Nursing Process/Plan of Care
• Provides total, comprehensive care to patients by applying the nursing process in an organized and systemic manner according to hospital policy.
• Communicates proactively to the health care team, plan of care, changes in patient condition, the patient progress, the discharge plan and other relevant information.
• Completes admission according to policy utilizing a multi-system approach for the assessment and reassessment.
• Documents assessment/reassessment, plan, interventions and outcomes according to policy and interprets and utilizes clinical data in the plan of care:
- Documents pain assessment and plan of care.
- Documents fall risk and plan of care
- Documents wound risk and plan of care.
- Documents suicide assessment and plan of care.
- Documents infection control assessment (MDRO protocols).
• Performs accurate and thorough nursing physical assessment and documents thoroughly.
• Reassesses patient condition per policy.
• Interprets & utilizes clinical data in the plan of care.
• Assesses patient for potential risk factors.
• Recognizes and integrates patient special needs and individualizes care.
• Includes pain management and supportive care issues in plan of care.
• Adheres to infection control standards specific to patient care.
• Assumes accountability for managing the delivery of patient care.
• Responsible for learning policies and nursing procedure and communicates to others.
• Performs accurate and thorough nursing physical assessment.
• Participates in discharge planning, using a multi-disciplinary approach. Participates in multidisciplinary rounds.
• Assists patient/family with grieving process and end of life cases as appropriate.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.