ADMISSION OF A PATIENT TO HOSPITAL

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ADMISSION OF A PATIENT TO HOSPITAL
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DOCUMENTS FOR ADMISSION ASSESSMENT
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ADMISSION INTERVIEW

• Note-
• The reason for admission - as the patient
  understands it.
• The symptoms the patient has.
• Past illnesses that have any residual effects of
  bearing.
• Any problems the patient had with previous
  admissions.

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• Any allergies the patient has.
• Any medications taken - what for? AS the patient
  understands it. Any non-compliance and why.
• Smoking and drinking habits.
• Last menstrual period (where relevant).

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PATIENT ASSESSMENT 1

• OBSERVATIONS AND PHYSICAL ASSESSMENT
• To be carried out as quickly as possible on
  admission to the ward.

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PATIENT ASSESSMENT

• Vital signs within normal range
• Oriented to reality, time, place and person
• Pulse regular, full and equal
• Peripheral pulses present
• Normal chest movements
• No shortness of breath

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PATIENT ASSESSMENT

• No signs of infection
• Pressure areas intact
• Skin warm
• Pink healthy colour of skin and mucous membranes

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PATIENT ASSESSMENT 2

• SENSORY REGULATION
• Awake, alert, asleep
• At ease, comfortable
• Able to see, use of glasses
• Appropriate size, colour and shape of eyes
• Sclera white

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PATIENT ASSESSMENT 2

• Pupils equal, react
• Hears voices within normal range
• Use of hearing aid
• Abe to sense by touch

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PATIENT ASSESSMENT 3

• FOOD AND DRINK
• Weight in normal range for age, height
• Maintains usual body weight
• No restrictions of food
• Eats normally and retains food
• Chews and swallows easily

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PATIENT ASSESSMENT 3

• Eats balanced diet
• Use of dentures
• Teeth and gums - strong and smooth
• Adequate fluid intake/output
• Urine has normal colour
• No abnormal fluid loss
• Pink moist mucous membranes

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PATIENT ASSESSMENT 4

• ELIMINATION
• Has regular bowel movement every 1 to 3 days
• Formed brown stool, moderate amount
• Abdomen soft, active bowel sounds
• Able to void urine comfortably
• Urine has normal characteristics

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PATIENT ASSESSMENT 5

• SLEEP AND REST
• Usual bedtime_______
• Usual rising time_____
• Naps_______________
• No interruptions of sleep
• Awakes well rested, feels refreshed
• Falls asleep easily

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PATIENT ASSESSMENT 6

• Activity
• Limbs present, in good proportion
• Good muscle size
• Smooth, co-ordinated movement
• Unrestricted movement of joints
• Good strength, moves independently

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PATIENT ASSESSMENT 6

• Good balance able to weight bear
• Able to change position freely
• Walks without assistance, normal gait
• Performs daily living activities

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PATIENT ASSESSMENT 7

• SELF EXPRESSION
• Able to express thoughts and feelings
• Body language congruent with speech
• Has realistic expectations about illness

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PATIENT ASSESSMENT 7

• Able to accept and cope with changes in body/loss
• Able to make decisions about care
• Feels able to cope

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PATIENT ASSESSMENT 8

• SOCIAL
• Able to interact socially
• Has support of family/loved ones
• Social support is continued throughout admission
• Unworried about family/loved ones
• Ability to cope at home

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RISK ASSESSMENT

• Falls
• Pressure sores
• Lifting and handling

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CARE PLANNING
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DISCHARGE PLANNING

• Planning of assessment for discharge should
  begin from the point of admission.

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DISCHARGE 2

• Most patients discharged from hospital are able
  to return home with little or no support, while
  others will require a package of care to
  support them back to optimum health.

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DISCHARGE 3

• An accurate assessment of the patients care
  needs should be communicated to relevant service
  providers.
• A realistic discharge date should be set.