Patients are admitted, stay in the hospital, and then are discharged according to a set of rules. Some procedures must be coordinated such that nursing care is constant for patients who require long-term care. The nurse administers the precise medical treatment ordered by the doctor as well as the nursing regime.
Deesha Vyas
Executive Recruiter
Patients are admitted, stay in the hospital, and are discharged according to a set of rules, which includes certain planned nursing activities. Activities must be coordinated such that nursing care is constant for patients who require long-term care and frequent hospitalization. The nurse administers the precise medical treatment ordered by the doctor as well as the nursing regime followed by the nurse to suit the patient's needs. Throughout the stay, the nurse keeps track of the patient's replies.
Procedure for Admission
The patient's admission to the nursing unit prepares them for their stay in the hospital. Whether the admittance is planned or as a result of an emergency.
Definition
Allowing a patient to stay in the hospital for observation, investigation, treatment, and care is referred to as admission.
The admission of a patient to a hospital or ward for therapeutic or diagnostic purposes is known as admission.
Purpose
- To develop policies and procedures for the admission of patients.
- Make the patient feel welcome, at ease, and comfortable.
- Obtain critical information about the patient
- To determine the patient's needs so that a nursing care plan can be developed and implemented.
Involved Principles
- Fear and anxiety are triggered by sudden changes or strangeness in the environment.
- Visiting the hospital puts one's identity in jeopardy.
- People have a wide range of habits and behaviors.
- Illness can be a new yet different experience for the sufferer, which puts their physical and mental health at risk.
Instructions for Use
Receiving the patient and assisting them in acclimating to the hospital surroundings
To greet the patient and their family and generate a favorable first impression.
Obtaining the necessary identifying information about the patient
To provide immediate assistance, protection, and comfort
To work with the patient in the planning and delivery of comprehensive treatment.
Observe and describe the patient's signs and symptoms, as well as his or her overall state.
To ensure the safety of the patient and their belongings
The following objectives should be met by effective admission procedures:
- Verify the patient's identity and evaluate his medical condition.
- Make them feel as relaxed as possible.
- Introduce them to their roommates as well as the rest of the staff.
- Introduce them to their surroundings and daily routine.
- Provide the necessary supplies and unique equipment for daily care.
Admissions procedures that are fast and show adequate concern for the patient can reduce anxiety and enhance cooperation and treatment receptivity. In contrast, admission procedures that the patient considers as thoughtless or indifferent can result in:
- Anxiety getting heightened
- Cooperation will be reduced.
- Possibly exacerbate symptoms and impair their response to treatment
Types of Hospital Admission
- Patients suffering from accidents, poisoning, burns, and heart attacks are admitted in emergencies as these require quick treatment.
- Patients with hypertension, diabetes, and bronchitis are admitted for evaluation and medical or surgical therapy is given if and when needed.
Admission entails
- A doctor's note states that the patient requires particular attention and treatment.
- The health care agency's admitting department collects billing information.
- Nursing personnel complete the agency's admission database.
- Documenting the client's medical history and physical examination findings
- The creation of a preliminary nursing care plan
- Initial treatment orders from a doctor
- Authorization from a physician
- The admissions office (preliminary data collected, addressograph plate)
- Initial nurse care plan
- Responsibilities for medical admission
Some instructions to keep in mind
- Nurses should make every attempt to interact with patients in a friendly and respectful manner.
- Make accurate observations of the patient's condition, document them, and send them to the doctor.
- Educate the patient and his family about the hospital's and ward's policies.
- Adhere to policies when dealing with medico-legal cases
- Patients with communicable diseases should be isolated and handled with extreme caution
- The nurse should be able to notice the patient's numerous requirements and respond to them as soon as possible.
- It is necessary to comprehend the patient's concerns and anxieties and to assist them in overcoming them.
- The nurse should learn about the patient's likes and dislikes and include them in his care plan.
- The nurse should refer to the patients by their first and last names, as well as their official titles.
- The patient's assets and clothing should be given to relatives with proper documentation.
Equipment
Gown, personal property form, valuables envelope, admission form, nursing evaluation form, thermometer, emesis basin, bedpan or urinal, bath basin, water pitcher, cup, tray, and urine specimen container, if required. Soap, comb, toothbrush, toothpaste, mouthwash, water pitcher, cup, tray, lotion, facial tissues, and thermometer are normally included in an entry pack. The use of an admission pack reduces cross-contamination and improves nursing efficiency.
Equipment Preparation
- Obtain a gown and a packet of admission information.
- Place the bed in the appropriate position for the patient's condition. Place the bed in the low position if the patient is ambulatory; if they are arriving on a stretcher, place the bed in the high position.
- Fold the top linens down.
- Have any emergency or special equipment such as oxygen or suction, on hand.
Patient's Preparation
- Greet and introduce yourself to the patient and his family.
- Warmly welcome the patient and provide a comfy seat.
- Introduce them to the rest of the ward's residents.
- Fill out the admissions form.
- Compile a medical history and perform a basic physical examination.
- Follow the treatment plan and keep a record of your progress.
- Assist the patient with personal hygiene and changing into hospital attire.
- Orient the patient to the ward's amenities, including the toilet, shower, drinking water, nurse's station, and treatment room.
- Hand over the valuable patients to their relatives.
- Obtain a guest pass.
- Encourage the patient to follow the hospital diet, particularly if a therapeutic diet is prescribed.
- Obtain a local address or phone number, as well as a relative's lodging room, and record their information in the admissions file.
Procedure
- Adjust the lighting, temperature, and ventilation in the space.
- Before the patient's entrance, double-check that all equipment is in functioning order.
- The adult patient's admission
- Speak slowly, addressing the patient by his full name, and introduce yourself and any other staff members who may be there.
- Compare the patient's identification bracelet's name and number to the information on the admission form. Make sure the patient's name and spelling are correct. Any changes should be reported to the admissions office.
- Review the admittance form and the physician's orders as soon as possible. Note the cause for admission, any activity or dietary limitations, and any diagnostic test orders that require specimen collection.
- Take and record the patient's vital signs, as well as any specimens that have been requested. If possible, note their height and weight. Use a chair or bed scale to measure his height if he is unable to stand. It's crucial to know the patient's height and weight when planning treatment and food, as well as when determining medicine and anesthetic doses.
- Demonstrate how to operate the equipment in the patient's room. This includes the phone and calling system, bed controls, TV controls, and lights.
- Describe your healthcare facility's routine. Mention when meals, vital sign checks, and prescriptions should be expected. Examine the visitation hours and any restrictions that may apply.
- Take a thorough medical history of the patient. Include all prior hospitalizations, illnesses, and operations, as well as current medication and food or drug allergies. Inquire as to why the patient came to the hospital. As the major complaint, write down the replies (in the patient's own words). Follow up with a physical examination, focusing on the complaints. On the nursing evaluation form, note any wounds, marks, bruises, or discoloration.
- After you've assessed the patient, let them know whether any tests have been requested and when they'll be done. Give them a rundown of what they should expect.
- Make sure the patient is comfortable and safe before leaving their room. Adjust their bed and put the call button, as well as other equipment (such as a water pitcher and cup, an emesis basin, and facial tissues) within easy reach. Increase the height of the side rails.
Reminders for Patient Care
Treatment reminders, which are put at the head of the patient's bed, draw attention to the patient's unique needs and assist in maintaining consistent care by informing hospital staff, the patient's family, and other visitors. Important information about the patient can be written on a specifically designed card or a simple piece of paper, such as:
- Allergies
- Dietary limitations
- Fluid limitations
- Collection of specimens
- In the right ear, the patient is deaf or has hearing loss.
- Speaker of a foreign language.
Taking Care of the Pediatric Patient
- To reduce concerns and anxiety, your first goal will be to build a warm, trusting relationship with the child and their parents.
- Before acquiring more information from their parents, speak directly to the child and allow them to answer questions.
- Describe the layout of the room and bathroom, as well as the location of the playroom, television room, and snack room, if provided, while orienting the parents and child to the unit.
- Teach the child how to contact the nurse(s).
- Explain the facilities' rooming-in and visiting policies so that parents can spend as much time with their children as possible.
- Inquire about the child's normal routine so that favorite foods, nighttime routines, toileting, and adequate rest can all be included.
- Encourage parents to bring some of their child's favorite toys, blankets, or other objects to help their youngster feel more at ease in new situations.
Particular Points to Consider
- Contact the relevant resource if the patient does not speak English and is not accompanied by a multilingual family member.
- Keep in mind that the patient who has been admitted to the emergency room necessitates specific treatment.
- Take an inventory of the patient's medications and write it on the nursing evaluation form if the patient brings them from home. Instruct the patient not to take any medication until the physician has given his or her permission.
- Find out what the patient's typical routine is and see if they want to make any changes to the facility's routine.
Documentation
Complete the nursing assessment form or your notes after leaving the patient's room, as needed. The completed form should include the patient's vital signs, height, weight, allergies, and medication and health history; a list of his belongings, including those sent home with family members; the results of your physical examination; and a record of laboratory specimens collected.
Aspects of Patient Admission that are Legal
- Applicable legislation governs the disclosure of patient information to family members and the next of kin.
- A detention procedure, also known as the "procedure involving patient admission and detention by a healthcare facility," is implemented in the case of acutely ill patients who are unable to agree to hospitalization (e.g., unconscious, following strokes, etc.). Without the patient's agreement, the healthcare provider notifies the patient's admission to the court.
- The court will appoint a guardian to represent the patient during detention in the event of emergency hospitalization.
Published: January 28 2022
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