POSITION SUMMARY The Registered Professional Nurse is responsible and accountable for prescribing, delegating and coordinating all nursing care. This is done by utilizing standards of care and standards of practice. Comprehensive mental health nursing care focuses on helping the substance abuser and psychiatric patient achieve their optimum health potential. This is best achieved within the framework of the nursing process. The activities are carried out in collaboration with other members of the health care team in response to patient and family needs. The Registered Professional Nurse is responsible and renders service to acutely ill adult psychiatric/substance abuse patients ranging from 16 years old and older. DUTIES AND RESPONSIBILITIES In accordance with professional nursing standards and practice, the mental health nurse will provide optimum health care to the substance abuser, emotionally disturbed patient and patients with a dual diagnosis by assisting them in attaining the highest level of wellness of which they are capable. The mental health nurse provides care of the patient using the nursing process. The mental health nurse assumes a leadership role in prioritizing assignments based on patient activity, complexity, resources available, staffing and skills mix. NURSING PROCESS-Assessment Assesses patient s physical, social and psychological status through direct observation, interview of the patient and the medical, physical and mental assessment. Utilizes observational skills to assess patients and family needs. Documents a complete nursing assessment to include fall, pain, suicide and nutrition, psychosocial, environmental factors, educational level and needs and discharge planning factors. Obtains and review available data base and any data collected by other members of the health team. Identifies nursing care problems resulting from substance abuse or prolonged use of neuroleptics, mental illness. Re-assesses continuously to improve patient care. Communicates findings with other members of the health team. Summarizes and documents all findings clearly and concisely. Nursing Diagnosis Formulates, prioritizes and document nursing diagnosis consistent with the assessment data. Includes physiological, psychosocial, emotional and educational needs of the patients. Planning Formulates and documents patient centered, measurable goals consistent with the nursing diagnosis. Documents the written plan of care reflecting knowledge of physiological, psychological, and emotional aspect of care for patients. Identifies patient level of education, learning needs and discharge planning needs on the day of admission.
Intervention/Implementation Communicates and collaborates with the interdisciplinary team in implementing comprehensive plan of care in response to patient needs. Utilizes clinical skills in the provision of nursing care and management of patient including but not limited to: o Identification of withdrawal symptoms o Management of the agitated patient o Administration of medications o Management of the dependent / suicidal patient. Intervenes appropriately in psychiatric emergencies utilizing the non-violent crisis interventions. Maintains all levels of Infection Control Standards. Provides for psychosocial and educational needs of the patients. Provides health teaching /counseling sessions on an individual basis and in a group setting on the unit. Provides health teaching counseling sessions on an individual basis and in a group setting on the unit. Participates in treatment plan, medical rounds, interdisciplinary rounds and clinical assessment as scheduled. Ensures that all procedures are performed based on established nursing mental health standards. Demonstrates competency in performing all procedures within scope of practice. Investigate, resolve, communicates, and documents all required information regarding unusual occurrences. Delegates, guides, and assists ancillary nursing personnel in tasks appropriate to their role. May have unsupervised patient contact while performing their duties. Performs other duties as required. Evaluation Interprets, communicates, and documents the patient s response based on the nursing and medical regimen. Revises the patient s plan of care based on evaluation of the interventions and expected outcomes in collaboration with other members of the health care team. Evaluates the patient s/significant other response to patient/discharge teaching.