Patient assessment: Obtains and documents nursing history from the patient and/or significant other that is comprehensive of present condition and prior problems. Performs basic assessment of the patient, indicating adequate knowledge of anatomy, physiology, and pathology. Records vital signs, notes changes, and pursues more-specific investigation as needed. Makes pertinent observation, using language that correctly describes body parts and functions, and draws logical conclusions which direct formation of nursing care plan. Identifies abnormal diagnostic data and shows a fundamental understanding of its implications by reporting information to the physician and others caring for the patient, and by incorporating information in the nursing care plan.
Nursing care plan: Uses assessment information to develop a care plan that communicates information for incoming personnel to adequately care for the patient. Reviews plans for assigned patients. Includes the patient and his or her family in planning care, establishing priorities, and setting goals.
Plan implementation: Uses care plans as a basis for providing safe and therapeutic care to patients. Consistently follows established standards, policies, and procedures in providing nursing care. Accepts accountability for clinical care of assigned patients, including supervision of nonprofessional personnel. Communicates with the patient and his or her family and other members of the health care team in carrying out the goals of the care plan. Indicates an understanding of the roles of other health-care team members in patient care and incorporates their input into the care plan. Performs competently those technical skills considered basic to the type of care given on that unit. Identifies patient teaching needs and provides instructions for the patient and his or her family on an education level that they can clearly understand. Notes discharge planning elements and incorporates these in care plans, demonstrating an awareness of community care available after discharge. Responds appropriately in urgent and/or emergency situations.
Evaluation: Evaluates and notes the individual patient's response to nursing care defined in the nursing care plan and medical records. Participates in the evaluation of nursing care given to groups of patients. Identifies strengths and weaknesses of nursing care systems.
Leadership: Supports standards of nursing care through adherence to existing policies and procedures. Supervises care given by nonprofessional personnel, providing instruction as needed. Accepts reassignment as needed to provide necessary care for all patients
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