HOSPICE RN CASE MANAGER Full-Time

Mô tả công việc

The full-time registered nurse plans, organizes and directs the care of the terminally ill patient by promoting patient comfort and optimizing quality of life. This professional nurse builds from the resources of the community to plan and direct these services to meet the needs of the terminally ill individual and their families within the patient's home and their community. Patient Care Completes the initial assessment of the patient and family to determine hospice needs. Provides complete physical assessment focused on disease progression and decline including history of current and previous illness(es), pain assessment, safety assessment, wound assessment as applicable. Performs the admission process to include: signed legal forms, verbal physician certification for hospice service, completed IPOC, completed narrative note of admission process, medication entry to computer, completed appropriate clinical summary, copied patient records to support hospice appropriateness, and copied Advanced Directives. Provides professional nursing care by using the Nursing Process. Initiates the POC based on the patient and family/caregiver needs reflecting assessment data obtained to determine the nursing diagnosis and establish goals for care incorporating palliative nursing actions. Includes both the patient and family/caregiver in the care planning process. Re-evaluates this POC regularly and revising as needed to reflect the patient and family/caregiver care needs. Initiates appropriate palliative nursing procedures. Makes recommendations for symptom management; administers medications and treatments as prescribed by the physician in the physician's plan of care. Counsels the patient and family/caregiver in meeting care needs of the terminally ill patient. Provides health care instructions to the patient and family/caregiver as appropriate per the assessment data and POC. Assists the patient with the activities of daily living and facilitates the patient's efforts toward self-sufficiency as consistent with the POC. Acts as Case Manager assigned by the Team Manager assuming the responsibility of coordinating the patient care for each assigned patient. Communication Completes, maintains and submits accurate and relevant clinical notes regarding patient condition and care given at the time the assessment is done or care given. Records pain/symptom assessments and management, changes/outcomes to pain/symptom management as appropriate. Communicates with the primary care physician regarding the patient's needs and reports changes in patient condition; obtains/receives physician orders as needed. Communicates with the facility staff or community health related persons to coordinate the plan of care for each assigned patient. Teaches the patient and family/caregiver care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician recognizing and using opportunities for health counseling with patient and family/caregiver. Works in concert with the hospice Interdisciplinary Group/Team members. Provides and maintains a safe environment for the patient. Assists the patient, family/caregiver and other team members in providing continuity of care. Works in cooperation with the patient and family/caregiver and the hospice Interdisciplinary Group/Team members to meet the emotional needs of the patient and family/caregiver. Attends the Interdisciplinary Group/Team meetings regularly.