Admission, Transfer, and Discharge (Client Care) (Nursing) Part 3

Reporting the Admission

The Joint Commission (JCAHO) requires that an RN perform formal admission assessments and formulate nursing diagnoses. When a nursing student or licensed practical nurse or licensed vocational nurse (LPN/LVN) has completed the client orientation and the assigned admission procedures, he or she can notify the admitting RN. The LPN/LVN reports his or her specific observations, along with other pertinent data, such as the client?s vital signs, weight, and client-reported symptoms.

The orders given by the primary care provider are checked, and the dietary order is sent to the Food Services Department. Other orders are sent to the laboratory, radiology, pharmacy, and other departments. The client is also logged into the computer during this process. (In most acute-care facilities, all of the orders are entered into the computer and automatically transmitted to other departments, such as the laboratory.)

Head-to-toe observations are an important component of the admission process .Much data are collected by the admitting nurse and/or primary healthcare provider, but the LPN/LVN assists in the process. These observations provide a starting point for the later development of a medical diagnosis and nursing care plan. The assigned RN is responsible for completing the admission assessments, formulating a problem list, and developing nursing diagnoses. The individualized nursing care plan is based on the identified problem list, and the entire team works to develop a multidisciplinary care plan. Box 45-2 lists pointers for admission documentation. (Most acute-care facilities document admissions by computer. Each client unit may have its own computer. In other cases, a mobile computer, connected to the facility?s network, is brought to the client?s room for the admission. These computers are sometimes called ?COWs??computers on wheels.)

BOX 45-2.

Admission Documentation

In many facilities, it is the responsibility of the RN to document official interview information, but nursing students and licensed practical nurses or licensed vocational nurses (LPNs/LVNs) often record the following information:

???? Weight and height

???? Vital signs, including pain

???? Pulse oximetry

???? Whether any laboratory tests were done, blood drawn, or x-ray studies done

???? Any other procedures

???? Who is accompanying the client

???? Specimens sent to the laboratory: note the amount of urine voided and its appearance, or the client?s inability to void

???? Any prostheses or appliances the client uses (e.g., dentures, contact lenses, glasses); note where these items were placed ("at bedside,? "sent home with family,? etc.)

???? Listing and location of the client?s property, including all clothing. List all items sent to the vault. Provide a receipt to the client and place one in the client record.

???? Report any other information or symptoms directly to the charge nurse or team leader:

???? Tag and send any dangerous items, such as knives or other weapons, to the Security Department for safekeeping until the client is discharged. Illegal weapons, street drugs, or other contraband, such as drug paraphernalia, may be confiscated and destroyed. It may also be necessary to notify the police. Refer any questions to the team leader or charge nurse.

Advance Directives

As stated previously, the law requires all clients to be informed about advance directives on admission to a healthcare facility.Ensure and document that the client has received information regarding advance directives when admitted to the facility. If the client has an advance directive or a living will, be sure this is entered in the appropriate location on the computer. Sometimes, a paper copy is kept in a separate place. In some facilities, a special ID band is also worn.

Nursing Alert A copy of any advance directive must be in an accessible location. If the client has an electronic form of medical information, such as the E-HealthKey,the pertinent data must be transferred to the facility?s records, either in hard copy or electronically

TRANSFER TO ANOTHER UNIT

The client may be transferred to another unit for several reasons:

???? Assignment to a certain unit is temporary.

???? A change in client acuity (level of illness) necessitates placing the client in another department.

???? The client is becoming agitated by a very busy unit and requires a quieter environment.

???? The client is disturbing others, for example by snoring loudly, and needs a private room.

???? The client?s condition becomes serious enough to require transfer to an intensive care unit (ICU).

???? Another, more acute condition is discovered than that for which the client was first admitted. Another unit specializes in care of clients with that condition.

???? The client has delivered a baby and is being moved into a postpartum area.

???? The client has had surgery and is being moved to postsur-gical care.

???? The client is exhibiting behavior that is dangerous to himself or herself or to others and requires transfer to a psychiatric or other secure unit.

???? The client has some form of dementia and must be moved to a locked unit for safety.

In Practice: Nursing Care Guidelines 45-3 outlines steps to follow when transferring a client.

Key Concept The procedures for transfer to another area of the facility are carried out in much the same manner as if a client is to be transferred to another healthcare facility

DISCHARGE

Planning for the client?s discharge (D/C) begins at admission. The nursing care plan is updated and resolved throughout the client?s stay. At discharge, nursing problems are either resolved or progress toward resolution and follow-up plans are noted. The client and family are taught about the illness or surgery; they have an opportunity to practice procedures and to learn about dressing changes, care of tubes and drains, medications, and special diets. The client is informed as to who to call if any questions or problems arise. Plans for home care or Public Health Nursing visits can be made. The staff and client work on completing these activities throughout the client?s hospitalization, but at discharge, final plans are made. Discharge from a rehabilitation center or extended-care facility is similar, with the goal of returning the client home to self-care as soon as possible.

IN PRACTICE :NURSING CARE GUIDELINES 45-3

TRANSFERRING THE CLIENT TO ANOTHER UNIT

Preparation for the Transfer

???? Explain the transfer to the client and family Give the reason for the transfer and when the transfer will take place. Rationale: Clients may become anxious and fearful when moved to an unfamiliar setting.

???? Assemble all the client?s personal belongings, as well as paper records, permits, and advance directives, addressograph cards, name stickers, vault receipts, x-ray films, medications, and special reports. Be sure the client?s information is transferred in the computer to the new location. Double-check for all clothes, flowers, and other articles. Rationale: If items are left behind, the client?s care may be compromised because the new unit does not have all pertinent information. In addition, it is more difficult to find items once they have been left behind. It causes more work and frustration for everyone.

???? Determine how the client will be moved. Rationale: You are responsible for safely moving the client. Type of transportation depends on the client?s condition. Seldom is the client allowed to walk.

???? Provide for client safety Take measures to accommodate IV bottles, drains, and catheters. Protect the client from drafts, and cover the client with a blanket for warmth and privacy Rationale: It is important not to worsen the client?s condition.

???? Collect all the client?s medications, IV bags, and tube feedings, and take these to the new unit. Check the computer or medication administration record for accuracy Rationale: All treatments that have been performed and medications given must be documented, to ensure lack of duplication and to prevent omission.

???? Review the client?s health record and check for completeness.

???? Record the transfer in a transfer note, usually done on the computer Give the time, the unit to which the transfer occurs, type of transportation (wheelchair or stretcher), and the client?s physical and psychosocial condition. The nurse may need to include a brief review of the client?s history as well. For example, ?1410: Client diagnosed with COPD transferred from Room 3I2B to Room I 10A via W/C (wheelchair). Medication, chart, and belongings given to P Johnson, RN. Client?s VS. (vital signs) stable, O2 sat = 97% on room air.Rationale: It is important for the receiving unit to know as much about the client as possible. This will ensure continuity of care from all staff on the new unit, around the clock.

???? Make sure the receiving unit is ready Usually a short verbal report is given to the receiving nurse. Rationale: To provide immediate continuity of care on the new unit.

Transporting the Client

???? Keep the client safe during the move. Rationale: Being moved is traumatic in itself. It is important not to further upset or endanger the client.

???? Introduce the client to the staff at the new nurses? station, if his or her condition permits. Rationale: Make the client feel as much at home as possible.

???? Give a report to the staff on the new unit, if this was not done on the phone before the transfer

???? Leave medications and records. Double-check to make sure the transfer is completed in the computer If the facility is not computerized, notify the Admissions Office and Client Information Office. Rationale: To ensure that the client will continue to receive his or her mail, visitors, and flowers.

???? Take the client to his or her room.

???? Assist the client into bed and make sure he or she is comfortable.

???? When returning to the nursing unit, notify all necessary departments of the transfer This includes the dietary business, radiology and pharmacy departments. Make sure that all scheduled tests and treatments are still scheduled, with the new unit identification. In some cases, this will all be done automatically in the computer In other cases, when a client is moved, he or she will require all new orders. Rationale: Make sure no important procedures are missed because the client has been moved.

???? If the client is dangerous, under police custody or an escape risk, request assistance from security personnel. Rationale: This helps to make sure the client arrives at the new unit safely.

???? Observe procedures for transporting a client who requires reverse isolation or who has a condition requiring isolation to protect the public. This might include having the client wear a mask and/or gown. Be sure the receiving unit is aware of the isolation status. Rationale: This maintains client and public safety.

The total nursing care team, client, and family are involved in discharge planning and organizing care at home. Figure 45-7 shows an example of a written discharge summary. However, this form is usually part of the electronic record and is printed out to give to the client/family on discharge. The physician or other primary care provider orders medications and treatments and nursing staff members identify special nursing considerations for the client/family to follow at home. Home care is arranged, if needed, and follow-up appointments are listed as a reminder to the client.

Nursing students and LPNs/LVNs assist with teaching the client and family before discharge. In Practice: Educating the Client 45-1 lists pertinent information for discharge. The facility?s protocols will describe specific staff members? roles in discharge teaching. Report any suggestions you have for client teaching. The entire nursing care team needs to know the client?s responses to teaching.

To determine that the client and family members understand, it is important that they be able to verbalize information and to perform return demonstrations of procedures (Fig. 45-8). Carefully document all discharge teaching. For example, ?client was shown how to change colostomy bag and was able to return demonstration accurately. Plan to have client change bag independently tomorrow.?

Before the day arrives for the client to go home, discuss the best time for him or her to leave. Ask when the family will be available to pick up the client. Instruct the family to bring clothing, pillows, or blankets if they will be needed.

Key Concept Remember that discharge planning begins on admission to the healthcare facility All members of the healthcare team are responsible for a safe and efficient discharge.

FIGURE 45-7 ? Example of one facility?s multidisciplinary client discharge summary. In many facilities, this information is part of the electronic record and is printed out for the client at discharge.(Continued)

The Day the Client Is Discharged

On the day of discharge, if the person seems eager to leave and if his or her condition permits, the client can dress in street clothes and rest on the bed until it is time to go. Make sure all the steps in the discharge have been completed before the client leaves the facility. In Practice: Nursing Care Guidelines 45-4 provides guidelines on discharging the client.

Key Concept Written discharge instructions are provided to the client. These include restrictions, special diet instructions, and signs of complications, as well as the date and time of follow-up appointments. Included is a phone number to call if the client has any problems, questions, or concerns. The nurse discharging the client must provide verbal instructions and must go over the written instructions. All of these procedures must be documented. Often, the client is asked to sign a copy of the discharge instructions and this is placed in the permanent record. The client also signs a copy of his or her property sheet, verifying that all personal property brought to the facility is back in his or her possession.

Documentation

In some healthcare facilities, only RNs perform discharge documentation. A student or LPN/LVN may be asked to assist. The practical nurse?s observations are important, whether they are written or input directly into the health record, or reported to another person.

The nurse who discharges the client brings the health record up to date, records the hour of discharge, and documents who accompanied the client and whether the client was in a wheelchair or required an ambulance. Whether or not the client is returning to home or another place is noted, along with the address and phone number. A nursing summary that includes the identified nursing problems and their resolution or revision may be required in the client record. For example, ?42-year-old male admitted with a diagnosis of coronary artery disease. Status/post (S/P) placement of two stents. Client denies angina. BP 134/74, apical pulse 82, with normal rhythm, respirations even and unlabored, skin color pink. Client able to perform wound care independently; verbalize medications with doses, times, and side effects; and describe exercise and diet regimens. Client informed of time/date for postop examination. Postoperative course has been unremarkable. Client has phone numbers to call if problems.?

FIGURE 45-7 ? (Continued)

IN PRACTICE: EDUCATING THE CLIENT 45-1

DISCHARGE PREPARATION

Remember that planning and teaching for discharge begins immediately upon the client?s admission to the healthcare facility Teaching while preparing the client for discharge includes the following:

???? Explain the safe change of dressings. Give the client a list of needed supplies. Instruct the client as to when the dressings should be changed. If the client will not be able to obtain supplies immediately most facilities allow the nurse to send supplies with the client that will last for a day or two at home. Demonstrate the method for removing the old dressings and for safe disposal of them at home. Demonstrate how to put on the new dressing safely Allow the client and family to practice while you watch, to be sure they know how to do the procedure.

???? Describe the amount of rest the client will need and activities that are allowed and their duration. Describe and demonstrate suggested exercises, and detail walking regimens.

???? Detail dietary restrictions, such as foods the client should eat and their amounts; foods that are required each day; and foods that are not allowed on the client?s prescribed diet. A dietitian should consult with the client about special diets and be available to answer questions.

???? Show caregivers how to perform personal care; make the bed, give a bed bath, move and turn the client, give and remove the bedpan, adjust pillows, and maintain body alignment and skin integrity for clients who will be confined to bed at home. Allow caregivers to practice and demonstrate back to you.

???? Demonstrate the operation of equipment and care of tubes and ask the caregivers to demonstrate back to you.

???? Understand and communicate the client?s preferences for how treatments are performed.

???? Emphasize the importance of self-care and building the client?s independence and self-esteem. Teach the family to encourage selfcare by the client as much and as soon as possible.

???? Provide information about public health and home nursing services. Give the client/family the phone number to call if these services are needed or help to arrange services.

???? Explain where to buy or rent equipment, materials for dressing changes, special beds, wheelchairs, and so forth. Give this information to the client in writing.

???? Advise the family if substitute pieces of equipment can be used. (For example, in some cases a regular bed placed on blocks can replace a special hospital bed. Make sure the client can safely get in and out of a higher bed.)

EDUCATING: THE CLIENT 45-1 continued

???? Describe medication administration, such as how and when to take medications and undesirable side effects. Give the client/family written guidelines for medication administration and a list of possible side effects. Be sure the client and family understand the need for accuracy

???? Identify situations that require the client to be seen by the primary care provider. Provide the client with a list of possible adverse signs and symptoms that would require immediate emergency attention. Write the name and phone number of this provider and instructions on how to contact this person or get emergency assistance.

???? Write down the phone number of your hospital unit, so the client can call if there are any questions.

???? Communicate the date, time, and location of the next scheduled examination, if known. This should also be given to the client/family in writing as a part of the discharge instructions.

???? Discuss with the physician the need for a public health nursing referral, if the team feels that the client and/or the family will not be able to manage the client?s care safely at home.

???? Make sure the client has all personal property Retrieve items from the vault if the client or family will be unable to do so.

These measures complete the nursing record of the client?s stay in the healthcare facility. The primary healthcare provider is also required to write a discharge summary for the health record within 24 hours of discharge.

Source: http://what-when-how.com/nursing/admission-transfer-and-discharge-client-care-nursing-part-3/

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