Admitdischarge Powerpoint 1197589545369206 5

8/11/2019 Admitdischarge Powerpoint 1197589545369206 5

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ADM ISSIONS/DISCHARGE/TRANSFER



ADMISSION

(ENTERING A HEALTH CARE AGENCY FOR NURSINGCARE AND MEDICAL/SURGICAL TREATMENT)

INVOLVES: A. AUTHORIZATION FROM A PHYSICIAN

B. COLLECTION OF BILLING INFO FROM THE ADMITTING DEPARTMENT

C. COMPLETION OF THE ADMISSION PROCESS BYNURSING

D. DOCUMENTING PT’S MED HX & PHYSICAL EXAM

E. INITIAL MED ORDERS FOR TREATMENT



RESPONSIBI LI TIES OF THE ADMITTING DEPARTMENT

GATHER INFO FOR BILLING

INITIATE MEDICAL RECORD

PREPARE ID BRACELET. THIS IS

THE SINGLE MOST EFFECTIVEWAY OF IDENTIFYING THE

PATIENT

MAY BYPASS IN EMERGENCY

SITUATION

AN ADDRESSOGRAPH CARD IS

MADE

CONSENT FORMS ARE SIGNED,

EG. LIVING WILL, DIRECTIVES,

WAIVERS

INITIAL ORDERS OBTAINED

VERBAL REPORT GIVEN TO

FLOOR RNPATIENT IS ESCORTED



NURSING RESPONSIBI L I TES

PREPARE ROOM

IDENTIFY SELF

ORIENT PATIENT

GATHER INFO



PREPARE ROOM

PROVIDE PERSONALCARE ITEMS

SUCTION

OXYGEN

IV POLE

BED IN HIGH POSITIONIF ARRIVING BY

GUERNEY

BED IN LOW POSITIONIF ARRIVING BY W/C

BLUE PADS IF NEC.



I DENTIFY SELF

MAKES PT FEEL SECURE

MAKES PT FEEL WELCOME

ALLEVIATES ANXIETY/FEAR



ORIENT PATIENT

LOCATION OF NURSE’S

STATION

CLOTHES STORAGE

CALL LIGHT

BED CONTROLS

LIGHT SWITCHES

TELEPHONE POLICY

TV CONTROLSMEALTIMES

SAFETY MEASURES SUCH ASBEDRAILS

VISITING HOURS

WHAT TESTS ARESCHEDULED

DIET

ROOM BOUNDARIES

SCHEDULED SURGERY TIMETIMES FOR DR VISITS



GATHER INFORMATION

THE NURSE WILL GATHER INFO ABOUT:

MEDICAL ORDERS

TX’S

LABS

TESTS

DIET

ACTIVITY

PHYSICAL ASSESSMENT WITHIN 24HRS.



TYPES OF ADM ISSION

INPATIENT

OUTPATIENT



I NPATI ENT STAY

LONGER THAN 24HRS

PLANNED:NO IMMEDIATE THREATPLANNED ELECTIVE SURGERY, TESTSPT IS PREPAREDEMERGENCY:UNPLANNEDSTABILIZE IN EMERGENCY ROOM (CHEST PAIN, TRAUMA)DIRECT ADMISSION:UNPLANNEDBYPASS EMERGENCY (VOMITING, DIARRHEA)



VALUABLES

WHEN DOCUMENTING VALUABLES, MAKE

SURE TO USE WORDS LIKE:WHITE/YELLOW METAL NOT GOLDCLEAR STONE NOT DIAMONDS, RUBIES, ETC.HAVE A WITNESSHAVE NURSE & PT SIGN VALUABLES LISTDON’T FORGET DENTURES, GLASSES, ETC. WHEN TRANSFERRING PT, SIGN-OFF WITHNURSEKNOW YOUR FACILITY’S VALUABLES POLICY



PATIENT COMFORT

PROVIDE PRIVACY. (SHUT DOOR & PULL CURTAIN.)

ASSIST IF NEEDED TO REMOVE CLOTHING AND PUT

GOWN ON.PROVIDE EXTRA BLANKETS IF REQUESTED.

COLLECT INFO FOR DATABASE.

PERFORM INITIAL ADMISSION ASSESSMENT IF APPROPRIATE. (SOME FACILITIES REQUIRE AN RNTO DO INITIAL ASSESSMENTS).

OBTAIN PHYSICIAN ORDERS FOR TX’S, LABS,TESTS, MEDS, ACTIVITY, ETC. WITHIN 24HRS.



COMPONENTS OF A MEDICAL H ISTORY

•IDENTIFYING DATA

•CHIEF COMPLAINT

•PERSONAL HX

•PAST HEALTH HX

•HX OF PRESENT ILLNESS

•FAMILY HX

•REVIEW OF BODY SYSTEMS

•CONCLUSION



WHAT TO WATCH FOR IN NEWLY ADMI TTED PATIENTS

ANXIETY

LONELINESS

DECREASED PRIVACY

LOSS OF IDENTITY



ANXIETY

APPEARANCE

Exhibits Separation Anxiety.

Sad.Worried.

Restless.

Reduced Appetite.

Insomnia.

HOW TO HELP

Acknowledge feelings.

Provide explanations andinstructions beforeperforming procedures.

Inquire about stress due tochildren/pets/spouse at

home.Reassure. Separation Anxiety can cause the elderlyto be confused anddisoriented.



DECREASED PRIVACYPull curtain and closedoor.Knock.

Identify roomboundaries, esp. ifsharing room.Be careful of exposingpatient.

Patient feelsuncomfortable becauseof unkempt appearance,so announce visitors.



LOSS OF IDENTITY

Call patient by namethey prefer.

Allow patient towear own gown.

Display pictures.

Give them somechoices. (bathing,eating, etc.)



DISCHARGETERMINATION OF CARE FROM

A HEALTH CARE AGENCYMETHOD (ACRONYM)M-MEDS

E-ENVIRONMENTT-TREATMENTH-HEALTH TEACHINGO-OUTPATIENT REFERRALD-DIET AMA (Against Medical Advice)PT LEAVES PRIOR TO OBTAINING A

WRITTEN ORDER. NURSEREQUESTS PT TO SIGN FORM. IFREFUSES, NURSE MUST LET PTLEAVE AND NOTE REFUSAL TOSIGN AMA IN CHART.



NURSES RESPONSIBI LI TY FOR DISCHARGING A PATIENT

GATHER BELONGINGS/CHECK INVENTORY

ARRANGE TRANSPORTATION

INFORM PT OF CHECKOUT TIME TO AVOID BEINGBILLED FOR AN EXTRA DAY

ESCORT UNTIL PT SAFELY INSIDE VEHICLE

WRITE DISCHARGE SUMMARY

TERMINAL CLEANING. BED STRIPPED ANDDISINFECTANT USED. BEDSIDE CABINETRESTOCKED/CLEANED.



TRANSFERDISCHARGING A PATIENTFROM ONE UNIT OR AGENCY AND ADMITTINGTHEM TO ANOTHER UNIT

INFORMS PATIENT/FAMILYCOMPLETE TRANSFERSUMMARYSPEAKS WITH NURSE ONTRANSFER UNIT

TRANSPORTSPATIENT/BELONGINGS/SUPPLIES & CHARTCHECKS ORDERS/MAKESNEW ADDRESSOGRAPHCARD W/NEW ROOM #



WHO/WHAT IS INVOLVED IN A PLANNED DISCHARGE?

PHYSICIAN’S ORDER UNIT SECRETARY

CALLS FOR TRANSPORT,COPIES CHART/ORDERS

CARE PROVIDER RN OR SOCIAL WORKER

SAFEKEEPING EXTENDED CARE FACILITY

PATIENT NURSE-EXPLAINSDISCHARGE INSTRUCTIONSTO FAMILY/CARE GIVER



SETTING STANDARDS

*REMEMBER*

THE AMERICAN NURSE’S ASSOCIATION SETS

THE STANDARD FOR PT CARE &DOCUMENTATION FOR RN’S

LPN’S ARE GOVERNED BY JCAH

DO NOT USE “SEEMS” OR “APPEARS” IN

DOCUMENTATION. IMPLIES DOUBT ANDLACK OF KNOWLEDGE.STUDENTS DO NOT NEED TO READ P.126-129(EXTENDED CARE FACILITIES) BUT NEED TO READNURSING GUIDELINES ON TRANSFERRING A CLIENT, P. 126, GENERAL GERONTOLOGICCONSIDERATIONS & CRITICAL THINKING EXERCISES.

Admitdischarge Powerpoint 1197589545369206 5

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