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Maintains professional decorum and communicates in English in the areas of work with colleagues.
Address to the grooming standards laid down by the department
Evaluates effectiveness of nursing care on patient condition
Inform Team leader/Supervisor of current activities on the unit and reports unusual occurrence, incidents or other problems and also follow up as needed
Utilizes changes of shift report to accurately and effectively to communicate patient condition and intervention
Ensure all documentation is clear concise and timely. Utilize appropriate clinical terminology
Performs independent problem solving and decision making in a logical and deliberate manner, utilizing available resources when needed
Exhibits flexibility and adaptability to meet the needs of the patient and the unit
Demonstrates understanding of emergency levels and effectively and safely responds to emergency situation in a calm constructive positive manner
Nursing Admission Assessment
Performs comprehensive nursing assessment on all patients with consideration to clinical condition, pain activities of daily living, skin allergies, integrity, valuables, safety needs, age ,mental, social and physical status.
Identifies patient problems based upon data collected through nursing assessment as well as integrated information obtained through the family. Takes measures to address any vital concerns compromising the hemodynamic stability and safety issues
Follows all aspects of the hospital policy in terms of safety, personal belongings, medico – legal entity, medications etc.
Assesses vital signs, important information and reports abnormalities to the consultant and team and carries out orders as per instructions.
Accurately and thoroughly documents nursing assessment and patient problems using appropriate clinical terminology.
Completes and documents ongoing assessment
Assesses and communicates educational, spiritual, pain management and dietary needs to the concerned
Involves, communicates and educates the family members in the future plan of care
Plan of Care
Formulates nursing care plan in context to care due, care given, safety first, PFE, diet and other needs in each shift noting patients needs, age, behaviour and concerns identified through nursing assessment.
Ensures that care is provided with a comprehensive approach always ensuring safety and clinical outcomes.
Establishes priorities for nursing needs based on nursing assessment, problems identified and estimated length of stay.
Actively participates in the development of interdisciplinary plan of care as per policy
Ensures unmet needs are handed over to the next shift accurately
Acts as liaison with the treatment team and other multidisciplinary staff ensuring accurate communications of relevant information
Ensures evidence through accurate documentation.
Provision of Nursing Care
Practices within the general policies, philosophy and objectives of the department of nursing and the hospital with focus on safety, quality, infection control and empathy.
Provides nursing care in a therapeutically efficient manner demonstrating social, clinical and professional judgment and competency.
Participates in the implementation of the treatment plan utilizing intervention appropriate to the needs of the patient. Demonstrates knowledge and skills related to special treatment, procedures, precautions, seclusions, restraints etc.
Provides supportive counselling of current patient concerns.
Assesses unit milieu and maintains a safe, therapeutic environment for patients, family members and staff.
Assesses and meets activities of daily living needs of patients in dressing, bathing, grooming, toileting, eating and sleeping.
Identifies all vulnerable patients and ensures that the safety first program is followed at all times
Demonstrates ability to recognize different types of incidents and responding mechanism for such issues.
Accurately and thoroughly documents nursing interventions.
Provides ongoing patient / family education according to individual needs, considers factors influencing learning and documents same in the patients medical record
Safely uses and maintains biomedical equipments.
Updates and keeps abreast of the HAI statistics and control measures and practices them in the working environment
Actively participates in discharge planning, education and care at home along with patient and the family.
Medication Management
Is knowledgeable about the medication process and ADR
Accurately transcribes medication and treatment orders for the indenting process
Recognizes improper or inadequate orders and reports these to supervisors and physician before proceeding
Checks and receives medication against the order during pharmacy delivery.
Accurately and safely administers prescribed medications and treatments using correct methods of administration and adheres to policy (6 R’s of medication, 2 identifiers, allergic history, double check for applicable medicines), admixtures , outside medication, self medication policy etc..)
Accurately maintains medications administration record
Monitors the patient post administration and reports any adverse events and accurately completes the ADR forms
Demonstrates safe storage and control of medication.
Evaluates and documents patient response to medication regimen Implements the waste management policy
Is knowledgeable of action, side effects proper dosage and contraindication of drugs being administered
Demonstrates knowledge of and documentation requirements for proper administration of medication to protesting patients.
Accurately identifies need to administer SOS medication and documents effect.
Immediately reports any medication error, ADRs and accurately completes incidents report or ADR forms.
Teaches medication management to patients as per discharge planning requirement
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