Provides normalized, therapeutic and preventative nursing care to individuals in a given assignment at Woods Services within the scope of the Pennsylvania Practical Nurse Law and in accordance with licensing standards and Woods Services Policies and Procedures. Maintains communication with Campus Nurse and Nursing Management.
- Evaluates individual’s health status utilizing technical skills and knowledge on admission, when health needs indicate and on discharge. Performs more detailed assessments in conjunction with campus nurse as indicated.
- Requests back-up from campus nurse or another nursing staff when individual’s signs and symptoms indicate the need.
- Performs monthly nutritional evaluation of individuals by weight and knowledge of dietary habits.
- Assists physicians with rounds in unit and clinics as necessary.
- Attends psychotropic medication reviews and actively participates in the multi-disciplinary treatment process.
- Prepares and administers medications as ordered by Woods’ physicians in accordance with Woods’ Medication Procedures.
- Reports therapeutic effectiveness of medication with pertinent data and any observed side effects or relevant laboratory values to Woods’ physicians.
- Reviews monthly medication sheets and quarterly physician order sheets from pharmacy and makes corrections as necessary, communicating with pharmacy.
- Administers approved immunizations as required after demonstrating adequate skills, knowledge of procedures, and immunizations.
- Documents all relevant information according to Woods’ Medication Procedure Manual on MAR sheets, physicians’ orders and nurses’ notes.
- Assists individuals with the self-administration of medications goals as indicated by the SAM assessment and IHP goals
- Accurately administers and documents treatments as ordered by Woods’ physicians. .
- Instructs, supervises, and insures documentation of any treatments in which direct care staff or MTS staff may be involved.
- Documents evaluations in the medical chart and on all appropriate reports, forms, graphs, etc.
- Documents the health needs of specific individuals in residential logs on a daily basis, where applicable.
- Documents quarterly summary of health status including an update of all health issues and effectiveness of medications.
- Documents weekly on “Medical Profile DYFS” form for appropriate individuals.
- Prepares paperwork for annual physical examinations, GYN, neurological reviews, IHP’s consults on and off campus, and completes hospital and emergency room transfer sheets.
- Completes division of paperwork forms and is responsible for same.
- Relays pertinent health concerns requiring follow-up (i.e. seizures, elevated temperatures, unusual behavior, rashes) to the campus nurse as necessary and on a daily basis at the end of the shift.
- Coordinates appointments with Health Services for individuals.
- Participates in Interdisciplinary Team process, as necessary, functioning as an integral member of the team. Documents monthly progress on identified goals.
- Coordinates lab work.
- Notifies family/guardians/agencies/Residential Manager/Day Program Manager of health issues as necessary. Contacts families/guardians/agencies for non-routine testing, consultations after clarifying insurance/funding.
- Participates in continuing education relevant to the area of nursing. Obtains minimum of 40 hour inservice training per year. Obtains CPR certification yearly, First Aid certification every three years, and other mandatory inservices.
- Conducts inservices as a resource person regarding health issues for other staff persons.
- Provides health teaching to individuals as necessary.
- Attends nurses’ meetings/inservices and serves on committees when requested.
- Covers units other than scheduled assignment when necessary for campus wide coverage. Rotates coverage of school programs. Carries beeper/radio for school and back-up coverage.
- Assists with emergencies.
- Maintains medical equipment in units, assesses functioning of emergency equipment monthly and after use, and reports any malfunctioning equipment immediately.
- Assists in orientation of new nursing employees.
- Performs other duties as assigned.