Fundamental Nursing Skills and Concepts

1
Fundamental Nursing Skills and Concepts

• Chapter 10
• PAGE 117

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ADMISSION

• Entering health care agency for nursing care,
  medical or surgical treatment. The process
  includes
• 1. obtaining medical authorization
• 2. collecting billing info. by the admitting
  dept.
• 3. completion of admitting procedure by nursing
  personnel
• 4. documenting patients medical history and
  findings of the physical
• Initial medical orders for treatment

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Admission to the Health Care Agency

• Authorization from a physician- admission must be
  determined by a physician either for the clients
  condition, testing that may be needed, special
  care or treatment that can only be carried out in
  that particular health care setting.
• The admitting dept.- initiates a medical record.
  Gathering of information from or about the client
  for record keeping and billing purposes.

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Admission to the Health Care Agency

• Collection of billing information, done be
  admitting dept.. The ID bracelet may be put in
  place here or later in the pts. room by the
  admitting nurse. Completion of the admission
  procedure- the bracelet is very important and
  contains the name of the pt. , Id , pts. doctor,
  and the pts. room . It will stay in place
  throughout the hospital stay. Other than, asking
  the patients name, the bracelet is the single
  most important method of identifing the patient.

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Admission to the Health Care Agency

• Addressograph card- identifies all pages of the
  pts. chart. So it is important that it is
  correct. Room change- card must be changed.
• In the hospital setting now sticky labels with
  clients info printed on them are now furnished
  to Id. clients paperwork as well as belongings.

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Nursing admission activities

• Nurse checks to see that the room is clean, well
  stocked with basic equipment. Oxygen equipment
  available. IV standard in place.
• Nurse welcomes patient, smile, greets the client,
  gives a handshake.
• Nurse wears name badge so it can be easily read
  and introduce self.
• Double occupancy room, please do not overlook
  introducing room mate.

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Orienting the Client to the Room

• The location of the nursing station
• Where to store clothing and personal items
• How to call for nursing assistance
• How to adjust the bed, equipment in environment
• How to regulate the room lights

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Orienting the Client to the Room

• How to use the phone
• How to operate the television
• The daily routine, schedule such as meal times,
  activities
• When the physician visits
• When surgery or diagnostic testing is performed
• Answer any questions, this will make him more
  comfortable

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Valuables and clothing

• Clothing usually remains in pts. room, but
  valuables should be encouraged to make a return
  trip home with the family or loved ones. Always
  document what was sent home with the name of the
  person taking it home on the inventory check
  list. If sending valuables home is a problem,
  observe the agencys policy on safeguarding
  valuables. Hospital safe is used be descriptive
  of object- 1 yellow metal ring with a clear stone
  or red stone. You are not a gemologist so do not
  assume it is a diamond or ruby. Just put down
  what you see. A second nurse, supervisor, or
  security personnel should be in attendance when
  the nurse and patient co-sign an inventory list.
  A copy to the patient, another attached to the
  chart.

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Valuables and clothing

• Inventory list of patients belongings on page
  120.
• Patients name should be labeled on all personal
  equipment, such as walkers, c-pap machines,
  wheelchairs. Special cups for dentures should be
  labeled. Please take care of eyeglasses and
  hearing aids also. If negligence is proven in
  loss, the agency replaces.

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Helping patient to undress

• Provide for privacy
• Bed in low position
• Remove shoes
• Remove the most comfortable way in the least
  disturbing fashion. Remove unaffected side last,
  but, dresses it first.
• Apply hospital gown if possible. Page 120 lays
  steps used.

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Admission to the Health Care Agency

• Documentation of clients medical history- some
  of these skills may be delegated out. Such as
  v/s, weight, and admission questions may be done
  by the receiving nurse who is the LVN.
• The patients condition and the agencys policy
  may deviate the procedure.
• Documentation of clients physical examination

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Admission to the Health Care Agency

• Development of an initial nursing care plan-
  completed within 24 hours following admission.
  Initial plan generally identifies the clients
  priority problems and may include the projected
  needs for teaching prior to discharge. Revise as
  needed.
• Initial medical orders for treatment, lab and dx.
  tests, activities and diet are done -medical hx.
  obtained and a physical exam within 24 hours is
  done and documented. An associate may be
  delegated to do so but it must be done with in 24
  hours. Medical hx. and physical exam generally
  include, identifing data, chief complaint,
  history of present illness, personal history,
  past health history, family history, review of
  body systems and conclusions.

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Cont.

• Page 121 identifies the 8 components of a medical
  history.
• Conclusions are reached, if not, physician may
  document rule out, ( R/O ) , this is for
  suspected diagnosis and more testing is required
  to determine the diagnosis.

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Initial Nursing Plan For Care

• Admission data is collected
• Nurses develops an initial plan of care within 24
  hours
• Skill 10-1 describes basic steps in admitting a
  client page 132.
• Identifies the clients priority problems
• Identifies the projected needs for teaching prior
  to discharge
• The nurse revises the care plan as the clients
  condition changes.

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Specific Responses to Admission

• Anxiety
• Fear
• Decisional conflict
• Situational Low Self-esteem
• Powerlessness
• Social Isolation
• Risk for Ineffective Therapeutic Regimen
  Management

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Admission Responses

• Anxiety-uncomfortable feeling caused by
  insecurity. Always explain, instruct or teach, to
  inform the patient what is going to happen. They
  have a fear of the unknown, so keep them informed
  for more cooperation. Also you will find it takes
  less pain medication to combat there pain if they
  are well informed. Nursing care plan on page 122.
• Loneliness-occurs when a client cannot interact
  with family and friends. Admission limits
  interaction with family and friends. Make
  frequent contact with the client. Many
  facilities recognize that their clients need more
  liberal times for their loved ones to visit.
  Contact with those that are young is very
  important. Check with your facility to see if age
  limits are enforced.

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Admission Responses

• Decreased privacy-ensure privacy by closing
  doors. It is common courtesy to knock before
  entering a clients room. You need to demonstrate
  respect and ensure protection of each patients
  rights to privacy. On admission inform the client
  of where they may retreat for solitude, such as
  the chapel, reading room, solarium. Smoking
  areas now are limited to none available.
• Loss of identity-a healthcare facility may
  temporarily deprive a person of his or her
  identity. Client may feel like they are receiving
  care, but no caring. Learn and call all patients
  by their name. The goal is to keep the admission
  as brief as possible and to discharge patients
  back to their homes as soon as possible.

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Discharge a client

• Skill 10-2 page 135

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The Discharge Process page 124

• Obtain authorization for medical discharge- by
  obtaining a written medical order

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The Discharge Process page 124

• Provide discharge instructions- page 124,
  planning for discharge actually begins when
  patients are admitted. Use the acronym METHOD,
  table 10.2. The nurse reviews the teaching that
  was done, gives the prescriptions to be filled,
  advises to make an office visit appointment,
  gives the client a written summary of discharge
  instructions, patient signs, carbon copy is
  attached to patients chart.
• Notify the business office of discharge- need to
  make sure all insurance info. is complete,
  authorizations signed for release of medical
  info. for reimbursement or financial arrangements
  have been completed

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The Discharge Process page 124

• Gather the clients belongings
• Arrange the clients transportation if needed
• Escort the client at the time of discharge

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The Discharge Process page 124

• Write the discharge summary-of patients condition
  at the time of discharge
• Request room be terminally cleaned. The room is
  terminally cleaned, stripped of linen cleaned
  with disinfectant, restocked with basic equipment
  and the admissions department notified of a ready
  room.

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The Discharge Process page 124

• Authorization, physician writes discharge order,
  prescription and any follow up instructions.

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The Discharge Process page 124

• Leaving against medical advice or AMA, this is
  when a patient leaves before the physician
  authorizes the discharge. The nurse negotiates
  with the patient or family. To no avail, notify
  the nursing supervisor and the physician of the
  patients wishes. Patient still determined the
  nurse asks the patient to sign a special form.
  The AMA form releases the physician and health
  agency from future responsibility for any
  complications that may occur. Patient refuses to
  sign, cannot be detained. Document the AMA form
  was presented, explained and refused to be signed
  and this is all noted in the patients medical
  record.

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Transferring patients page 125

• Involves discharging from one unit or agency and
  admitting him to another without going home.
  Maybe to a step down unit or progressive care
  unit or a unit that requires less intensive
  nursing care. Nursing guidelines 10-1 page 126.

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Admission to Other Nursing Facilities

• Extended Care Facilities-Health care agency that
  provides long-term care. Provides care for people
  who are unable to care for themselves but do not
  require hospitalization
• Skilled Nursing Facilities-Provides 24-hour
  nursing care under the direction of a registered
  nurse. Must be referred by a physician and
  require specific technical nursing skills such as
  

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Admission to Other Nursing Facilities

• (1) observation during an acute or unstable
  phase of illness.
• (2) enteral feedings or IV fluid
  administration.
• (3) bowel or bladder retraining.
• (4) administration of injectable meds.
• (5) sterile dressing changes.
• This facility must provide rehabilitative
  services, physical therapy, occupational therapy,
  pharmaceutical therapy, dietary services,
  diversional activities, therapeutic activities,
  routine and emergency dental services.

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Cont.

• Those who have Medicare are entitled to 20 days
  of full coverage and 80 days of partial coverage
  per year for skilled care. Some folks have
  private insurance policies to cover costs that
  medicare doesnt, but for those that go beyond
  100 days they bear the cost personally, until all
  their resources are used and those of their
  spouse. Then when they are considered indigent
  they can apply for medicaid or its equivalent in
  their respective state.

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Admission to Other Nursing Facilities

• Intermediate Care Facilities-Provides health care
  for people who require institutional care due to
  a physical or mental condition, but not 24 hour
  nursing care. They need supervision, assistance
  with meds, bathing and dressing. They tend to
  wander or are confused. Medicare provides no
  reimbursement for ICF. The costs are assumed
  personally or by state welfare programs like
  medicaid.
• Basic Care Facilities- BCF-Agency that provides
  extended custodial care. Provides shelter, food,
  laundry services in group home settings. ADLS
  carried out on own.

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Minimum Data Sets (MDS)

• Assess level of care using a standardized form.
• Repeated at 3 month intervals.
• MDS required assessments are listed on page 128.
• Problems that are identified an MDSs are
  reflected in the nursing plan of care.
• These defeciencies must be addressed and focused
  on for the care of that client.

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Client Referral

• Selecting a nursing home, page 128
• A referral- sending someone to another agency or
  special services. Table 10-3 Common Community
  Services

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Client Referral

• Continuity of care, care remains uninterrupted
  despite change in caregivers.
• Home health care- care provided in the home by a
  home health agency employee, either a nurse, LVN
  or RN, aide or therapist. Medicare and insurance
  companys reimbursements are limiting hospital
  stays, so this adds to the need for extended care
  to be carried out in patients homes. There is
  also a greater number of older Americans that can
  use these types of services.
• This type of nursing service help shorten the
  time spent in the acute care facility.
• Display 10-3 responsibilities of Home Health
  Nurses