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Fundamentals of Nursing Taylor Ch 9
Terms in this set (32)
Two concepts necessary for nursing care of patients within and across healthcare settings:
-Continuity of care
-Community based care
Continuity of care
A process by which healthcare providers give appropriate, uninterrupted care and facilitate the patients transition between different settings an levels of care. It ensures a smooth transition between healthcare settings. (i.e. ambulatory to acute, home healthcare, or others)
Important roles of the nurse in continuity of care
Healthcare provided to people who live within a defined geographic area. Community-based care is:
-Centered on individual and family healthcare needs
-Emphasizes the provisions of comprehensive, coordinated, and continuous services for patients with acute and chronic health problems.
-Designed to meet the needs of people as they move into, between, and among different healthcare settings within the overall healthcare system.
Role of the nurse in community-based care
Provide continuity of care when patient moves from one level of care to another:
-Manage acute or chronic illness
Establishing an Effective Nurse-Patient Relationship
Reduce anxiety through therapeutic communication, teaching and acceptance.
Remember that the patient has other concerns and needs other than medical ones. (Maslows)
Communicate with the patient as an individual
Take time to learn about the patient being admitted
Provide for family participation in all aspects of care.
HIPPA Privacy rule
All patients entering a healthcare setting of any type must sign a statement that they understand the protection of their medical information. Health info cannot be used and shared without a person's written permission unless the law allows it.
HIPPA protected information
Individual health info that could identify a person:
-Name and demographic info (age, address, gender, etc.)
-Past, present, or future physical or mental health condition
-Healthcare provided to the individual
-Past, present, or future payment for the healthcare provided
Admission to Ambulatory Care Setting
-Patient receives healthcare services but does not remain overnight.
-In most offices and clinics, patients complete a short health history.
-In same-day surgery facilities, screening tests, teaching and admission usually take place before patients enter the setting.
-Goal is to provide healthcare services to patient who are able to provide self-care at home. Individuals go to ambulatory settings for health promotion, health maintenance, or medical or surgical treatment.
Admission to the Hospital
-Starts in the Admitting office
-Admission sheet becomes part of the medical record
-Bracelet is placed on wrist of patient (Required by the Joint Commission National safety standards)
-A nursing interview is conducted where all legal and ethical info is given (HIPPA, avanced care directives, POA, will, Patient Care Partnership/Bill of Rights, etc.)
-An admission health history and physical assessment are conducted
-A room is prepared for the patient
Information Obtained on the Admission Sheet
-Name, address and date of birth of patient
-Name of admitting physician
-Gender and marital status
-Name pf nearest relative
-Occupation and employer
-Financial status for health care payment
-Date and time of admission
Computerized or paper medical records containing information such as medical orders, assessments, and care, Nursing documentation of plan of care, assessments, and interventions and diagnostic/surgery results is completed upon admission to the unit. The nurse completes the admission assessment and documents the info on the admission database; the info is used for the nursing care plan and also used for discharge planning and home care.
Preparing a Room for a Patient: Guidelines for Nursing Care
-Position and open the bed
-Assemble necessary equipment and supplies (admission pack, etc)
-Assemble special equipment and supplies (i.e. oxygen therapy, cardiac monitoring)
-Adjust the physical environment of the room (lights, temp, etc.)
-Nurse may delegate; but is responsible that tasks are done
A system used to provide patient information in a brief format is completed is completed upon admission to the unit. The nurse completes the admission assessment and documents the info on the admission database; the info is used for the nursing care plan and also used for discharge planning and home care.
Transfer within Hospital Setting
-Move patient's personal belongings to a new room
-Transfer patient chart, Kardex, care plan and medications
-Other hospital depts. are notified of the transfer (i.e. dietary, pharmacy, PT, etc.)
-The nurse in the original area gives verbal report to the nurse in the new area.
Information Included in Verbal Report
-Patient name and age
-Physicians and admitting diagnosis
-Surgical procedure, if applicable
-Current condition and manifestation
-Allergies, medications and treatments
-Necessary laboratory data and any special equipment
-Nursing care priorities are identified and the existence of advance directives is noted
Transferring a Patient to a Long-Term Facility
-A copy of the chart is usually sent with the patient; the original chart remains at the hospital.
-All the patient's belongings are carefully packed and sent with the patient
-Prescription and appointment cards are sent
-Detailed assessment and care plan is sent
-The nurse often provides verbal report to the new nurse
Systematic process of preparing the patient to leave the healthcare facility while maintaining continuity of care as the patient moves from the acute care setting to care at home.
Essential Components of Discharge Planning
-Discharge planning begins on admission
-Assess strengths and limitation of the patient, family or support person
-Assess the environment
-Implement and coordinate the plan of care
-Consider individual, family and community resources
-Evaluate the effectiveness of care
Criteria for Formal Discharge Plan on and Referrals
-Lack of knowledge of treatment plan
-Recently diagnosed chronic disease
-Prolonged recuperation from major surgery or illness
-Emotional or mental instability
-Complex home care regimen
-Lack of available or appropriate referral sources
Guidelines for Discharge Planning
-Assess and identify healthcare needs
-Set goals with patient
-Teach patient and family
-Provide home healthcare referrals
-Evaluate discharge planning effectiveness (ongoing process that requires follow up interview a few weeks after discharge)
-Focused Assessment Guide
Leaving against medical advice (AMA)
-Patient is legally free to leave
-Choice carries a risk for increased illness or complications
-Patient must sign a form releasing the physicians and institution from legal responsibily
-Patient is informed of risk prior to signing form
-Patients signature must be witnessed
-Form becomes part of medical record
(T/F) In an ambulatory care facilities, patients receive healthcare services and remain in the facility overnight?
(T/F) It is the responsibility of the nurse to ensure that the hospital room is prepared for the patient?
(T/F) When a patients transferred to another unit, the nurse in the original area gives a report about the patient in the new area?
(T/F) When transferring a patient to a long-term facility, the medical chart should be sent to the new facility with the patient?
False (A copy is sent)
(T/F) It is the responsibility of the nurse to write an order for all referral services?
CONTINUITY of care is the principle by which healthcare providers give appropriate, uninterpreted care and facilitate the patients transition between different settings and levels of care.
Healthcare provided to people who live within a defined geographic area is known as COMMUNITY based healthcare.
Discharge PLANNING ensures that patient and family needs are consistently met as the patient moves from the acute care setting to care at home.
A patient who decides to leave the hospital prior to completing the medical plan of care is leaving against medical advise.
Based on the HEALTH insurance Portability and Accountability Act, all patients must sign a statement that they understand the protection of their medical information.
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