Position : LPN Long Term Care
Initiate observation of vital signs, orientation to room/smoking policy, (Long Term Care, Acute, and ER).
Observe each patient’s physical, psychosocial, and social status (LTC, Acute, and ER)
Integrate all information through completion of the initial patient observation document within 24 hours of
Observe each patient every 4 hours at a minimum or when there is a change in the patient’s condition and/or
diagnosis (Acute), after initial RN assessment.
Integrate information from various assessments of the patient in order to identify and assign his or her care
Independently perform a through physical observation on admission, to include (Acute, ER) per LPN
Document observation findings in the chart.
Take appropriate action on abnormal findings.
Assess allergies according to standard. Document in MAR, front of medical record, and on patient Kardex.
Apply red allergy bracelet, if applicable. Document appropriately in acute care chart and long term care
chart per documentation standards.
Assess patient/significant other’s educational needs. Assess patient/significant other’s Educational readiness,
barriers to learning, and preferred methods of learning.
Document the effectiveness of patient/significant
other education provided. Involve all of the necessary disciplines including physicians, in the education
Monitors patient condition, notes changes in status, utilizes judgment, and takes appropriate action.
Accurately measure vital signs.
Assist patient/resident in daily living, going to the bathroom, bathing, grooming, hair care, eye care, foot