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  • Completes an initial assessment of patient and family to determine home care needs.
  • Utilizes nursing process to assess physiological, functional and safety status of each individual patient.
  • Initiates the plan of care and makes necessary revisions as patient status and needs change while coordinating care with all other disciplines and patient’s family.
  • Includes the patient and the family in the planning process while developing a care plan which establishes goals, based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions.
  • Demonstrates active listening while providing emotional and social support.
  • Provides health care instructions to the patient and family as appropriate per assessment and plan.
  • Assess risk for impaired skin integrity, educate on wound prevention, and provide appropriate wound care as prescribed by physician.
  • Initiates appropriate preventive and rehabilitative nursing procedures, as well as implementing treatments as prescribed by physician.
  • Regularly re-evaluates patient nursing needs such as medication management, safety management, and management of overall health regimen.
  • Initiates discharge planning and promotion of patient’s return to highest functional level.