Admission Nursing Assessment

1
Admission Nursing Assessment
2

• A comprehensive admission assessment, also
  referred to as an initial database, nursing
  history, or nursing assessment is completed when
  the client is admitted to the nursing unit.
• These forms can be organized according to body
  systems, functional abilities, health problems
  and risks, nursing model, or type of health care
  setting.

3
Documentation

• Complete the nursing assessment form which
  include vital signs, height, weight, allergies,
  drug, health history, a list of his belongings
  and those sent home, the result of your physical
  assessment and a record of specimens collected
  for laboratory tests

4

• Kardexes is concise method of organizing and
  recording data about the client, making
  information quickly accessible to all health
  professionals. The information on kardex may be
  organized into sections, for example
• Pertinent information about the client, such as
  name, room number, age , religion, marital
  status, admission date, physicians name,
  diagnosis
• List of medications

5

• List of intravenous fluids
• List of daily treatments and procedures
• List of diagnostic procedures ordered
• Specific data on how the clients physical need
  are to be met, such as type of diet, activity,
  hygienic needs
• A problem list, stated goals, a list of nursing
  approaches to meet the goals and relieve the
  problems.

6
(No Transcript)
7
(No Transcript)
8

• Flow Sheet, it enables nurses to record nursing
  data quickly and concisely and provides an
  easy-to-read record of the clients condition
  over time.
• Graphic Record, this record typically indicates
  body temperature, pulse, respiratory rate, blood
  pressure, weight.
• Fluid Balance Record, all routes of fluid intake
  and all routes of fluid loss or output are
  measured and recorded on this form.

9

• Medication Administration Record, medication flow
  sheets usually include designated areas for the
  date of the medication order, the expiration
  date, the medication name and dose, the frequency
  of administration and route and the nurses
  signature.
• Skin Assessment Record, a skin or wound
  assessment is often recorded on a flow sheet.
  These records may include categories related to
  stage of skin injury, drainage, color, odor, and
  treatment

10

• Progress Notes, it made by nurses provide
  information about the progress a client is making
  achieving desired outcomes.
• - Progress notes include information about
  client problems and nursing interventions.

11
Nursing Discharge/Referral Summaries

• A discharge note and referral summary are
  completed when the client is being discharged and
  transferred to another institution or to a home
  setting where a visit by a community health nurse
  is required.
• Some records combine the discharge plan,
  including instructions for care, and the final
  progress note.
• If a client is transferred within the facility or
  from a long-term facility to a hospital, a report
  needs to accompany the client to ensure
  continuity of care in the new area. It should
  include all components of the discharge
  instructions.

12

• Regardless of format, discharge and referral
  summaries usually include some or all of the
  following
• Description of clients physical , mental, and
  emotional status at discharge or referral
• Resolved health problems
• Unresolved continuing health problems and
  continuing care.
• Treatment that are to be continued such as wound
  care
• Current medications
• Restrictions that relate to (a) activity such as
  lifting, stair climbing (b) diet, and (c) bathing

13

• Functional/self-care abilities in terms of
  vision, hearing, speech, mobility
• Comfort level
• Support network including family, significant
  others
• Client education provided in relation to disease
  process, activity, and exercise
• Discharge destination and mode of discharge such
  as walking, wheelchair
• Referral services.

14
Discharge teaching Goals

• Your discharge teaching should aim to ensure
  that the patient
• Understands his illness
• Complies with his drug therapy
• Carefully follows his diet
• Manages his activity level
• Understands his treatment
• Recognize his need for rest
• Knows when to seek follow up care

15
Discharge Against Medical Advice AMA

• Occasionally, the pt or his family may demand
  discharge against medical advice "AMA". If this
  occurs, notify the physician immediately.
• If the physician fails to convince the pt to
  remain in the facility, he'll ask the pt to sign
  an AMA form releasing the facility from leg
  responsibility for any medical problems the pt
  may experience after discharge

16
Aims of discharge planning

• Teach the pt and his family about his illness and
  its effect on his lifestyle
• Provide instruction for home care
• Communicate dietary or activity instructions
• Explain the purpose, adverse effects and
  scheduling of drug treatment
• Can also include arranging for transportation
• Follow-up care if necessary
• Coordination of outpatient or home health care
  services

17
Transfer within the facility

• Review the new orders with the nursing staff at
  the receiving unit
• Send the pt's chart, laboratory slips, kardex
• Use a wheel chair to transport the ambulatory
  pts, in which case he may be allowed to walk
• Use a stretcher to transport the bed-riiden pts
• Introduce the pt to the nursing staff-take him to
  his room-place him in bed or seat him in chair
  introduce him to his roommate tell him about call
  bells

18
Implementation Transfer

• Explain transfer to the pt and family
• Assess the physical condition to determine the
  means of transfer wheelchair or stretcher
• Using the admission inventory of belongings as a
  checklist
• Collect the pt's property
• Don't forget valuables or personal medications

19

• Check the entire room, including the bedside
  stand, over-bed table, bathroom
• Gather the pts medication from the cart and the
  refrigerator
• Notify the business office, dietary department,
  the pharmacy, the facility telephone operator
  about the transfer
• Contact the nursing staff on the receiving unit
  about the pt's condition and review the nursing
  care plan to ensure continuity of care.

20
(No Transcript)