Zoila Rodriguez

• Assess the patient’s condition and nursing needs; coordinate nursing care activities with other health disciplines involved in the treatment effort to relate and integrate the nursing regimen with the treatment plan for patients.
• Develop a written individualized care plan which includes teaching needs and discharge planning.
• Administer direct care when professional nursing skills and judgment are needed.
• Administer medication.
• Practice infection control and participate in the maintenance of a clean and safe environment.
• Assumes responsibility and accountability for the delivery of nursing care to all assigned patients. Communicates changes in patient’s condition and questions regarding patient care to Charge RN/Clinician.
• Develops and maintains current written plan of care for assigned patients. Sets priorities to meet the patient’s needs. Sets patient goals and priorities with the patient and/or family.
• Provides document evidence in the medical record of patient/family teaching and their responses and understanding of the teaching. Ensures that patient education and instructions are consistent with that of the physician or designee.
• Communicates and works effectively with other staff and other departments.
• Participates in unit or hospital-based quality assurance activities or committees to contribute to the advancement of the nursing profession at SBSH.

• Assisted with daily living activities to enhance patient comfort.
• Communicated effectively with family members about patient needs.
• Maintain accurate medical records and documentation for compliance.
• Gathered entire medical histories and information to update medical records.
• Rendered therapeutic nursing interventions for individualized plan of care following homecare guidelines.

· Monitors residents for any signs of change in condition, change in vital signs, weight loss, decline in ambulation, change in ADLs, development of skin breakdown, etc.

· Informs appropriate staff per facility protocol of the need for evaluation and reports staff on any changes in assessment when appropriate.

· Administers medications and treatments to residents which includes monitoring administration of intravenous fluids and placing orders for medication

· Communicates with residents and families on any issues relating to care and services.

· Make referrals and collaborate with other departments.

· Maintain accountability for controlled substances by reviewing inventory medications with another licensed nurse and notifying supervisors of any discrepancies.

· Supervise CNAs regarding work procedures and expediting workflow

· Document resident care by charting in electronic progress notes