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ADMISSION OF A PATIENT TO HOSPITAL

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Past illnesses that have any residual effects of bearing. ... Chews and swallows easily. PATIENT ASSESSMENT 3. Eats balanced diet. Use of dentures ... – PowerPoint PPT presentation

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Title: ADMISSION OF A PATIENT TO HOSPITAL


1
ADMISSION OF A PATIENT TO HOSPITAL
2
DOCUMENTS FOR ADMISSION ASSESSMENT
3
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.

4
  • 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).

5
PATIENT ASSESSMENT 1
  • OBSERVATIONS AND PHYSICAL ASSESSMENT
  • To be carried out as quickly as possible on
    admission to the ward.

6
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

7
PATIENT ASSESSMENT
  • No signs of infection
  • Pressure areas intact
  • Skin warm
  • Pink healthy colour of skin and mucous membranes

8
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

9
PATIENT ASSESSMENT 2
  • Pupils equal, react
  • Hears voices within normal range
  • Use of hearing aid
  • Abe to sense by touch

10
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

11
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

12
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

13
PATIENT ASSESSMENT 5
  • SLEEP AND REST
  • Usual bedtime_______
  • Usual rising time_____
  • Naps_______________
  • No interruptions of sleep
  • Awakes well rested, feels refreshed
  • Falls asleep easily

14
PATIENT ASSESSMENT 6
  • Activity
  • Limbs present, in good proportion
  • Good muscle size
  • Smooth, co-ordinated movement
  • Unrestricted movement of joints
  • Good strength, moves independently

15
PATIENT ASSESSMENT 6
  • Good balance able to weight bear
  • Able to change position freely
  • Walks without assistance, normal gait
  • Performs daily living activities

16
PATIENT ASSESSMENT 7
  • SELF EXPRESSION
  • Able to express thoughts and feelings
  • Body language congruent with speech
  • Has realistic expectations about illness

17
PATIENT ASSESSMENT 7
  • Able to accept and cope with changes in body/loss
  • Able to make decisions about care
  • Feels able to cope

18
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

19
RISK ASSESSMENT
  • Falls
  • Pressure sores
  • Lifting and handling

20
CARE PLANNING
21
DISCHARGE PLANNING
  • Planning of assessment for discharge should
    begin from the point of admission.

22
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.

23
DISCHARGE 3
  • An accurate assessment of the patients care
    needs should be communicated to relevant service
    providers.
  • A realistic discharge date should be set.
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