LPN (008443

Summary Description To deliver nursing care to patients requiring long-term acute care. Essential Functions and Responsibilities 1. Workunder direct supervision in accordance with the state-specific Nurse Practice Act, facility Policies and Procedures, and nursing judgment. 2. Delivernursing care to patients/residents requiring long-term or rehabilitative care. 3. Collectpatient/resident data, makeobservations and reportpertinent information related to the care of the patient/resident. 4. According to state-specific regulations, implementthe patient/resident plan of care and evaluatethe patient/resident response. 5. In accordance with state-specific regulations, directand supervisecare given by other nursing personnel in selected situations. 6. Maintainknowledge of necessary documentation requirements. 7. Maintainknowledge of equipment set-up, maintenance, and use, i.e., monitors, infusion devices, drain devices, etc. 8. Maintainconfidentiality and patient/resident rights, regarding all patient/resident/personnel information. 9. Providepatient/resident/family/caregiver education as directed. 10. Conductself in a professional manner in compliance with unit and facility policies. 11. Workrotating shifts, holidays and weekends as scheduled. 12. Initiateemergency support measures (i.e., CPR, protects patients/residents from injury). 13. Data Collection A. Admission and routine patient/resident observations/transfer notes are complete and accurately reflect the patient's/resident's status. B. Documentation of observations is complete and reflects knowledge of unit documentation policies and procedures. C. Nursing history is present in the medical record for all patients/residents. D. Changes in patient's/resident's physical/psychological condition (i.e., changes in lab data, vital signs, mental status), are reported appropriately. 14. Planning of Care: Contributions to the formulation/review of nursing care plans are made as appropriate, under the direct supervision or delegation of an RN. A. Pertinent nursing problems are identified B. Goals are stated. C. Appropriate nursing orders are recommended. 15. Evaluation of Care A. Observations related to the effectiveness of nursing interventions, medications, etc. are reported as appropriate and documented in the progress notes. B. Care Plans: C. Evaluation of care plan is noted monthly or as indicated. D. Contributions to care plan revision are made as indicated by the patient's/resident's status. 16. General Patient/Resident Care A. Patient/Resident is approached in a kind, gentle and friendly manner. Respect for the patient's/resident's dignity and privacy is consistently provided. B. Interventions are performed in a timely manner. Explanations for delays in answers/ responses are provided. C. Independence by the patient/resident in activities of daily living is encouraged to the fullest extent possible. D. Treatments are completed as indicated. E. Safety concerns are identified and appropriate actions are taken to maintain and assure patient safety including but not limited to: 1. Side-rails and height of bed are adjusted. 2. Patient/Resident call light and equipment is within reach. 3. Restraints, when used, are maintained properly. 4. Rooms are neat and orderly. F. Patient/Resident identification bands and allergy bands (if applicable) are present. G. Functional assignments are completed. H. Emergency situations are recognized and appropriate action is instituted. I. All emergency equipment can be readily located and operated (emergency oxygen supply, drug box, fire extinguisher, etc.). 17. Patient/Resident Education/Discharge Planning A. Patient/Resident/Family teaching is conducted according to the nursing care plan. B. Explanations are given to the patient/resident prior to interventions. C. Discharge/death summaries are complete and accurate. D. Transfer forms are complete and accurate. E. Active participation in patie t/resident care management is evident. 18. Adherence to Facility Procedures A. Facility Policy and Procedure Manual or reference materials are utilized as needed. B. Procedures are performed according to method outlined in procedure manual. C. Body substance precautions and other appropriate infection control practices are utilized with all nursing interventions. D. Safety guidelines established by the facility (i.e., proper needle disposal) are followed. 19. Documentation A. The patient's/resident's full name and room number are present on all chart forms. Allergies are noted on chart cover. B. Only approved abbreviations are used C. Vital signs are properly and timely recorded D. IandO summaries are recorded and added correctly. E. Progress notes are timed, dated and signed with full signature and title. F. Unit flow sheets are completed properly (i.e., wound care records, treatment records, weight sheets, etc.). 20. Medication Administrations/Parenteral Therapy Record A. Adhereto state-specific Nurse Practice Act for administration of medication and parenteral therapy. B. Datesthat medications are started or discontinued are documented. C. Medications are charted correctly with name, dose, route, site, time, and initials of nurse administering. D. Pulse and blood pressure are obtained and recorded when appropriate. E. Medications not given are circled, reason noted and physician notified if applicable. F. Appropriate notes are written for medications not given and actions taken. G. Name and title of nurse administering medication are documented. H. Patient's/Resident's medication record is labeled with full name, room number, date, and allergies. I. The procedure for administration and counting of narcotics is followed. J. All parenteral fluids, including additives, are charted with time and date started, time infusion completed, site of infusion and signature of nurse. K. All parenteral fluids are administered according to the ordered infusion rate. L. Parenteral intake is accurately recorded on the unit flow sheet or IandO record. M. Appropriate actions are taken related to identified IV infusion problems (infiltration, phlebitis, poor infusion, etc.). N. IV sites are monitored and catheters changed according to unit policy. O. IV bags and tubings are changed according to unit policy. 21. Coordination of Care A. Tests are scheduled and preps are completed as indicated. B. Co-workers are informed of changes in patient/resident conditions or of any other changes occurring on the unit. C. Information is relayed to other members of the health care team (i.e., physicians, respiratory therapy, physical therapy, social services, etc.) and family/responsible party. D. Unit activities are coordinated (i.e., changing patients/residents rooms for admissions, coordinating transfer/discharge forms, etc.). 22. Leadership A. Equitable care assignments that are appropriate to patient/resident needs are made prior to the beginning of the shift. B. Staffing needs are communicated to the nursing supervisor. C. Assistance, direction, and education are provided to unit personnel and families. D. Problems are