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ADMISSION, TRANSFER, AND DISCHARGE
Terms in this set (44)
entry of a patient into the health care facility
HEALTH CARE FACILITY
any agency that provides health care
the patient is usually very concerned about health problems or potential health problems and the potential outcome of treatment.
THE FIRST CONTACT WITH NURSES
and health care workers is important; anxiety and fears can be lessened and a positive attitude regarding the care to be received can be initiated
ADMISSION ROUTINES THAT ARE
efficient and show appropriate concern for the patient can ease anxiety and promote cooperation and positive response to treatment
THE NURSE CAN ANTICIPATE SOME COMMON REACTION:
fear of the unknown
loss of identity
ADMITTING DEPARTMENT (information usually includes)
name, address, telephone number
age, birth date
social security number
next of kin
insurance company, policy number
place of employment
reason for admission
ID BAND IS PREPARED AND PUT ON THE PATIENT'S WRIST. (admitting department)
the day before a planned admission, a clerk from the admitting office calls the patient at home and gathers all the information needed to begin the records.
instructions are given regarding time to arrive at the hospital, items to bring to the hospital, and things that should not be brought to the hospital (jewelry and large sums of money)
people brought to the emergency department may be admitted directly to a patient care room or a special care unit, intensive care unit, coronary care unit, or burn unit.
a family member goes to the admitting office to provide the necessary information
WHEN THE UNIT STAFF ARE NOTIFIED THAT A NEW PATIENT IS BEING ESCORTED TO A ROOM,
the room should be made ready. the room should be
clean and neat
of appropriate temperature
have personal care items in place
any special equipment should be placed and ready when the patient arrives.
GREETING THE PATIENT BY NAME AND MAKING THE PATIENT FEEL WELCOME IS
one of the MOST IMPORTANT ASPECTS of the admission procedure.
Regardless of the time or activity occurring on the unit, the nurse should be courteous to, interested in, and receptive of the new patient.
the new patient should be given an orientation to the unit and the room.
THE HOSPITAL ROUTINE SHOULD BE EXPLAINED:
when meals are served
when family and friends may visit
when laboratory or diagnostic imaging evaluations are scheduled
when the physician usually makes rounds
policy on use of side rails
many hospitals have booklets for the patient that explain these routine activities.
ADMITTING PROCEDURE ON THE PATIENT CARE UNIT
check the ID band and verify the information with the patient.
assess immediate needs such as pain, shortness of breath, or severe anxiety.
introduce roommate, if one is present
WHEN ADMITTING THE PATIENT TO THE PATIENT CARE UNIT, JEWELRY, MONEY
and medications should be given to the family to take home.
IF NO FAMILY IS PRESENT VALUABLES MUST BE
put int the hospital safe. follow the hospital policy.
SOME FACILITIES REQUIRE ALL MEDICATIONS BROUGHT IN BY THE PATIENT BE SENT TO THE
pharmacy to be identified; they are then returned to the patient upon dismissal.
THE PATIENT IS USUALLY ASKED TO PUT ON
pajamas or hospital gown; the nurse may need to help the patient change clothes.
clothing should be inventoried along with other personal items the patient uses.
JEWELRY AND MONEY KEPT IN THE ROOM MUST BE
ONCE THE PATIENT IS ESTABLISHED IN THE ROOM
take the health history
perform the initial assessment
admission assessment must be prepared by a Registered nurse
aspects of the data collection may then be delegated by the RN to the LPN/LVN
the physician is notified when the patient has been admitted.
TRANSFERRING THE PATIENT
the changing condition of a patient, whether improved or more critical, may require transfer either to another unit in the hospital or to another health care institution, such as a nursing home or rehabilitation hospital.
THE PATIENT TRANSFER REQUIRES
thorough preparation and careful documentation.
PREPARATION (PATIENT TRANSFER)
explain transfer to patient and family; discuss the patient's condition and plan of care with the staff of the receiving unit or facility; arrangements for transportation
DOCUMENTATION (PATIENT TRANSFER) (FIB)
preparation includes an explanation of the transfer to the patient and family, discussion of the patient's condition and plan of care with the staff of the receiving unit or facility, and arrangements for transportation, if necessary
the patient's condition before and during transfer and adequate communication among nursing staff ensures CONTINUITY OF CARE.
systemic process of planning for patient care after discharge from the hospital.
although discharge from a health care facility is usually consider routine, EFFECTIVE DISCHARGE REQUIRES
careful planning and continuing assessment of the patient's needs during hospitalization.
IDEALLY, DISCHARGING PLANNING BEGINS SHORTLY AFTER
teach the patient and family about the patient's illness and its effect on his or her lifestyle.
provide instructions for home care
communicate dietary or activity instructions.
explain the purpose, adverse effects, and scheduling of medication treatment.
planning can include arranging transportation.
follow-up care may be necessary.
coordinate outpatient or home care services.
another approach to discharge planning using transition specialist.
begin discharge planning and usually makes a home visit before the patient is discharge.
COMMUNICATION AMONG THE PATIENT, FAMILY, AND HEALTH CARE AGENCIES IS
ESSENTIAL for effective discharge planning
includes patient's learning needs, how well they were met, the patient teaching completed, short-and long-term goals of care, referrals made, and coordinate care plan to be implemented after discharge.
REFERRALS FOR HEALTH CARE SERVICES
a patient may require the services of various disciplines within a hospital.
the nurse is OFTEN THE FIRST to recognize the patient's needs
referrals should be made as soon as possible after patient's need is identified
in many agencies, a physician's order is needed for a referral.
VARIOUS HEALTH DISCIPLINES (referrals for health care services)
Clinical nurse specialist
Home health care nurse
DISCHARGING THE PATIENT
many hospitals have a form with written instructions and teaching documentation for the patient to sign and acknowledge understanding of the instructions.
these instructions serve as a guide for the patient to use at home
DISCHARGE: Against Medical Advice (AMA)
this is when the patient leaves a health care facility without a physician's order for discharge.
Notify the physician immediately.
if the physician fails to convince the patient to remain in the facility, the physician will ask the patient to sign an AMA form, RELEASING THE FACILITY FROM LEGAL RESPONSIBILITY FOR ANY MEDICAL PROBLEMS THE PATIENT MAY EXPERIENCE AFTER DISCHARGE
DO NOT DETAIN THE PATIENT; this violates his or her legal rights.
As nurses today, we have to care for patients from many different cultures and backgrounds. the following are ideas/beliefs from the JAPANESE culture about how illness is caused.
Contact with blood
Contact with skin disease
Improper care of the body
Lack of sleep
moving a patient from one unit to another
SEPARATION ANXIETY CAN BE EXPRESSED IN CHILDREN BY
SEPARATION ANXIETY CAN BE EXPRESSED IN older ADULTS BY
THE NURSE CAN HELP DECREASE THE ANXIETY OF ADMISSION OF THE PATIENT BY
providing a warm, caring attitude.
courtesy and empathy (ability to recognize and to some extent share the emotions and state of mind of another and to understand the meaning and significance of that person's behavior)
to help them adapt, treat patients with respect
maintain their dignity
involve them in the the plan of care
whenever possible adjust hospital routine to meet their desires.
MANY HAITIANS BELIEVE THAT LEAVES HAVE A SPECIAL SIGNIFICANCE IN HEALING. (cultural sensitivity) (FIB)
you will sometimes find leaves in the clothes and on various parts of the body. LEAVES ARE THOUGHT TO HAVE MYSTICAL POWER RELATED TO REGAINING OR KEEPING HEALTH
THE OLDER ADULT SOMETIMES EXHIBITS (FIB)
disorientation or depression related to the stress caused by hospitalization
IF PATIENT HAS DIFFICULTY PAYING WHAT DO WE DO
-assists finding financial resources to cover medical costs
-provide counseling for major life crises such as terminal illness and family problems
-assists in finding community resources such as equipment after discharge from a hospital
THE JOINT COMMISSION (TJC) (2008) REQUIRES THE FOLLOWING INSTRUCTIONS BEFORE PATIENTS LEAVE HEALTH CARE FACILITIES: (MA) (discharge standards)
-Safe and effective use of medications and medical equipment
-Instruction on nutrition and modified diets
-Rehabilitation techniques to support adaptation to and / functional independence in the environment
-Access to available community resources as needed
when and how to obtain further treatment
-The patient's ongoing health care needs and the knowledge and skills needed to carry out those responsibilities
-Maintenance of good standards for personal hygiene
it is also necessary to identify risk factors. RISK FACTORS SHOULD BE IDENTIFIED FOR DISCHARGE PLANNING
multisystem disease processes
major surgical procedure
chronic or terminal disease
DISCHARGE PLANNING INVOLVES
(discharge standards) (MA)
MULTIDISCIPLINARY action with participation by all members of the HEALTH CARE TEAM, THE PATIENT, AND THE PATIENT'S FAMILY.
MANY LARGER HOSPITAL HAVE DISCHARGE PLANNERS OR COORDINATORS; THEY ORCHESTRATE THE DISCHARGE PLANNING
ONE OF THE MOST IMPORTANT ASPECTS OF THE ADMISSION PROCESS IS
greeting the patient by name and making the patient feel welcome
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