Role of Nursing Personnel
- Role of Registered Nurse (RN)
- On admission, complete a comprehensive assessment.
- Obtain patient’s health history by interviewing patient and/or caregiver.
- Perform physical examination using inspection, palpation, percussion, and auscultation as appropriate.
- Document findings from the health history and physical examination in the patient’s record.
- Organize patient data into functional health patterns, if appropriate.
- Develop and prioritize nursing diagnoses and collaborative problems for the patient.
- Throughout hospitalization, perform focused assessments based on patient’s history or clinical manifestations.
- Role of Licensed Practical/Vocational Nurse (LPN/LVN)
- Collect and document specific patient data as delegated by the RN (after the RN has developed the plan of care based on the admission assessment).
- Perform focused assessment based on patient’s history, clinical manifestations, or as instructed by the RN
- Role of Unlicensed Assistive Personnel (UAP)
- Take and record vital signs, including oxygen saturation.
- Report abnormal findings to RN.
- Measure and document patient’s height and weight, oral intake and output.
- Report patient’s subjective complaints to RN.
- Per agency policy, perform point-of-care testing (e.g., glucose) and report findings to RN.
