Summary:
Responsible for provision of nursing care activities and coordinates care planning with other disciplines, utilizing the nursing process to provide quality nursing care in adherence to policies and procedures of CARE Hospitals, MOH regulations and accreditation standards.
- Ensures through his actions, either directly or indirectly, that a superior quality of medical treatment, compassion and understanding is given to every patient served at the CARE Hospitals and Clinics.
- Performs other applicable tasks and duties assigned within the realm of his/her knowledge, skills and abilities.
- Ensures Clear understanding of unit specific nursing staffing plan, patient acuity-based assignment systems nursing allocation list, unit scope of service and standards of practice in order to appropriately carry out patient care responsibilities during the assigned shift.
- Ensures through his actions, either directly or indirectly, that a superior quality of medical treatment, compassion and understanding is given to every patient served at the CARE Hospitals and Clinics.
- Performs other applicable tasks and duties assigned within the realm of his/her knowledge, skills and abilities.
- Ensures availability to report for duty as scheduled and to accomplish all patients care assignments and delegated work assignments given by the charge nurse or head nurse in the unit within the duty, including but not limited to:
- Medication preparation, supply management, crash cart checking, and equipment, etc.
- Ensures readiness to float to other units based on the unit's Cross-trained List.
- Receives shift endorsements from outgoing nursing staff and gives endorsement to the incoming shift nursing staff.
- Attends the unit general endorsement and patient bedside endorsement.
- Ensures awareness of the active list of all patient.
- Receives patient assignments and unit work assignment as delegated.
- Ensures awareness about special documents, any special procedures, or any other instructions especially for the assigned patient.
- Follows the Nursing Standards of Practice and Nursing Process (assessment, diagnosis, planning, implementation, and evaluation) as a framework in providing quality nursing care and documenting patient care.
- Performs nursing assessment comprehensive data pertinent to patient's health and situation to collect which is not limited to the following:
- Assess & recorded patient vital signs (temperature, pulse, respiration, blood pressure, oxygen saturation, Pain utilizing the appropriate Pain Scale).
- Performs physical assessment.
- Assessing for patient's risk for fall Scale, pressure ulcer, Venous Thromboembolism (VTE), others.
- Records Height & weight measurement
- Reviews diagnostic results indicating patient's medical/surgical conditions.
- Involves the patient and family in the care management
- Ensures that the delivery of care to assigned patients is being carried out independently and dependently.
- Ensures awareness of the patient care management plan to guide in administering daily care to the patients.
- Facilitates patient's admissions, referrals/ consultation, treatment procedures, transfer and/or discharge in accordance with inpatient protocols.
- Make rounds with the doctors as necessary.
- Provides and care for patients in arterial and intravenous therapy.
- Initiate and responds effectively in emergency situations and unexpected circumstances, in accordance with BLS guidelines
- Ensures patient care activities are within established hospital, departmental and unit specific guidelines, policies and procedures, standards and protocols.
- Ensures that doctor's order been carried out accordingly.
- Initiates emergency resuscitative measures as required
- Assists with medical/surgical emergencies of any patients with change of conditions by coordinating with other disciplines.
- Administration of medications, blood & blood products, feedings, as ordered by the attending physician.
- Performs and assist in unit invasive procedures as needed.
- Ensures standard precautions and prevention activities for patients at risks for fall, pressure ulcer, infection.
- Ensure the limitation and responsibility to be carried out as stated in the specific competencies.
- Ensures that nursing care services provided to the patients are documented.
- Ensure that nursing notes are informative and descriptive of the nursing care being provided and reflect the patients significant response to the care.
- Evaluates and reassess the patient based on the hospital policy (routine or according to doctor's order).
- Makes regular patient rounds to determine if their nursing needs are being met.
- Evaluates patient outcome after any medication and/or treatment regimen rendered.
- Maintains effective and therapeutic communication to ensure continuity of care and maintain a good working relationship with all the members of the healthcare team.
- Reports any significant change in the condition of patients to the Charge Nursephysician immediately.
- Reports abnormal POCT (Point of Care Testing) results and promptly takes immediate corrective actions as directed by the physician.
- Communicates and extends any needed assistance to unit staff when providing patient nursing care services to patients and families
- Monitors and guides the non-nursing staff (porters, cleaners, etc.) for their provision of work services assistance in the unit and ensuring patient and environmental safety as well as their own safety.
- Communicates and provides for the patient's and family's needs, including necessary education related to nursing care management.
- Assists the Head Nurse/Charge Nurse and ensures the maintenance of the approved floor stock level of medications, medical equipment and supplies, linens to adequately meet the needs of the patient during each shift.
- Ensures optimum utilization of resources within the unit and follow established safety regulations in the use of medications (emergency, narcotics, controlled drugs, high alert), equipment and supplies.
- Accountable each shift for the inventory and endorse any medication floor stock level or unit dose stock for the assigned patients.
- Ensures medical equipment operable functions and safety use.
- Aware of reporting system for any malfunctioned equipment and unavailability of supplies in the unit to be reported to Charge Nurse.
- Follows established infection control procedures.
- Aware of reporting system for any infection control concerns to be notified to the Charge Nurse, practice chain of command.
- When isolation precautions become necessary, follow guidelines accordingly.
- Practice and comply with standard precautions in managing patients.
- Follows established policies, procedures and programs to ensure patient safety as well as environmental safety.
- Ensures nursing service work areas and patient care rooms and treatment rooms are maintained in a clean, safe and sanitary manner.
- Implements and maintain a procedure for reporting hazardous conditions or equipment.
- Participates in fire safety and disaster preparedness drills in a safe and professional manner.
- Aware and is prepared for his/her roles and responsibilities during hospital codes
- Aware of the sentinel events and the reporting system based on hospital policies.
