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.
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
Kardexesis 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, physician’s name, diagnosis • List of medications
List of intravenous fluids • List of daily treatments and procedures • List of diagnostic procedures ordered • Specific data on how the client’s 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.
Flow Sheet, it enables nurses to record nursing data quickly and concisely and provides an easy-to-read record of the client’s 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.
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 nurse’s 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
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.
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.
Regardless of format, discharge and referral summaries usually include some or all of the following: • Description of client’s 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
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.
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
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
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
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
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
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.