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Admit/Discharge Powerpoint
 

Admit/Discharge Powerpoint

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This is part of the Nursing Skills powerpoints.

This is part of the Nursing Skills powerpoints.

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    Admit/Discharge Powerpoint Admit/Discharge Powerpoint Presentation Transcript

    • ADMISSIONS/DISCHARGE/TRANSFER
    • ADMISSION
      • (ENTERING A HEALTH CARE AGENCY FOR NURSING CARE AND MEDICAL/SURGICAL TREATMENT)
      • INVOLVES:
      • A. AUTHORIZATION FROM A PHYSICIAN
      • B. COLLECTION OF BILLING INFO FROM THE ADMITTING DEPARTMENT
      • C. COMPLETION OF THE ADMISSION PROCESS BY NURSING
      • D. DOCUMENTING PT’S MED HX & PHYSICAL EXAM
      • E. INITIAL MED ORDERS FOR TREATMENT
    • RESPONSIBILITIES OF THE ADMITTING DEPARTMENT
      • GATHER INFO FOR BILLING
      • INITIATE MEDICAL RECORD
      • PREPARE ID BRACELET. THIS IS THE SINGLE MOST EFFECTIVE WAY OF IDENTIFYING THE PATIENT
      • MAY BYPASS IN EMERGENCY SITUATION
      • AN ADDRESSOGRAPH CARD IS MADE
      • CONSENT FORMS ARE SIGNED, EG. LIVING WILL, DIRECTIVES, WAIVERS
      • INITIAL ORDERS OBTAINED
      • VERBAL REPORT GIVEN TO FLOOR RN
      • PATIENT IS ESCORTED
    • NURSING RESPONSIBILITES
      • PREPARE ROOM
      • IDENTIFY SELF
      • ORIENT PATIENT
      • GATHER INFO
    • PREPARE ROOM
      • PROVIDE PERSONAL CARE ITEMS
      • SUCTION
      • OXYGEN
      • IV POLE
      • BED IN HIGH POSITION IF ARRIVING BY GUERNEY
      • BED IN LOW POSITION IF ARRIVING BY W/C
      • BLUE PADS IF NEC.
    • IDENTIFY SELF
      • MAKES PT FEEL SECURE
      • MAKES PT FEEL WELCOME
      • ALLEVIATES ANXIETY/FEAR
    • ORIENT PATIENT
      • LOCATION OF NURSE’S STATION
      • CLOTHES STORAGE
      • CALL LIGHT
      • BED CONTROLS
      • LIGHT SWITCHES
      • TELEPHONE POLICY
      • TV CONTROLS
      • MEALTIMES
      • SAFETY MEASURES SUCH AS BEDRAILS
      • VISITING HOURS
      • WHAT TESTS ARE SCHEDULED
      • DIET
      • ROOM BOUNDARIES
      • SCHEDULED SURGERY TIME
      • TIMES FOR DR VISITS
    • GATHER INFORMATION
      • THE NURSE WILL GATHER INFO ABOUT:
      • MEDICAL ORDERS
      • TX’S
      • LABS
      • TESTS
      • DIET
      • ACTIVITY
      • PHYSICAL ASSESSMENT WITHIN 24HRS.
    • TYPES OF ADMISSION
      • INPATIENT
      • OUTPATIENT
    • INPATIENT STAY
      • LONGER THAN 24HRS
      • PLANNED :
      • NO IMMEDIATE THREAT
      • PLANNED ELECTIVE SURGERY, TESTS
      • PT IS PREPARED
      • EMERGENCY :
      • UNPLANNED
      • STABILIZE IN EMERGENCY ROOM (CHEST PAIN, TRAUMA)
      • DIRECT ADMISSION:
      • UNPLANNED
      • BYPASS EMERGENCY (VOMITING, DIARRHEA)
    • OUTPATIENT STAY
      • LESS THAN 24 HRS
      • OBSERVATIONAL:
      • HEAD INJURY
      • PREMATURE LABOR
      • UNSTABLE VITAL SIGNS
    • VALUABLES
      • WHEN DOCUMENTING VALUABLES, MAKE SURE TO USE WORDS LIKE:
        • WHITE/YELLOW METAL NOT GOLD
        • CLEAR STONE NOT DIAMONDS, RUBIES, ETC.
        • HAVE A WITNESS
        • HAVE NURSE & PT SIGN VALUABLES LIST
        • DON’T FORGET DENTURES, GLASSES, ETC.
        • WHEN TRANSFERRING PT, SIGN-OFF WITH NURSE
        • KNOW YOUR FACILITY’S VALUABLES POLICY
    • PATIENT COMFORT
      • PROVIDE PRIVACY. (SHUT DOOR & PULL CURTAIN.)
      • ASSIST IF NEEDED TO REMOVE CLOTHING AND PUT GOWN ON.
      • PROVIDE EXTRA BLANKETS IF REQUESTED.
      • COLLECT INFO FOR DATABASE.
      • PERFORM INITIAL ADMISSION ASSESSMENT IF APPROPRIATE. (SOME FACILITIES REQUIRE AN RN TO DO INITIAL ASSESSMENTS).
      • OBTAIN PHYSICIAN ORDERS FOR TX’S, LABS, TESTS, MEDS, ACTIVITY, ETC. WITHIN 24HRS.
    • COMPONENTS OF A MEDICAL HISTORY
      • IDENTIFYING DATA
      • CHIEF COMPLAINT
      • PERSONAL HX
      • PAST HEALTH HX
      • HX OF PRESENT ILLNESS
      • FAMILY HX
      • REVIEW OF BODY SYSTEMS
      • CONCLUSION
    • WHAT TO WATCH FOR IN NEWLY ADMITTED PATIENTS
      • ANXIETY
      • LONELINESS
      • DECREASED PRIVACY
      • LOSS OF IDENTITY
    • ANXIETY
      • APPEARANCE
      • Exhibits Separation Anxiety.
      • Sad.
      • Worried.
      • Restless.
      • Reduced Appetite.
      • Insomnia.
      • HOW TO HELP
      • Acknowledge feelings.
      • Provide explanations and instructions before performing procedures.
      • Inquire about stress due to children/pets/spouse at home.
      • Reassure. Separation Anxiety can cause the elderly to be confused and disoriented.
    • LONELINESS
      • Make frequent contact with your patient.
      • Orient your client.
      • Allow liberal visitation.
    • DECREASED PRIVACY
      • Pull curtain and close door.
      • Knock.
      • Identify room boundaries, esp. if sharing room.
      • Be careful of exposing patient.
      • Patient feels uncomfortable because of unkempt appearance, so announce visitors.
    • LOSS OF IDENTITY
      • Call patient by name they prefer.
      • Allow patient to wear own gown.
      • Display pictures.
      • Give them some choices. (bathing, eating, etc.)
    • DISCHARGE
      • TERMINATION OF CARE FROM A HEALTH CARE AGENCY
      • METHOD (ACRONYM)
      • M-MEDS
      • E-ENVIRONMENT
      • T-TREATMENT
      • H-HEALTH TEACHING
      • O-OUTPATIENT REFERRAL
      • D-DIET
      • AMA (Against Medical Advice)
      • PT LEAVES PRIOR TO OBTAINING A WRITTEN ORDER. NURSE REQUESTS PT TO SIGN FORM. IF REFUSES, NURSE MUST LET PT LEAVE AND NOTE REFUSAL TO SIGN AMA IN CHART.
    • NURSES RESPONSIBILITY FOR DISCHARGING A PATIENT
      • GATHER BELONGINGS/CHECK INVENTORY
      • ARRANGE TRANSPORTATION
      • INFORM PT OF CHECKOUT TIME TO AVOID BEING BILLED FOR AN EXTRA DAY
      • ESCORT UNTIL PT SAFELY INSIDE VEHICLE
      • WRITE DISCHARGE SUMMARY
      • TERMINAL CLEANING. BED STRIPPED AND DISINFECTANT USED. BEDSIDE CABINET RESTOCKED/CLEANED.
    • TRANSFER
      • DISCHARGING A PATIENT FROM ONE UNIT OR AGENCY AND ADMITTING THEM TO ANOTHER UNIT
      • INFORMS PATIENT/FAMILY
      • COMPLETE TRANSFER SUMMARY
      • SPEAKS WITH NURSE ON TRANSFER UNIT
      • TRANSPORTS PATIENT/BELONGINGS/SUPPLIES & CHART
      • CHECKS ORDERS/MAKES NEW ADDRESSOGRAPH CARD W/NEW ROOM #
    • WHO/WHAT IS INVOLVED IN A PLANNED DISCHARGE? NURSE-EXPLAINS DISCHARGE INSTRUCTIONS TO FAMILY/CARE GIVER PATIENT EXTENDED CARE FACILITY SAFEKEEPING RN OR SOCIAL WORKER CARE PROVIDER UNIT SECRETARY CALLS FOR TRANSPORT, COPIES CHART/ORDERS PHYSICIAN’S ORDER
    • SETTING STANDARDS
      • * REMEMBER*
      • THE AMERICAN NURSE’S ASSOCIATION SETS THE STANDARD FOR PT CARE & DOCUMENTATION FOR RN’S
      • LPN’S ARE GOVERNED BY JCAH
      • DO NOT USE “SEEMS” OR “APPEARS” IN DOCUMENTATION. IMPLIES DOUBT AND LACK OF KNOWLEDGE.
      • STUDENTS DO NOT NEED TO READ P.126-129( EXTENDED CARE FACILITIES) BUT NEED TO READ NURSING GUIDELINES ON TRANSFERRING A CLIENT, P. 126, GENERAL GERONTOLOGIC CONSIDERATIONS & CRITICAL THINKING EXERCISES.