Okay, in this video, we are going to start off by talking about the nursing process.

So, there are four step in the nursing process.

Oke, dalam video ini, kita akan memulai dengan membahas

tentang proses keperawatan.
Jadi, ada empat langkah dalam proses keperawatan.

The first is assessment and data collection.

So this includes collecting data such as subjective information, like the patient’s pain level,
and what that pain feels like, and also objective information such as the patient’s vital sign,
So what’s really important for you to remember is as a nurse you always want to asses,
before you take action.

So if you get an exam question saying a patient is short of breath, what is your priority
nursing action, well it’s not gonna be to just call the provider, or crank up the oxygen. Right
it’s probably going to be something like listen to the patient’s breath sounds to see what you
hear check their SpO2. Do your assessment first, before you take action. So super important
to know for exams.

Okay, the secound step in the nursing process is analysis and data collection.
So you want to cluster the collected data during this stage identify any patterns or trends,
and then compare the data you collect it to the expected values.

And then the third step is planning.

So this is where you would prioritize, your interventions, and identify measureable
outcomes.
So you want to make sure these outcomes are time limited, and specific
So they’re not going to be something vague, like the patient will be feeling better in a
couple days, right it’s just very big.

So the next step is implementation.

So this is where you’re going to perfom your nursing care, and you’re going to document
your patient’s responses to, the interventions that you’re doing.
And then the fifth step is evaluation
So this is where you’re going to compare the actual results with the planned outcomes and
determine next steps.

So if your intervention were successfull, and the patient has met those outcomes then great,
if not then you got to work on a plan B and determine next step.

Okay, so that is the nursing process

Lets talk about patient admission.
Ehm. There’s several things you need to do, admitting a patient is pretty time – counsuming,
but there’s a lot of important things you need to do, and we’re gonna go over a few of those
key items.

So first of all you want to document your patients advance directive status, like right away,
because of something go south while they’re in the hospital like if you can’t feel a pulse, do
you call a code blue, or they a DNR (do-not-resuscitate) patient.

So you have to get real clear with that at the beginning, you want to document the patient’s
vital signs, their height and weight, their allergies, you want to do a head-to-toe assessment,
take a health history, and then (aem) figure out if they have any spiritual or cultural,
considerations that need to that you need to accomodate while they’re at the hospital.
The other really important thing you need to do, when you’re admiting a patient is to asses
them for their ability, to swallow safely.

So we would wheat at my hospital, we give them just a little bit of water, and check for their
swallowing are they like coughing immediately, are they having difficulty swallowing, if
you have any concerns, that they are not able to swallow, safely, then you need to keep then
NPO, until you get a swallow evaluation, by, and you can guess who the resources based on
our last video, it’s the speech-language pathologist.
That’s the person whos’s going to do the swallow evaluation.

Okay you also want to do a safety assessment, and implement fall precautions if appropriate.
So if your patient is at risk for falls, because they’re either unsteady, they’re on medicatons
that can make the unsteady, you need to make sure you keep the bed in the lowest position,
you want to set the bed alarm, and then (aem) depending on your facility, we put like a little
like falling star of something outside, their room to let staff know, that this patient is on
small precautions and sometimes they also get a bracelet that indicates, they are on fall
precautions.

And then you want to inventory the patient belongings, lock valuables in the facility safe,
ideally we want to send home, as many valuables as possible with like a family member, but
if there’s any that remain, we want to call security and get those put in the safe.

And then we‘re going to want to do a medication reconciliation.

So this is where we, (uhm) take in like with the patient intake we figure out what all their
home medication are, what they take at home, what dose, what time, etcetera, and we try to
reconcile this with whatever the provinder is prescribing for the patient.

And then lastly but probably most importantly, discharge planning actually starts at
admission. And that’s a really important one to know for your test.
So, we’re already thingking about how this patient is going to discharge as soon, as they
walk in the door at admission.

Okay, let’s talk about patient transfor now.

So when they’re going form one unit to another.
You want to use some kind of tools, such as an SBAR. So SBAR stands for situation,
background, assessment, and recomendations.
So this is a great tool to use, as you are giving report to the receiving nurse at the other unit.
So you’re letting them know what the patient’s situation is, a little bit of the background,
and your correct assessment, and what your recomendations are, for the patient.

And then in term of discharge.

Let’s talk about some key components of discharge (aem) paperwork and just the teaching
you need to do.
So in the discharge paperwork, you definitely want to include the patient’s diet, and activity
restrictions, you want detailed instructions provided to the patient, for procedures that will
need to be done at home, such a wound care.
And then you want to provide a list of medications to the patien, when to take each
medication, and any kind of precautions regarding the medication.

You want to provide the patient information about signs, and symptoms of complicattions,
and when to seek medical attention, and you want to provide follow – up appointment
information.
So nine times out of ten as a patient is leaving the hospital, they will need to follow up with
their primary care provider with in a couple days.

And then you always want to provide names and numbers of provides and or community
resources that the patient may need when they discharge.

So that is some information about admission, transfer, and discharge.

We will pict it up with my next video.
Thanks to watching!