Primary Nurse RN

Primary Nurse - RN

The Primary Nurse - RN is responsible for the general oversight, assessment, planning, and construction of the nursing care delivered to the participant. The primary nurse may delegate some direct care, data collection, and nursing assessment responsibilities to other nurses and nursing assistants on the team but retains responsibility for ensuring that interventions are carried out in accordance with the participant's care plan and the orders of the participant's medical providers. The RN is responsible for the delivery and documentation of quality patient care in accordance with departmental policies and procedures, and in collaboration with other members of the Interdisciplinary Team. ESP RNs may provide care in the PACE Day Health Center or in participant's homes.

• Assess health status and symptoms of ESP participants and record the related health data in the participant's electronic medical record a.) Collect health/symptom data from the participant and/or caregivers b.) Navigates the medical record
• Analyze and interpret recorded data, and make informed judgments as to the specific elements of nursing care mandated by a particular situation: a.) Correlate new data and symptoms with the existing medical records. b.) Determines indication for the appropriate response level utilizing consultation from the other team members within established guidelines.
• Plan and implement nursing intervention, including all appropriate elements of nurse care and prescribed medical or other therapeutic regimens mandated by an acute or chronic condition, other relevant conditions (such as care giver status, health wishes, etc) scientific principles, recent advancements and current knowledge in the field: a.) Review documentation to assure consistence with current planned regime. b.) Communicate with the patient's provider and other relevant members of the IDT c.) Educate the patient or HCP on test results and other findings, proposed changes to care plan, new treatment plans and/or other relevant health care information including the use of newly prescribed medications and/or changes in the current medication regime.
• Dispense medication by mouth, nebulizer, IM, IV, and SC as ordered by an MD/NP/PA/DO or per protocol.
• Provide and coordinate health teaching required by individuals, families and groups to maintain the optimal possible level of health: a.) Educate on health maintenance, current health status, and changes in health status.
• Evaluate outcomes of nursing interventions, and initiate change when appropriate: a.) Assess the reassess patients as needed. b.) Determine the need for and schedule nurse visits for ongoing nursing management. c.) During data collection and patient interviews, review the current plan of care to determine appropriateness and areas of weakness. Communicate status of plan of care with other members of the health care team.
• Collaborate, communicate and cooperate as appropriate with other IDT members to ensure quality and continuity of care: a.) Report to the other team members through documentation in the medical record a comprehensive integration of newly acquired information with the patient's history and related changes in the nurse's plan of care. b.) Report to other team members through morning meeting, primary care conference, and other ESP vehicles for communication about the needs of ESP participants
• Serve as a patient advocate, within the limits of the law: a.) Integrate the vital patient advocacy function into the nursing role in a continuous effort to encourage patient self-determination to the fullest degree possible through patient and family education and facilitation of a process whereby participants are encouraged to give voice to the concerns, questions, and preferences they may have regarding their care. b.) Utilize the information gathered in the role of advocate to inform other providers caring for the patient of special needs and concerns and ensure the appropriate systemic changes and care of plan modifications to the degree possible based on specific patient need.

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