Nurse - Surgical Wing

Assessment and Diagnosis

Collects and analyzes assessment data to determine diagnosis/issues:

Assesses comprehensive data including but not limited to physical, psychosocial, emotional, cognitive, and spiritual needs and interprets assessment information to derive the diagnosis or issues as defined by the patient's condition.

Uses evidence-based assessment techniques and instruments in collecting data and validates the diagnosis or issue with the patient, family, and healthcare team members as appropriate.

Prioritizes the data and information collected based on the patient's immediate condition or anticipated needs and identifies potential risks or barriers to the patient's health or safety.

Documents the data and information collected in compliance with established guidelines and reflective of the needs of the patient.

Planning and Outcomes Identification

Identifies expected outcomes and develops a plan that addresses health promotion, health restoration, and health maintenance to attain expected outcomes.