case Manager or multidisciplinary care team initiates. |
• | Interprets overt and subtle data to determine physiologic or psychosocial risk. |
• | Establishes goals and strategies for meeting discharge and/or continuing care needs of patient, family, and/or other care provider based on admission and ongoing assessment. Involves the patient and family in planning. |
• | Teaches patient, family, and/or other care provider critical knowledge and skill necessary to accomplish self-care regimens and manage decision-making of continuing care needs. |
• | Ensures that patient and family demonstrate knowledge of health status, treatments, skills, medications, and adaptive behaviors gained as a result of teaching interventions. |
• | Ensures patient and family/caregiver understanding of safety, functional, self-care, and home maintenance measures gained as a result of discharge planning interventions. |
• | Documents information which leads to insights or the solutions of usual patient problems, the response to, and the outcome of care provided. Documents in accordance with UW Health polices and procedures. |
• | Safely and competently executes technical skills required for practice. |
• | The Registered Nurse considers factors related to safety, effectiveness, and cost in planning and delivering care. They demonstrate knowledge of the UW Health care delivery system as multidisciplinary and multifaceted with a variety of entry and access points along the care continuum. |
• | Contributes to and supports the effective management of the unit/clinic. |
• | Incorporates standards of practice, clinical practice protocols, etc. into practice in order to maximize clinical effectiveness. |
• | Acts to facilitate cost control in use of material and human resources. |
• | Effectively utilizes technology to support practice and efficiencies in care delivery. |
• | Implements practice protocols competently and consistently dependent on practice setting such as sitter decision-tree, support surface decision protocol, etc. |
• | Plans interventions and evaluates patient response based on expected outcomes identified on the critical pathway or multidisciplinary plan of care in order to facilitate transition to home or continuing care and ensure a timely discharge. |
• | Is alert to duplication of patient care services and questions need. |
• | Identifies opportunities and participates in evaluations designed to measure the impact of new products and technology on patient outcomes or enhancements to the care delivery process. |
• | The Registered Nurse collaborates with the patient, significant others, and health care providers in providing patient care. The RN delegates and supervises care in accordance with nurse practice acts and the professional nursing role. |
• | Initiates multidisciplinary collaboration to positively impact the outcomes of health provided. |
• | Collaborates with Case Manager, Clinical Nurse Manager, and Care Team Leader in the provision of patient care. |
• | Initiates steps to support and enhance the patient’s responsibility and self-determination in decision-making concerning health, treatment, and well-being. |
• | Involves the individual patient/family in identification of requirements/perceptions of learning needs and preparation to assume self-care on discharge. |
• | Participates in unit/clinic and/or departmental shared governance structure in order to improve care. |
• | All staff will be cross-trained to work through department. |
• | Develops a therapeutic relationship by establishing trust and enabling patient and/or family to verbalize requirements for help comfortably and clearly. |
• | Evaluates effectiveness of teaching interventions and patient/family level of understanding and adjusts teaching and plan of care accordingly. |
• | Implements policy on Advanced Directives. |
• | Demonstrates effective delegation and supervision of other nursing team members. |
• | Participates as leader or active member of unit and/or department shared governance council. |
• | The Registered Nurse uses research findings in practice. |
• | Participates in organizational improvement activities. |
• | Identifies recurring clinical practice issues and contributes to the development of specific plans to address identified issues. |
• | Demonstrates knowledge of research findings related to clinical specialty. |
• | Incorporates changes in practice to reflect new advances and ensure effectiveness of interventions. |
• | Demonstrates knowledge of IOP activities relevant to specialty area. |
• | Utilizes unit/clinic, multidisciplinary committee, and departmental resources such as patient care teams and PRN and RISC nurses to improve quality and outcomes of care. |
• | The Registered Nurse acquires and maintains current knowledge in nursing practice and assumes responsibility of the professional development of self, other nursing staff, and students. |
• | Evaluates own performance and that of peers and other nursing staff in relation to standards. |
• | Demonstrates an awareness of elements in own performance needing further development and seeks opportunities to improve. |
• | Contributes to the learning experiences of students in cooperation with the instructor and other staff. |
• | Serves as a preceptor. Works directly with new employees to see that planned orientation to the unit/clinic is accomplished. |
• | Assists in orientation, instruction, direction, and evaluation of students assigned to the unit/clinic. |
• | Identifies and communicates educational needs. |
• | Shares knowledge gained through participation in continuing education activities. |