Admission Of A Patient PDF

ADMISSION OF A PATIENT Definition: The care a patient receives upon entering the hospital. Purposes: 1. To reduce anxiety and stress. 2. To prepare the patient physically and emotionally for his/her hospitalization experience. 3. To make the patient and his/her family f...

ADMISSION OF A PATIENT Definition: The care a patient receives upon entering the hospital. Purposes: 1. To reduce anxiety and stress. 2. To prepare the patient physically and emotionally for his/her hospitalization experience. 3. To make the patient and his/her family feel at ease to the hospital environment. 4. To provide appropriate, timely and efficient medical management and nursing measures. 5. To restore/maintain health and prevent disability. Equipment: In the Emergency Room Bed/wheeler Patient’s chart Patient’s gown Sphygmomanometer Stethoscope Thermometer Weighing scale Others as needed to include but not limited to the following: Suction machine Defibrillator with ECG Oxygen tank and cannula Others In the wards/clinical departments Admission pack containing: Bath soap Calibrated drinking glass Detergent (powder) Face towel Purified bottled water Silverware (spoon, fork) Toilet paper Toothbrush Toothpaste Digital thermometer (individual, as needed) Open bed Orientation checklist (optional) Patient’s chart Sphygmomanometer Stethoscope Others as needed to include but not limited to the following: Air Conditioner and TV Remote Controls Kidney basin Oxygen tank/Oxygen concentrator and cannula Suction machine Urinal and/or bedpan Procedure: Emergency Room 1. Meet the patient and accompanying persons at the ER entrance door and do a quick (2-minute) head-to-toe assessment. 2. Greet the patient and accompanying persons and ask for the patient’s chief complaint(s) or reason for seeking emergency treatment/admission. Note: - Use therapeutic techniques in communicating with the patients and their families. Refer to the fact sheet entitled “Communicating with Patients and their Families”. - For OB patients in labor with or without carried Attending Physician’s admitting orders on off clinic hours, let the Male Nurse Aide transport the patient directly to the OB Ward Labor Room and/or call the OB ward of the incoming patient and follow the procedure on “OB Ward (for Parturient Women…..)”. 3. Observe appropriate infection control measures before, during, and after caring for the patient. 4. Get the patient’s height and weight. If the patient is not ambulatory height and weight may be estimated. Note: Taking of the patient’s height and weight is delegated to the Female/Male Nurse Aide. 5. Usher patient to appropriate cubicle/bed, assist in lying down/positioning and make the patient comfortable. 6. Adjust the head part of the bed to the appropriate height as indicated by the patient’s condition and/or tolerance. 7. Gather preliminary data to include: Name Age Sex Civil Status Date of birth Address PhilHealth/Health Insurances Brief History of Present Condition Attending Physician 8. Assess the patient’s vital signs – TPR and BP, including pain as the 5th vital sign, and oxygen saturation. Note: TPR taking is delegated to the Female Nurse Aide. BP and Cardiac Rate should be taken by the Nurse. Succeeding BP taking may be delegated to the Female Nursing Aide as appropriate. 9. Perform nursing interventions. 10. Inform the Resident Doctor in-charge of the patient’s demographics and chief complaint(s) Note: Resident Doctor does the following: a. Examines the patient b. Refer the patient to his/her Attending Physician (AP) or to the Attending Physician on deck if the patient has no AP and/or without a preferred AP. c. Makes admission orders. 11. Instructs the accompanying person to go to Admission Section. Note: From 11 p.m. to 6 a.m. call the assigned ward for room accommodation and to prepare for the patient’s room and instruct the accompanying person to proceed to Window 3. 12. Execute doctor’s orders and nursing interventions. a. Start I.V. Therapy b. Make laboratory examination/diagnostic examination forms and forward them to the Billing Clerk: Note: For those that are to be performed on the next day, requisition forms are forwarded to the patient’s ward assignment. c. Give medications as prescribed. d. Assist in procedures. e. Do independent nursing interventions. 13. Ask the accompanying person Patient’s Data Sheet, PHIC forms 2 & 3, and Consent for Admission. 14. Attach Consent for Admission to the patient’s chart. 15. Transport patient to the assigned ward once the patient’s room is ready and endorse the patient and his/her chart to Senior Nurse/Charge Nurse. Note: Patients need to be stabilized before transporting to the assigned ward. If the patient is admitted to Room 358, ICU and PICU; and for close monitoring; the E.R. Nurse and PGI/Resident Doctor shall accompany him/her and endorse appropriately. For a patient to be transported to O.R., the E.R. Nurse shall accompany him/her and endorse to the O.R. Nurse appropriately. Male Nurse Aides are delegated to transport patients up to the appropriate ward and room. Addendum: For OPD patients coming to ER for consultation from 12 midnight to 12noon and are advised admission, the procedure is the same as above. Patients with stat (at once) and scheduled surgical procedures in the Operating Room shall be asked to secure a Business Office clearance. If the patient for admission is coming from the Attending Physician’s clinic with written orders, he/she directly goes to the Admitting Section except for medical patients with stat laboratory orders for IV Therapy. Admitting Section clerk calls the appropriate ward for room accommodation and coordinates with the ward clerk before letting the Male Nurse Aide transport the patient and chart up. Ward/Clinical Departments 1. Check if the room and bed are ready. Note: The Female Nurse Aide is delegated to check if the room and bed are ready for admission. Needed equipment like an Oxygen tank, suction machine, and others are to be checked by the Charge Nurse if these are ready. Cleaning the room is done by the housekeeping personnel. 2. Inform ER Nurse/Admitting Clerk that the room is ready. Note: This is done either by the Charge Nurse, Senior Nurse, or Ward Clerk. Often, the Ward Clerk coordinates with the ER Nurse or Admitting Clerk. 3. Receive and greet the patient on the floor/ward/unit. Note: Charge Nurse in either 358, ICU, or PICU receives the patient and chart in the Nurse’s Station. In cases where any of them are not available, the Ward Clerk receives the patient with the chart in the Nurse’s Station and informs the Charge Nurse soonest that the patient is in his/her room. Male Nurse Aide transports the patient to his/her room and makes him/her comfortable in bed. Use therapeutic techniques in communicating with the patients and their families. Refer to the fact sheet entitled “Communicating with Patients and their Families”. 4. Read the patient’s chart. Take note of the following but not limited to: IV Therapy Ordered laboratory and diagnostic examinations to be done Medications and treatments Diet Restrictions-fluid and movement Turning schedule Special precautions 5. Do hand hygiene before and after patient contact. 6. Go to the patient’s room. 7. Greet the patient and accompanying person(s). 8. Introduce yourself.  9. Assess the patient. General appearance, noting signs and symptoms of physical distress. Check vital signs including pain. Check the following: IV Therapy, condition of the site and rate of flow, Blood transfusion flow FBC is in place and draining or clamped as ordered Oxygen inhalation rate Others Ask for concerns. 10. Explain before doing any procedure or giving medications and treatment. Note: Patients coming from the Attending Physician’s clinic with written orders for admission (except for medical cases) are started with IV Therapy in their room. 11. Do nursing measures/interventions/protocol. 12. Orient the patient and/or accompanying person(s). May use Orientation Checklist attached as needed. Ask if there are any questions/clarifications. 13. Leave the room and patient/accompanying person(s) in a pleasant manner. Before leaving, ask the patient and/or accompanying person(s) if there is something they need. If none, inform them that you will leave and that you will be back from time to time. Remind the patient and/or accompanying person(s) to call you at the nurse’s station if they have concerns. Open and close the door gently. Avoid boisterous talking. 14. Document assessment, procedures/medications/treatment/interventions accordingly. OB Ward (for Parturient Women with or without Carried Attending Physician’s Admitting Orders During Off Clinic Hours): 1. Greet and receive the patient in the Labor Room. 2. Assist the patient change to a hospital gown. 3. Get the weight. 4. Assist the patient to the labor bed. 5. Take vital signs. 6. Assess the patient’s general appearance, noting signs and symptoms of physical distress. 7. Do hand hygiene before and after patient contact. 8. Prepare the patient for a physical examination. Explain the procedure Inform the patient what is expected from her Answer the patient’s questions. 9. Assist the physician in physical examination. 10. Carry out doctor’s orders and do nursing interventions. 11. Instruct the accompanying person to go to Admission Section to admit the patient. Note: From 11:00 pm to 6:00 am the LR-DR Nurse fills up the Admission Initial Data Sheet and instructs the accompanying person to proceed to Window 3 to register/admit the patient. 12. Let the Male Nurse Aide transport the patient to her room of choice as indicated or make the patient comfortable in the labor bed. 13. Do aftercare of used equipment/materials/supplies. Discard according to the hospital’s waste management protocol. 14. Document assessment, procedures/medications/treatment/interventions accordingly. Reference(s): SUCN Procedure Manual Level 3 Actual Hospital, Clinical Nursing Practice