I.

JOB PURPOSE
The Neuroscience Nurse Practitioner works in collaboration with the physicians of the
Neuroscience program and other members of the professional health care team to provide
continuity of care from admission to discharge. The NNP participates in the diagnosis,
treatment and management of patients admitted to the Neuroscience service. The NNP is
responsible for coordinating the care of patients and includes making both independent
and collaborative decisions under the direct supervision of the physicians of the
Neuroscience program. Evidenced based practice and established clinical protocols are
used to guide practice and provide high quality patient care. The Nurse Practitioner is
responsible to the medical director and the chief nursing officer (CNO) and functions as
an integral part of the medical team.

II. MAJOR ACCOUNTABILITES/SPECIFIC JOB

COMPETENCIES
This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be
required to perform any Job, with related instruction given by their supervisor, subject to
reasonable accommodation.

a. Clinical Practice Functions:

i. Attend daily neuro rounds; participate in ongoing patient evaluation,
assessments and coordination of treatment plan. Review lab tests,
radiology studies and other pertinent data to determine interventions in
collaboration with the neuroscience physicians.

ii. Completion of medical records including, dictating history and physicals,

transfer and discharge summaries. Daily documentation of assessment
findings and interventions and treatments.

iii. Perform procedures such as central line and arterial line placement and
lumbar punctures. Perform minor procedures such as removal of
ventriculostomy drains, Licox probes, lumbar drains, both hemovac and
Jackson Pratt drains as specified by the Medical staff credentialing
Committee.

iv. Evaluate patients readiness for discharge or transfer. Discuss goals and
parameters with multidisciplinary team. Discuss and define discharge
and or transfer plan. Complete discharge exam, dictate discharge
summaries and implement identified follow-up consult or referrals.
 v. Provide detailed and updated information to patients and their families in
regards to clinical course and ongoing treatment plan.

vi. Establish individualized plan of care in regards to rehabilitation, facilitate

occupational, physical therapy and speech therapy.

b. Medical Knowledge
The Neuroscience Nurse Practitioners must demonstrate competency in
the management of inpatients with neurological disorders including those
who require emergency and intensive care.

i. Anatomy and Physiology

1. Correlate deficits or expected complications to site of injury.
2. Understand basic vascular anatomy
3. Understand basic brain structures.
4. Understand stroke syndromes
5. Understand stroke mimics
6. Define stroke types
7. Understand neuroplasticity and stroke recovery
ii. Perform initial triage
1. Communicate effectively with pre-hospital personnel
2. Establish ABCs
3. Differentiate between anterior and posterior circulation signs and
symptoms
4. Differentiate between hemorrhagic and ischemic signs and
symptoms.
5. Facilitate urgent diagnostics (e.g., telemedicine)
6. Perform baseline neuro assessment (e.g., NIHSS, physical
exam).
7. Understand implications of various stroke scores (i.e., NIHSS,
Hunt and Hess, GCS, ABCD 2, ICH, Fischer-Miller)
8. Take basic medical and symptom history
9. Establish nursing diagnosis and develop plan of care
10. Identify door to treatment times
11. Administer thrombolytics
a. Calculate dosing
b. Identify inclusion and exclusion criteria
c. Know delivery method
d. Provide post-administration care
e. Identify post-administration complications
f. Assess oxygenation
g. Assess hydration
h. Assess oral intake and swallow ability
i. Manage blood pressure
j. Manage blood glucose
k. Stabilize patients for transfer to appropriate level of care
l. Describe and facilitate advanced interventions for
ischemic strokes (i.e., mechanical embolectomy, intra-
arterial thrombolysis, hemicraniectomy).
 12. Describe and facilitate interventions for hemorrhagic strokes.
a. Correct coagulopathy
b. Understand need for ventriculostomy
c. Manage ICP
d. Understand surgical decompression
iii. Hyperacute Care
1. Perform initial triage
a. Communicate effectively with pre-hospital personnel.
b. Establish ABCs
c. Differentiate between anterior and posterior circulation
signs and symptoms
d. Differentiate between hemorrhagic and ischemic signs
and symptoms
2. Facilitate urgent diagnostics
3. Perform baseline neuro assessment (e.g., NIHSS, physical exam)
4. Understand implications of various stroke scores (i.e., NIHSS,
Hunt and Hess, GCS, ABCD 2, ICH, Fischer-Miller)
5. Take basic medical and symptom history
6. Establish nursing diagnosis and develop plan of care
7. Identify door to treatment times
8. Administer thrombolytics
a. Calculate dosing
b. Identify inclusion and exclusion criteria
c. Know delivery method
d. Provide post-administration care
e. Identify post-administration complications
9. Assess oxygenation
10. Assess hydration
11. Assess oral intake and swallow ability
12. Manage blood pressure
13. Manage blood glucose
14. Stabilize patients for transfer to appropriate level of care
15. Describe and facilitate advanced interventions for ischemic
strokes (i.e., mechanical embolectomy, intra-arterial
thrombolysis, hemicraniectomy)
16. Describe and facilitate interventions for hemorrhagic strokes.
a. Correct coagulopathy
b. Understand need for ventriculostomy. Manage ICP
c. Understand surgical decompression.
iv. Acute Care
1. Implement generalized stroke care
a. Perform proper health assessment to identify patient's
needs.
i. Identify and prioritize patient's needs
ii. Use proper neurological assessment techniques
(e.g., NIHSS, GCS, Cincinnati stroke scale).
iii. Conduct comprehensive assessment
iv. Correlate patient's history with signs and
symptoms
v. Prioritize patient's needs based on assessment
(e.g., seizure prophylaxis, communication
 abilities, mobility)
vi. Facilitate diagnostic tests according to stroke
guidelines (e.g., echo, swallow study, MRI,
Carotid studies, lab work)
vii. Monitor patient safety before, during, and after
procedures
b. Establish nursing diagnosis and develop plan of care
c. Collaborate with other healthcare teams to use holistic
approach in providing quality nursing care based on
patient's identified needs
i. Implement emergency nursing measures if
needed
ii. Monitor, report, and document:
1. Neuro assessments and vital signs
2. Cardiac rate and rhythm
3. Proper oxygenation and ventilation
4. Readiness for activity
5. Pain assessment and management
iii. Manage blood glucose.
iv. Manage body temperature
v. Provide safety measures:
1. Aspiration precautions
2. Fall precautions
3. Seizure precautions
4. Skin precautions
5. Infection prevention protocols
6. VTE prophylaxis
7. Stress ulcer prophylaxis
vi. Provide personal care measures:
1. Patient positioning (e.g.,
affectedextremities, splinting, turning)
2. Early mobilization
3. Range of motion
4. Elimination (i.e., bowel and bladder
management)
vii. Provide a therapeutic environment
1. Establish appropriate levels of
stimulation
2. Orient to time, place, and person.
3. Establish alternative means of
communication if necessary
4. Adapt environment according to
patient's deficit
5. Promote sleep hygiene
viii. Provide spiritual and psychosocial care
1. Encourage verbalization of feelings
2. Identify positive coping mechanisms.
3. Respect patient's culture
4. Assess patient's healthcare beliefs
5. Facilitate patient's spiritual needs
6. Assess and manage depression, anxiety,
 and fatigue
ix. Facilitate care goals and decision making
1. Palliative care
2. Organ donation
x. Provide individualized education:
1. Patient
2. Family
xi. Assess patient's capabilities to perform ADLs
and provide alternative means if necessary
xii. Manage nutrition (i.e., specialty diets,
consistency of diet, alternate forms of feeding)
v. Implement care specific to ischemic stroke
1. Manage blood pressure:
a. Permissive hypertension
b. Orthostatic hypotension
2. Manage and assess patient post-thrombolytic administration:
a. Frequency of monitoring
b. Angioedema
c. Hemorrhagic conversion
d. Other bleeding
3. Manage patient post-interventional procedures and assess for
complications:
a. Site and distal extremity assessment
b. Arterial sheath management
c. Hematoma
d. Arterial dissection
e. Arterial thrombosis
f. Pseudo-aneurysms
4. Recognize signs of reperfusion syndrome
5. Manage hydration (e.g., euvolemia)
a. Select proper IV solutions
b. Monitor oral fluid intake
6. Understand treatment options
a. Carotid endarterectomy
b. Carotid stenting
c. PFO management
d. Atrial fibrillation management
e. Medical management
vi. Implement care specific to hemorrhagic stroke
1. Monitor and maintain blood pressure within identified
parameters:
a. Aneurysmal subarachnoid pre- and posttreatment
b. Arterio-venous malformation rupture
c. Intracerebral hemorrhage
d. Intraventricular hemorrhage
2. Understand treatment options:
a. Coiling
b. Embolization
c. Clipping
d. Radiosurgery
e. Craniotomy and craniectomy
 f. Intraventricular thrombolysis
g. CSF diversion
i. Ventriculostomy
ii. Shunt
iii. Medical management
h. Monitor and prevent increased ICP
i. Monitor and mitigate vasospasm
i. Transcranial Doppler
ii. Endovascular management
j. Manage fluid and electrolyte balance (e.g., sodium,
magnesium, osmolarity).
3. Identify associated stroke disorders
a. Transient ischemic attack
b. Cerebral venous thrombosis
c. Dissection
i. Carotid
ii. Vertebral
d. Moya Moya disease
e. Hypercoaguable states
f. Vasculitis
g. Arterio-venous fistula
h. Cavernous angioma
i. Intracranial and extracranial stenosis
j. Dural arterio-venous fistula
vii. Post-acute Care
1. Understand roles within the multidisciplinary team
2. Understand levels of rehabilitative care (e.g., acute rehab,
subacute rehab, home health, outpatient rehab)
3. Establish nursing diagnoses and develop plan of care
4. Coordinate early rehabilitation and discharge planning
a. Assist patient toward maximum functional capacity
b. Involve patient's family and significant others in
decision making and care plan
c. Initiate rehabilitation upon admission
d. Assist patient in performing ADLs along with other
healthcare team members
e. Encourage adherence to medications
f. Demonstrate transfer techniques and assistive devices
g. Provide options for adherence to outpatient follow-up
h. Assess caregiver dynamics
i. Utilize appropriate assessment scales (e.g., modified
Rankin, Barthel, Rancho Los Amigos)
j. Assess psychosocial impact of stroke
5. Assist in sustaining and maintaining patient's healthy, productive
lifestyle
a. Provide guidelines for home care
b. Establish goals and provide discharge plan
i. Activity and exercise
ii. Medication regimen
iii. Symptoms needing referral
iv. Nutrition
 v. Medical follow-up
vi. Sexual function
c. Facilitate referrals to resources and community support
groups
d. Involve patient in activities that will enhance self-
esteem
e. Guide patient in adaptation to lifestyle changes based on
identified risk factors
f. Understand specialized rehab treatments
viii. Systems and Quality Care
1. Understand rationale for use of the following
a. Protocols or pathways
b. Stroke units
c. Acute stroke team
d. Chain of survival
e. Apply quality improvement techniques to improve
stroke outcomes
f. Understand criteria for stroke center certification
ix. Preventive Care
1. Provide individualized preventive care through health education
a. Provide information about stroke, risk factors, lifestyle
changes, and regular medical exams
b. Identify learning needs
c. Use appropriate teaching materials
d. Understand the role of the nurse in health education for
stroke prevention
e. Provide education on the recognition of stroke
symptoms and immediate access to care
f. Establish goals for medication management
2. Identify patients with risk factors
a. Assess modifiable and non-modifiable risk factors
b. Identify individuals and populations who are at risk for
developing stroke
c. Refer patients identified as high risk for stroke to a
medical provider
3. Establish nursing diagnosis and develop plan of care
4. Individualize care and education
a. Identify patients' limitations to care treatments
b. Assess patients' financial and social resources
c. Refer to multidisciplinary teams
5. Participate in community health education regarding lifestyle
changes
a. Identify, promote, and participate in health education
regarding lifestyle changes (e.g., diet, exercise, tobacco
cessation)
b. Identify resources in community that have programs for
lifestyle changes related to stroke prevention
c. Refer patients to appropriate community or healthcare
agency regarding lifestyle changes.
III. Coordination and Collaboration Functions:
a. Provide patient care management across the health care continuum from
preventative to acute care through post-discharge as needed.

b. Collaborate with the multidisciplinary team regarding all aspects of the care of
the neuroscience patients.

c. Facilitate Physician consultations when necessary and implement their

recommendations after discussion with the team.

d. Communicate with nursing staff the plan of care and implementation of plan.
Provide feedback to staff.

e. Arrange for transfer outside facility including hospitals, rehabilitation facilities,

and skilled nursing facilities in collaboration with the case manager.

f. Assist with development and implementation of clinical practice guidelines.

IV. Patient Education Functions:

a. Provide information to patients and families about procedures, surgery, diagnosis,

prognosis and expected hospital course. Provide ongoing discussions and updates
about patients current condition during hospital stay. Arrange for family
meetings when necessary.

b. Promote patient and family self-care through education and support. Counsel
patients and families and encourage optimal physical, social and psychological
adjustment. Act as a patient advocate, counselor and supporter.

c. Provide supportive interventions and referrals to families of hospitalized

neuroscience patients when appropriate.

d. Provide individualized preventive care through health education

i. Provide information about stroke, risk factors, lifestyle changes, and

regular medical exams

ii. Identify patients' limitations to care treatments

iii. Assess patients' financial and social resources.

iv. Identify learning needs

v. Use appropriate teaching materials

 vi. Understand the role of the nurse in health education for stroke prevention

vii. Provide education on the recognition of stroke symptoms and immediate

access to care

e. Establish goals for medication management

i. Identify patients with risk

ii. Assess modifiable and non-modifiable risk factors

iii. Identify individuals and populations who are at risk for developing stroke

iv. Refer patients identified as high risk for stroke to a medical provider.

v. Participate in community health education regarding lifestyle changes

vi. Identify, promote, and participate in health education regarding lifestyle

changes (e.g., diet, exercise, tobacco cessation).

vii. Refer patients to appropriate community or healthcare agency regarding

lifestyle changes

V. Research Functions:
a. Promote scientific inquiry in clinical practice, using the research process to
improve practice.

b. Evaluate published research for application into clinical practice. Disseminates

information about recent innovations and research findings relevant to nursing
practice and patient outcomes to other health care team members.

c. Assist nursing staff in the interpretation and application of research findings to

clinical practice.

VI. Education Functions

a. Maintains professional competence by attending conferences and educational
seminars. Shares information from conferences with other members of
professional healthcare staff.

b. Facilitates the education and professional development of nurses and other

patient care practitioners.

c. Participates in the education of patients, families and other members of

healthcare team.
 d. Participates in the clinical orientation of new APP to the neuroscience program.

e. Facilitates clinical experiences and participates in the mentorship and

preceptorship of APP students as appropriate.

VII. System-based Practice:

Neuroscience Nurse Practitioners must demonstrate an awareness of and responsiveness to
the larger context and system of health care, as well as the ability to call effectively on other
resources in the system to provide optimal health care. They are expected to:

a. Work effectively in various health care delivery settings and systems relevant to their
clinical specialty
b. Coordinate patient care within the health care system relevant to their clinical specialty
c. Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or
population-based care as appropriate
d. Advocate for quality patient care and optimal patient care systems
e. Work in inter-professional teams to enhance patient safety and improve patient care
quality.

f. Act as interdepartmental liaison by demonstrating collaborative working

relationships with other professionals and working as a change agent.

g. Demonstrates effective time management to promote productivity and cost

efficiency.

h. Works collaboratively between departments to provide continuity of care.

VIII. Professionalism
a. Nurse Practitioners shall demonstrate responsibility for their patients' care, including:
i. Responding to communication from patients and health professionals in a
timely manner
ii. Establishing and communicating back-up arrangements, including how to seek
emergent and urgent care when necessary
iii. Using medical records for appropriate documentation of the course of illness
and its treatment
iv. Providing coverage if unavailable, e.g. when out of town or on vacation
v. Coordinating care with other members of the medical and/or multidisciplinary
team
vi. Providing for continuity of care, including appropriate consultation, transfer, or
referral if necessary
b. Nurse Practitioners shall demonstrate ethical behavior, integrity, honesty, compassion,
and confidentiality in the delivery of care, including matters of informed consent/assent,
professional conduct, and conflict of interest
c. Nurse Practitioners shall demonstrate respect for patients and their families, and their
colleagues as persons, including their ages, cultures, disabilities, ethnicities, genders,
socioeconomic backgrounds, religious beliefs, political leanings, and sexual orientations
 d. Nurse Practitioners shall demonstrate understanding of and sensitivity to end of life care
and issues regarding provision of care and clinical competence. E. Nurse Practitioners
shall review their professional conduct and remediate when appropriate. F. Nurse
Practitioners shall participate in the review of the professional conduct of their
colleagues.
IX. Interpersonal and Communication Skills
Nurse practitioners must demonstrate interpersonal and communication skills that result in the
effective exchange of information and collaboration with patients, their families, and health
professionals. Nurse practitioner are expected to:

a. Communicate effectively with patients, families, and the public, as appropriate,

across a broad range of socioeconomic and cultural backgrounds
b. Communicate effectively with physicians, other health professionals, and health
related agencies
c. Work effectively as a member or leader of a health care team or other
professional group
d. Act in a consultative role to other physicians and health professionals
e. Maintain comprehensive, timely, and legible medical records