Admission
● The activities surrounding a client’s arrival at the
facility for the purpose of receiving healthcare.
● Each continuous period of time a client spends in a
facility is considered one admission.
The Admitting Department
● The first contact most clients have on arrival at the
healthcare facility or it can be the admitting clerk in
the Outpatient Department.
● Exceptions: pre-registered clients or those that
arrive by ambulance for an emergency admission
and be taken immediately to surgery.
● Enter information about the client’s age, sex, marital
status, next of kin, employer, healthcare provider,
and health insurance into the health record.
Identification band (ID)
● An ID with a client’s name and agency identification
number (also called medical record number or
history number) is applied to the client’s wrist.
● Birth date, date of admission, healthcare provider’s
name, and facility unit, may also be printed on the ID
band.
● A separate wrist ID band is applied noting any client
allergies. (If the client has no known allergies, a band
must be worn stating this fact.)
○ If the client is at risk for falling, a fall risk
name band is applied as well.
○ Color coding: name band is white, allergy
band is red, fall risk band is yellow.
Nursing Alert: Legally, the client cannot be allowed to receive
treatment, undergo diagnostic tests or surgery or receive
medications without a legible ID band.
● Proper identification of each client is vital. ID bands
are used in all inpatient facilities, such as hospitals
and long-term care facilities, as well as Emergency
Departments and diagnostic treatment areas, such
as dialysis, magnetic resonance imaging (MRI), and
radiation therapy. In addition to the name band, the
client wears an allergy band.
Diagnostic tests
● Often performed before the client is escorted to a
nursing care unit (e.g., x-ray examinations and blood
tests).
● During admission, the client signs documents giving
consent for treatments. The client or responsible
person also signs documents accepting financial
responsibility for costs not covered by insurance.
● The agency’s privacy policies are reviewed with the
client, the client is given a copy of the policy, and the
client or responsible person signs a document
confirming that these policies were discussed.
Key Concept: In many facilities, the entire admission process
is carried out electronically. All data are immediately entered
on the computer. The client’s signature is required on some
items, and this can be done electronically or on paper.
Advance Directives and Donor Status
● The client who has any advance directive or living
will submit a copy of the documentation for notation
in the client’s record. (Some clients may provide this
in electronic form.)
● All clients must be advised of their right to create an
advance directive while in the healthcare facility and
they must be offered assistance in preparing this.
○ Whether or not the client has an advance
directive, what type it is, and that the
opportunity was given to prepare one, must
be documented in the admission notes.
(Remember, if it is not documented, legally
it was not done.)
● In addition, each new client should be asked if he or
she is an organ or tissue donor. Although the client’s
family must make the final decision, it is helpful for
them to know the client’s wishes in advance.
The Client’s Arrival on the Nursing Unit
● Before the client’s arrival, check to be sure that the
unit is completely equipped and the bed is available.
The client may walk in or may arrive in a wheelchair
or on a gurney.
○ If possible, introduce the client to the
charge nurse and staff before taking him or
her to the room.
● Routines, equipment, and procedures that are
common for healthcare workers and admitting staff
may seem threatening and frightening to the newly
admitted person.
○ Explain the purposes for all of these to the
client, to ease discomfort.
● On admission to the healthcare facility, the client is
assisted to be comfortable. Usually, the person is
asked to wait in the room for the admission
interview and physical examination.
Key Concept: Remember that the client’s impression of the
facility depends largely on you. Make the person feel as
comfortable and safe as possible.
Removing the Client’s Clothes
● In many situations, the client will be asked to put on
a hospital gown and robe. Some people may be
allowed to wear their own pajamas. In some areas,
such as chemical dependency or psychiatry, the
client is encouraged to wear street clothes.
● It is the responsibility of nursing staff to inventory all
items brought by the client. In the acute-care facility,
most valuable items are sent home with the family
or placed in the vault, but in the long-term care
setting, the client will usually bring more property.
FIGURE 45-4· It is the responsibility of nursing staff to
inventory all items brought by the client. In the acute-care
facility, most valuable items are sent home with the family or
placed in the vault, but in the long-term care setting, the
client will usually bring more property. In some cases, the
facility is responsible for helping to safeguard client property.
● Give the client whatever assistance is needed to
undress. Sometimes a family member will assist,
particularly if the client is immobile or is a child.
○ Rationale: A child may resist being
undressed by a stranger or may not
understand the need for wearing pajamas
during the day. Refer to In Practice: Nursing
Procedure 45-1 when undressing the
immobile client. The client’s clothing and
other property are inventoried and stored
appropriately (Fig. 45-4).
Inspecting for Skin Integrity
● Each client must be carefully checked on admission
for any open wounds or existing pressure areas.
● Any existing wounds or questionable areas must be
carefully documented when the client is admitted.
○ If the client’s skin is not intact on admission
and this is not documented, the facility will
most likely not be reimbursed for related
care given.
Assisting the Client Into Bed
● If a client is weak or tired when admitted, remove
the client’s shoes and outdoor clothing, and help him
or her to lie down immediately.
● Cover the client with a bath blanket or bedclothes.
Lying down helps prevent added fatigue.
● As soon as the client is able, assist him or her to put
on a hospital gown or pajamas, if necessary, and
explain why this is desirable.
○ Rationale: Wearing the hospital gown
facilitates the physical examination and
various treatments. It also prevents soiling
of the client’s clothes. Remember that in
some areas, street clothes are worn.
Key Concept: Nursing data collection begins immediately at
the nurse’s first contact with the client.
Orienting the Client to the Facility
● The healthcare provider’s admission orders will
include the client’s allowed activity status, such as
bathroom privileges (BRP) or complete bed rest.
○ If the client is able to be out of bed, indicate
the location of the bathroom and closet.
● Check to see if the client is to give a urine specimen
or is on intake and output (a recording of all fluids
taken in and urine expelled).
○ If so, give the client a urinal, toilet hat, or
urine cup and explain what the client is to
do and why. Ask the client not to void
directly into the toilet until needed samples
are obtained.
● Allow time for the client to unpack, if items have
been brought to the facility. Encourage clients to
send any unnecessary items home with the family.
● Help the client, if necessary, and tell him or her
where you are putting items.
○ Place the bathrobe and slippers in a handy
spot.
 ○ Arrange the client’s personal belongings.
○ Place special items, such as eyeglasses, on
the bedside table or in the drawer for easy
reach.
● Adjust the window coverings, regulate ventilation,
and position the head or foot of the bed for the
client’s comfort.
○ If the client is at risk for falls, the side rails
are usually put up until the client is
thoroughly evaluated. Explain how the bed
works as you adjust it.
○ Teach the client how to work the TV, nurse
call signal, and lights over the bed.
Key Concept: Make sure a meal is ordered for each new
client. Be sure to check the provider’s orders to determine if
the client is on a special diet or fluid restriction.
● Introduce the client who is sharing a room to any
roommates. Do not leave the client until convinced
that the client’s questions have been answered and
the person is comfortable and safe. Leave the door
or curtains open or closed, as the client wishes.
● Intercom System. Show the client how the
communication system works, and place the “nurse
call” signal within easy reach.
○ Rationale: Taking time to explain things to
the client helps alleviate fear and anxiety in
unfamiliar surroundings.
Key Concept: Explain to the new client that the signal light in
the bathroom is for emergencies only Usually there is both a
button and a pull cord. Using either signal will probably ring
an alarm bell, as well as activate the nurse-call light. Ask
clients not to use this signal unless they need emergency
assistance.
● Toilet Articles. The healthcare facility usually
supplies such essential toilet articles as
toothbrushes, toothpaste, combs or hair picks,
tissues, and soap.
○ If a denture cup is needed, be sure to label
it, on both the container and the lid. If you
handle the client’s dentures or used tissues,
wear gloves.
● Hospital Gown. Acute-care facilities have these
items available for client use.
○ As stated previously, clients may bring their
own pajamas, nightgowns, bathrobes, and
slippers with them. The client’s family or
other caregiver is then responsible for
laundering these items.
○ It is advisable for clients who are bleeding,
incontinent, or have wound drainage to
wear hospital pajamas and robes, rather
than their own clothes.
● For clients confined to bed, using gowns provided by
the healthcare facility is customary. Hospital gowns
are easy to put on and remove. The sleeves also may
open to accommodate IV tubing.
Key Concept: Most hospitals provide extra-large gowns and
robes. If a client is unusually large, it may be necessary to use
two gowns, one opening in the front and one opening in the
back. Some facilities allow very large clients to wear special
scrub suits. In some cases, jail clothing must be worn. Some
areas, such as mental health or chemical dependency units,
encourage clients to wear street clothes as part of their
therapeutic care plan.
● Individual Equipment. Inform clients as soon as
possible that the equipment in their unit is for their
use alone. This equipment includes items such as
suction machines, oxygen, and inhalation
equipment.
Caring for the Client’s Personal Belongings
● Clothing. Each client in the acute-care facility has a
place for a bathrobe and slippers and a drawer for
other articles. Clients are encouraged to keep only
essential items in the hospital.
○ Fill out a property sheet, including a
description of every item of clothing. Follow
the system the facility has established;
doing so protects the client and the facility.
Have the client sign the property sheet after
he or she checks the list.
● Valuables. Valuables, such as jewelry, credit cards,
and cash, should not be brought to the facility. If
they are brought, they should be kept in the facility’s
vault.
○ In some situations, such as in an
Alzheimer’s unit or mental health unit, the
hospital does assume some responsibility
for client belongings, because the client is
not competent to do so. In this case, your
careful listing and description of the client’s
property becomes even more important.
● The client who is competent sometimes keeps a few
personal items, such as eyeglasses, dentures, a
prosthesis, or a watch or wedding ring, at the
bedside. These items are noted and described on the
property sheet.
○ If the client goes to surgery or has a lengthy
examination, items such as a watch or
eyeglasses are given to the family for
 safekeeping or are sent to the hospital
vault. The client must sign later to verify
that the items have been returned.
○ Describe items as much as possible. For
example, "blue Nike ski jacket” or "3 white
t-shirts.”
○ When describing jewelry do not make
judgments about values. For example, it is
best to say "clear stone” instead of
"diamond” or "gold-colored bracelet”
instead of "gold bracelet.”
Preventing Dehumanization
● Dehumanization is the process of depriving a person
of personality, spirit, privacy, and other human
qualities.
● It means neglecting the individuality of clients,
ignoring their specific needs, and failing to recognize
their need for input about their care.
○ Whenever possible, the nurse should
develop rapport and trust with the client
before delving into personal matters or
procedures that may embarrass or threaten
the individuality or privacy of the client.
● The person admitted to the healthcare facility
surrenders clothes, belongings, and individuality to
follow orders about when to eat, sleep, take a bath,
and even when and where to go to the bathroom.
○ A stranger (nurse) asks when the client last
had a menstrual period, sexual relations, or
a bowel movement.
○ All these factors have the potential to
dehumanize the person.
● Anxiety or Apprehension. A person facing illness or
surgery often feels anxious or nervous.
○ Individuals may be worried about the
welfare of their family or about finances.
This anxiety may cause physical and
emotional stress that can aggravate the
client’s health problem.
● A state of great anxiety can have varying effects on
the client’s coping mechanisms. Remember
Maslow’s hierarchy of human needs.
○ If a person’s lower-level needs are not being
met, he or she will have difficulty
concentrating and learning.
○ This person will probably not be able to
remember and identify what medications
are being given, learn self-care, or
participate in the development of his or her
care plan at that time.
○ The client’s anxiety level may be estimated
as follows:
■ Calm = Not anxious
■ + 1 anxiety = Increasing uneasiness
and apprehension
■ +2 anxiety = Increasing uneasiness,
apprehension, dread
■ +3 anxiety = Increasing
apprehension, dread, paranoia
■ Panic = Symptoms may include a
feeling of choking, difficulty
breathing, inability to sit still, chest
tightness or pain, trembling,
sweating, increased pulse rate and
blood pressure, headache.
○ Anxiety may be rational (logical or justified)
or irrational (out of proportion, unrealistic,
inappropriate to the situation).
○ Anxiety differs from fear in that the person
often cannot identify a specific cause for
anxiety.
○ Nursing interventions aimed at alleviating
anxiety and fear include:
■ Assessment of level of discomfort
■ Clear explanations and clear
answers to questions.
■ Offering the client an opportunity
to express feelings
■ Providing more helpful coping
mechanisms
○ It is important to remember that severe
anxiety or panic can interfere with medical
care. For example, non-emergency surgery
may be canceled if the client is extremely
apprehensive.
■ Fear of the Unknown. Perhaps the
most intense fear is fear of the
unknown. The client may be afraid
of serious illness or death.
■ Fear of Body Image Changes. Body
image refers to the way an
individual perceives himself or
herself. A person may feel
threatened by an illness, especially
if treatment involves surgery. This
concern exists even when surgery
will not cause a visible change in
the client’s appearance. If surgery
involves a procedure such as limb
amputation or breast removal, the
 concern about disfigurement is
more real.
■ Financial Concerns. Insurance
coverage varies. Some people do
not have insurance to cover the
costs of healthcare. Others worry
that their insurance will not cover
every procedure or treatment they
receive.
■ Embarrassment. Many people are
embarrassed when personal
services, such as bathing or
assistance in toileting, must be
performed for them. Providing as
much privacy as possible and
explaining what is occurring during
treatment are of key importance.
■ The Client Who Has Difficulty
Hearing or Understanding English.
The client who does not speak or
understand English (or who cannot
hear) is much more likely to be
uncomfortable in a healthcare
facility where everyone else speaks
only English.
Assessment, Reporting, and Documentation
● After orienting the client to the nursing unit and the
room, the admissions interview and history are
done, unless the client’s health needs dictate that
this must be done earlier.
○ In some situations, such as in a psychiatric
or emergency department, the client may
be too agitated, confused, sedated, or ill to
participate in an interview; the interview
may need to be postponed.
● The nurse takes vital signs and measures height and
weight.
PERFORMING THE ADMISSIONS INTERVIEW
● Gather necessary supplies
○ e.g., healthcare provider’s orders; computer
or written records; equipment for vital signs
and oximetry; brochures regarding client
privacy client rights, advance directives, and
unit procedures, such as visiting regulations.
● Become familiar with information from the
Admitting Department before meeting the client.
● Introduce yourself; explain that you will be taking
information and discussing routines of the
healthcare facility.
● Verify the client’s name and birth date, as printed on
the ID band.
○ Ask the client to state this information and
check the name band to make sure it is
correct. (Do not ask the client if he is "Mr
Johnson." Some clients will say yes, even if
this is not the case.)
● Observe the client’s general appearance
○ e.g., posture, ability to ambulate, mood,
attitude.
● Note the client’s general condition
○ e.g., level of alertness, orientation.
● Observe the client’s skin condition
○ e.g., temperature, color, turgor, scars,
lesions, abrasions, pressure areas, edema.
○ Carefully describe any abnormalities on the
interview form, indicating their location and
size.
● Monitor the client’s respiratory status
○ e.g., coughing, wheezing, shortness of
breath.
● Assess the client’s psychological status, as evidenced
by verbal and nonverbal responses.
● Measure weight and height.
● Measure vital signs. Ask about pain.
● Measure pulse oximetry.
● Maintain the client’s privacy and confidentiality.
● Obtain health history and information regarding
current status:
○ Next of kin, emergency contact person
○ Reasons for admission
○ Past illnesses and dates
○ Current medications
○ Allergies to medications, foods, and other
substances (e.g., latex). Verify all allergies
with the allergy name band and in the client
record.
○ Use of tobacco, alcohol, and street drugs
○ Daily eating, sleeping, elimination, and
exercise routines
○ Use of appliances or prostheses (e.g.,
artificial limbs, hearing aids, contact lenses,
dentures).
■ Note if the client has brought these
items to the facility.
○ Family support
■ e.g., Will people visit regularly or
stay in the facility with the client?
Is someone available at mealtimes
to help feed the client? Who
should be contacted in an
 emergency? Be sure to obtain
home, work, and cell phone
numbers.
○ Employer or school
○ Resuscitation or DNR (do not resuscitate)
status
○ Advance directives. Be sure a copy is in the
record.
○ Payee or guardian
WEIGHING THE CLIENT
● Calibrate the scale so it is at zero before weighing
the client.
○ Chairs and slings will automatically deduct
the weight of the equipment.
○ Determine the client’s weight by using the
weights and indicator on the free-moving
balance arm or by using the digital readout.
○ This is done in the same manner for all
types of scales.
● The client who is strong enough may stand on a
transfer paper or paper towel on the balance scales
or step-on scale.
● The standing (step-on) scale is used most often. A
balance-beam type is used in many healthcare
settings, particularly in physician’s offices.
○ On the balance scale, the client’s weight is
determined by sliding the small and large
weights along the balance bar until the
pointer of the bar balances without
touching.
○ The client’s height can also be measured at
the same time. Standing scales with
electronic readouts are used most often in
inpatient facilities.
○ The electronic scale can convert between
kilograms and pounds.
● Clients who are unable to stand are weighed on
chair scales or on the bed itself, if it includes a scale.
○ The chair scale resembles the step-on scale
but is equipped with an armchair for the
client’s comfort.
○ Assist the client to step up onto the
platform under the chair and to be seated
in the chair.
● An immobile client is weighed lying down on a sling
scale (bed scale, litter scale), a sling-type apparatus
that looks like a suspended hammock or a client
hydraulic lift.
○ Ask for assistance to place the client on this
scale (for client safety).
○ The machine raises the client from the
bed’s surface and then displays the weight.
● Weight is recorded in kilograms (kg), particularly if
the client is to have surgery or if other medication
doses will be based on weight.
○ Some facilities use kilograms for all weights.
Electronic scales will convert kilograms to
pounds, for the client’s benefit, if
requested.
● During time with the client, the nurse must be
observant.
○ Report to the team leader if the client
complains of severe pain or seems to be
very uncomfortable.
○ Look for any physical signs or symptoms.
○ Knowing the client’s diagnosis is helpful
when observing signs and symptoms.
○ Listen to what the client says.
● Weight. Measure and record the client’s weight on
admission. (Do not go by what the client says.)
○ This measurement provides a baseline for
later comparison.
○ Fluctuating weight may indicate when the
client is or is not retaining fluids.
○ Recent changes in usual weight can also
indicate situations such as anorexia or binge
eating. In addition, some medications cause
weight gain.
○ The client may experience weight loss as a
result of many factors, including illness,
chemotherapy, and depression.
○ The initial weight, compared with the
client’s height, helps to determine if the
client is overweight or underweight.
○ The admission weight also establishes a
baseline for further observations or
calculations of medication doses or
anesthesia.
● Height. Measure and record the client’s height on
admission.
○ When measuring height, ask the client to
remove his or her shoes and to stand on the
scale with his or her back against the
measuring bar.
○ Ask the person to stand straight.
○ Lower the L-shaped sliding bar so that it
lightly touches the top of the client’s head.
○ Record the height in inches or centimeters
(not feet or meters) on the flow sheet or
graphic sheet, according to healthcare
facility policy.
VITAL SIGNS STEPS OF HEALTH ASSESSMENT
The assessment phase of the nursing process has four major
Vital Signs Normal Ranges
steps:
Adult Temp (C & F) 36-38 oC (98.6-100.4 oF) 1. Collection of subjective data
Avg. Oral 37 (98.6) 2. Collection of objective data
Avg Rectal 37.5 (99.5) 3. Validation of data
Avg Axillary 36.5 (97.7) 4. Documentation of data
Newborns's temp range 35.5-37.5 oC (95.9-99.5 oF)
● Although there are four steps, they tend to overlap
HR and you may perform two or three steps
Infant 120-160 concurrently.
Toddler 90-140 ○ For example, you may ask your client, Jane
Preschooler 80-110 Q., if she has dry skin while you are
School-age kid 75-100 inspecting the condition of the skin. If she
Adolescent 60-90
answers “no,” but you notice that the skin
Adult 60-100
on her hands is very dry, validation with the
RR client may be performed at this point.
Newborn 30-60
Infant (6 months) 30-50 PREPARING FOR THE ASSESSMENT
Toddler (2 yrs) 25-32 Before actually meeting the client and beginning the nursing
Child 20-30
health assessment, there are several things you should do to
Adolescent 16-19
Adult 12-20 prepare.
● It is helpful to review the client’s medical record, if
BP avg: <120/80 available.
(30-50 mmHg) ● Knowing the client’s basic biographical data (age,
sex, religion, educational level, and occupation) is
SPO2 95 - 100%
useful.
● The medical record provides background about
chronic diseases and gives clues to how a present
illness may impact the client’s activities of daily living
How convert F to C? (F - 32) x 5/9
(ADL).
How convert C to F? (9/5 x C) + 32
○ An awareness of the client’s previous and
current health status provides valuable
Additional Information: Health Assessment
information to guide your interactions with
● Assessment is the first and most critical phase of the
the client.
nursing process. If data collection is inadequate or
○ This information can be obtained from the
inaccurate, incorrect nursing judgments may be
medical record, other health care team
made that adversely affect the remaining phases of
members and significant others (client’s
the process: diagnosis, planning, implementation,
family).
and evaluation.

COLLECTING SUBJECTIVE DATA

Nursing Process
Subjective data are sensations or symptoms (e.g., pain, hun-
I. Assessment - Collecting subjective and objective
ger), feelings (e.g., happiness, sadness), perceptions, desires,
data
preferences, beliefs, ideas, values, and personal information
II. Diagnosis - Analyzing subjective and objective data
that can be elicited and verified only by the client. The major
to make a professional nursing judgment (nursing
areas of subjective data include:
diagnosis, collaborative problem or referral)
● Biographical information (name, age, religion,
III. Planning - Determining outcome criteria and
occupation)
developing a plan
● History of present health concern: Physical
IV. Implementation - Carrying out the plan
symptoms related to each body part or system (e.g.,
V. Evaluation - Assessing whether outcome criteria
eyes and ears, abdomen)
have been met and revising the plan as necessary
● Personal health history
 ● Family history ● The health history is an excellent way to begin the
● Health and lifestyle practices (e.g., health practices assessment process because it lays the groundwork
that put the client at risk, nutrition, activity, for identifying nursing problems and provides a
relationships, cultural beliefs or practices, family focus for the physical examination.
structure and function, community environment) ● The importance of the health history lies in its ability
to provide information that will assist the examiner
COLLECTING OBJECTIVE DATA in identifying areas of strength and limitation in the
This type of data is obtained by general observation and by individual’s lifestyle and current health status.
using the four physical examination techniques: inspection, ● The complete health history is modified or
palpation, percussion, and auscultation. shortened when necessary. For example, if the
Another source of objective data is the client’s physical assessment will focus on the heart and neck
medical/health record, which is the document that contains vessels, the subjective data collection would be
information about what other healthcare professionals (i.e., limited to the data relevant to the heart and neck
nurses, physicians, physical therapists, dietitians, social vessels.
workers) observed about the client. Objective data may also
be observations noted by the family or significant others Assessment Tool Nursing Health History Format Summary
about the client. (Used for Client Care Plan):
The examiner directly observes objective data. These data
include:
● Physical characteristics (e.g., skin color, posture)
● Body functions (e.g., heart rate, respiratory rate)
● Appearance (e.g., dress and hygiene)
● Behavior (e.g., mood, affect)
● Measurements (e.g., blood pressure, temperature,
height, weight)
● Results of laboratory testing (e.g., platelet count, x-
ray findings)

VALIDATING ASSESSMENT DATA

● Validation of assessment data is a crucial part of
assessment that often occurs along with collection of
subjective and objective data. It serves to ensure
that the assessment process is not ended before all
relevant data have been collected, and helps to
prevent documentation of inaccurate data. What
types of assessment data should be validated, the
different ways to validate data, and identifying areas
where data are missing are all parts of the process.

DOCUMENTING DATA
● Documentation of assessment data is an important
step of assessment because it forms the database
for the entire nursing process and provides data for
all other members of the health care team.
Thorough and accurate documentation is vital to
ensure that valid conclusions are made when the
data are analyzed in the second step of the nursing
process.

COLLECTING SUBJECTIVE DATA: INTERVIEW AND COMPLETE

HEALTH HISTORY
COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION
To become proficient with physical assessment skills, the
nurse must have basic knowledge in three areas:
● Types and operation of equipment needed for the
particular examination (e.g., penlight,
sphygmomanometer, otoscope, tuning fork,
stethoscope)
● Preparation of the setting, oneself, and the client for
the physical assessment
 ● Performance of the four assessment techniques:
extremities.
inspection, palpation, percussion, and auscultation. ➢ This position is also useful
because it permits full expansion
Preparing for the Examination of the lungs and it allows the
How well you prepare the physical setting, yourself, and the examiner to assess symmetry of
client can affect the quality of the data you elicit. As an upper body parts. Some clients
examiner, you must make sure that you have prepared for all may be too weak to sit up for the
entire examination. They may
three aspects before beginning an examination. Practicing
need to lie down, face up (supine
with a friend, relative, or classmate will help you to achieve position) and rest throughout the
proficiency in all three aspects of preparation. examination.
➢ Other clients may be unable to
PREPARING THE PHYSICAL SETTING tolerate the position for any
The physical examination may take place in a variety of length of time. An alternative
position is for the client to lie
settings such as a hospital room, outpatient clinic, physician’s
down with head elevated.
office, school health office, employee health office, or a
client's home. It is important that the nurse strive to ensure Supine ➢ Ask the client to lie down with
that the examination setting meets the following conditions: Position the legs together on the
● Comfortable, warm room temperature: Provide a examination table (or bed if in a
warm blanket if the room temperature cannot be home setting). A small pillow may
be placed under the head to
adjusted.
promote comfort.
● Private area free of interruptions from others: Close
➢ If the client has trouble
the door or pull the curtains if possible. breathing, the head of the bed
● Quiet area free of distractions: Turn off the radio, may need to be raised.
television or other noisy equipment. ➢ This position allows the
● Adequate lighting: It is best to use sunlight (when abdominal muscles to relax and
available). However, good overhead lighting is provides easy access to
peripheral pulse sites.
sufficient. A portable lamp is helpful for illuminating
➢ Areas assessed with the client in
the skin and for viewing shadows or contours. this position may include head,
● Firm examination table or bed at a height that neck, chest, breasts, axillae,
prevents stooping: A roll-up stool may be useful abdo- men, heart, lungs, and all
when it is necessary for the examiner to sit for parts extremities.
of the assessment.
Dorsal ➢ The client lies down on the
● A bedside table/tray to hold the equipment needed
Recumbent examination table or bed with
for the examination.
Position the knees bent, the legs
separated, and the feet flat on
PHYSICAL EXAMINATION TECHNIQUES the table or bed. This position
Four basic techniques must be mastered before you can per- may be more comfortable than
form a thorough and complete assessment of the client. the supine position for clients
These techniques are inspection, palpation, percussion, and with pain in the back or
abdomen.
auscultation.
➢ Areas that may be assessed with
the client in this position include
POSITIONING THE CLIENT head, neck, chest, axillae, lungs,
Sitting ➢ The client should sit upright on heart, extremities, breasts, and
Position the side of the examination table. peripheral pulses.
In the home or office setting, the ➢ The abdomen should not be
client can sit on the edge of a assessed because the abdominal
chair or bed. muscles are contracted in this
➢ This position is good for position.
evaluating the head, neck, lungs,
Sim’s Position ➢ The client lies on the right or left
chest, back, breasts, axillae,
side with the lower arm placed
heart, vital signs, and upper
behind the body and the upper
 arm flexed at the shoulder and
elbow. The lower leg is slightly
flexed at the knee while the
upper leg is flexed at a sharper
angle and pulled forward.
➢ This position is useful for
assessing the rectal and vaginal
areas. The client may need some
assistance getting into this
position. Clients with joint
problems and elderly clients may
have some difficulty assuming
and maintaining this position.
Standing ➢ The client stands still in a normal,
Position comfortable, resting posture.
➢ This position allows the examiner
to assess posture, balance, and
gait. This position is also used for
examining the male genitalia.
Prone ➢ The client lies down on the
Position abdomen with the head to the
side.
➢ The prone position is used
primarily to assess the hip joint.
The back can also be assessed
with the client in this position.
➢ Clients with cardiac and
respiratory problems cannot
tolerate this position.
Knee-chest ➢ The client kneels on the
Position examination table with the
weight of the body supported by
the chest and knees. A 90-degree
angle should exist between the
body and the hips. The arms are
placed above the head, with the
head turned to one side. A small
pillow may be used to provide
comfort.
➢ The knee–chest position is useful
for examining the rectum. This
position may be embarrassing
and uncomfortable for the client;
therefore, the client should be
kept in the position for as limited
a time as possible.
➢ Elderly clients and clients with
respiratory and cardiac problems
may be unable to tolerate this
position.
Lithotomy ➢ The client lies on the back with
Position the hips at the edge of the
examination table and the feet
supported by stirrups.
➢ The lithotomy position is used to
examine the female genitalia,
reproductive tracts, and the
rectum.
➢ The client may require assistance
getting into this position. It is an
exposed position, and clients
may feel embarrassed. In
addition, elderly clients may not
be able to assume this position
for very long or at all.
➢ Therefore, it is best to keep the
client well draped during the
examination and to perform the
examination as quickly as
possible.
Inspection
● Inspection involves using the senses of vision, smell,
and hearing to observe and detect any normal or
abnormal findings.
● This technique is used from the moment that you
meet the client and continues throughout the
examination.
● Inspection precedes palpation, percussion, and
auscultation because the latter techniques can
potentially alter the appearance of what is being
inspected. Although most of the inspection involves
the use of the senses only, a few body systems
require the use of special equipment (e.g.,
ophthalmoscope for the eye inspection, otoscope for
the ear inspection).
Use the following guidelines as you practice the technique of
inspection:
● Make sure the room is a comfortable temperature. A
too cold or too-hot room can alter the normal
behavior of the client and the appearance of the
client’s skin.
● Use good lighting, preferably sunlight. Fluorescent
lights can alter the true color of the skin. In addition,
abnormalities may be overlooked with dim lighting.
● Look and observe before touching. Touch can alter
appearance and distract you from a complete,
focused observation.
● Completely expose the body part you are inspecting
while draping the rest of the client as appropriate.
● Note the following characteristics while inspecting
the client: color, patterns, size, location, consistency,
symmetry, movement, behavior, odors, or sounds.
 ● Compare the appearance of symmetric body parts
(e.g., eyes, ears, arms, hands) or both sides of any
individual body part.
Palpation
Palpation consists of using parts of the hand to touch and feel
for the following characteristics:
● Texture (rough/smooth)
● Temperature (warm/cold)
● Moisture (dry/wet)
● Mobility (fixed/movable/still/vibrating)
● Consistency (soft/hard/fluid filled)
● Strength of pulses (strong/weak/thready/bounding)
● Size (small/medium/large)
● Shape (well defined/irregular)
● Degree of tenderness
Parts of Hand to Use When Palpating
Hand Part Sensitive To
Fingerpads Fine discriminations: pulses,
texture, size, consistency,
shape,
crepitus
Ulnar or palmar surface Vibrations, thrills, fremitus
Dorsal (back) surface Temperature
In general, the examiner’s fingernails should be short
and the hands should be at a comfortable temperature.
Standard precautions should be followed if applicable.
Proceed from light palpation, which is safest and the most
comfortable for the client, to moderate palpation, and finally
to deep palpation. Specific instructions on how to perform
the four types of palpation follow:
● Light palpation: To perform light palpation (Fig. 3-1),
place your dominant hand lightly on the surface of
the structure. There should be very little or no
depression (less than 1 cm). Feel the surface
structure using a circular motion. Use this technique
to feel for pulses, tenderness, surface skin texture,
temperature, and moisture.
● Moderate palpation: Depress the skin surface 1 to 2
cm (0.5 to 0.75 inch) with your dominant hand, and
use a circular motion to feel for easily palpable body
organs and masses. Note the size, consistency, and
mobility of structures you palpate.
● Deep palpation: Place your dominant hand on the
skin surface and your nondominant hand on top of
your dominant hand to apply pressure (Fig. 3-2). This
should result in a surface depression between 2.5
and 5 cm (1 and 2 inches). This allows you to feel
very deep organs or structures that are covered by
thick muscle.
● Bimanual palpation: Use two hands, placing one on
each side of the body part (e.g., uterus, breasts,
spleen) being palpated (Fig. 3-3). Use one hand to
apply pressure and the other hand to feel the
structure. Note the size, shape, consistency, and
mobility of the structures you palpate.
Percussion
Percussion involves tapping body parts to produce sound
waves. These sound waves or vibrations enable the examiner
to assess underlying structures. Percussion has several
different assessment uses, including:
● Eliciting pain: Percussion helps to detect inflamed
underlying structures. If an inflamed area is
percussed, the client’s physical response may
indicate or the client will report that the area feels
tender, sore, or painful.
● Determining location, size, and shape: Percussion
note changes between borders of an organ and its
neighboring organ can elicit information about
location, size, and shape.
● Determining density: Percussion helps to determine
whether an underlying structure is filled with air or
fluid or is a solid structure.
● Detecting abnormal masses: Percussion can detect
superficial abnormal structures or masses.
Percussion vibrations. penetrate approximately 5 cm
deep. Deep masses do not produce any change in
the normal percussion vibrations.
● Eliciting reflexes: Deep tendon reflexes are elicited
using the percussion hammer.
Types of Percussion
The three types of percussion are direct, blunt, and indirect.
● Direct percussion (Fig. 3-4) is the direct tapping of a
body part with one or two fingertips to elicit possible
tenderness (e.g., tenderness over the sinuses).
● Blunt percussion (Fig. 3-5) is used to detect
tenderness over organs (e.g., kidneys) by placing one
hand flat on the body surface and using the fist of
the other hand to strike the back of the hand flat on
the body surface.
● Indirect or mediate percussion (Fig. 3-6) is the most
commonly used method of percussion. The tapping
done with this type of percussion produces a sound
or tone that varies with the density of underlying
structures. As density increases, the sound of the
tone becomes quieter. Solid tissue produces a soft
 tone, fluid produces a louder tone, and air produces ● (ensure that this fingernail is short) to strike the
an even louder tone. These tones are referred to as middle finger of your nondominant hand that is
percussion notes and are classified according to placed on the body part.
origin, quality, intensity, and pitch (Table 3-3). ● Withdraw your finger immediately to avoid damping
the tone.
● Deliver two quick taps and listen carefully to the
tone.
● Use quick, sharp taps by quickly flexing your wrist,
not your forearm.
Practice percussing by tapping your thigh to elicit a
flat tone and by tapping your puffed-out cheek to elicit a
tympanic tone. A good way to detect changes in tone is to fill
a carton halfway with fluid and practice percussing on it. The
tone will change from resonance over air to a duller tone over
the fluid.

Tones Elicited by Percussion

Sound Inte Pitch Length Quality Exampl
nsity e of
Origin

Resonance Loud Low Long Hollow Normal

(heard over lung
part air
and part
solid)

Hyper- Very Low Long Boomi Lung

resonance loud ng with
(heard over emphys
mostly air) ema

Tympany Loud High Moder Drum- Puffed-

(heard over ate like out
air) cheek,
gastric
bubble

Dullness Medi Medi Moder Thud- Diaphra

(heard over um um ate like gm,
more solid pleural
tissue) effusio
n, liver
The following techniques help to develop proficiency in the
technique of indirect percussion:
● Place the middle finger of your nondominant hand Flatness Soft High Short Flat Muscle,
(heard over bone,
on the body part you are going to percuss.
very dense sternu
● Keep your other fingers off the body part being tissue) m,
percussed because they will damp the tone you thigh
elicit.
● Use the pad of your middle finger of the other hand
Auscultation
● Auscultation is a type of assessment technique that
requires the use of a stethoscope to listen for heart
sounds, movement of blood through the
cardiovascular system, movement of the bowel, and
movement of air through the respiratory tract.
● A stethoscope is used because these body sounds
are not audible to the human ear. The sounds
detected using auscultation are classified according
to the intensity (loud or soft), pitch (high or low),
duration (length), and quality (musical, crackling,
raspy) of the sound.
● These guidelines should be followed as you practice
the technique of auscultation:
○ Eliminate distracting or competing noises
from the environment (e.g., radio,
television, machinery).
○ Expose the body part you are going to
auscultate.
○ Do not auscultate through the client’s
clothing or gown. Rubbing against the
clothing obscures the body sounds.
○ Use the diaphragm of the stethoscope to
listen for high pitched sounds, such as
normal heart sounds, breath sounds, and
bowel sounds, and press the diaphragm
firmly on the body part being auscultated.
○ Use the bell of the stethoscope to listen for
low-pitched sounds such as abnormal heart
sounds and bruits (abnormal loud, blowing,
or murmuring sounds). Hold the bell lightly
on the body part being auscultated.
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
post-surgical 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.
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
sugery; 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.
● Plan 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.
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 for
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. The
physician or other primary care provider orders medications
and treatments and nursing staff members identify special
nursing considerataions 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. 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 clent change bag independently
tomorrow.”
Note: 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 pickup 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.
(See Figure 45-7 for example of 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.
 information is part of the electronic record and is printed
out for the client at discharge.

The Day the Clent is Discharged

● On the day of discharge, if the person seems eager
to leave and if his or her condition permits, the clent
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 clent
leaves the facility.
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 asist.
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 dicharge
● Documents who accompanied the client
● Documents whether the client was in a wheelchair
or required an ambulance
● Records whether or not the client is returning to
home or another place (is noted), along with the
address and phone number.
● Documents a nursing summary that includes the
identified nursing problems and their resolution or
revision (may be required).
○ Example: “A 42-year-old male admitted
FIGURE 45-7. Example of one facility’s multidisciplinary with a diagnosis of coronary artery disease.
client discharge summary. In many facilities, this Status/post (S/P) placeent of two stents.
Client denies angina. BP 134/74, apical
 pulse 82, with normal rhyth, 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 post-op examination. Post-operative
course has been unremarkable. Client has
phone numbers to call if problems.”
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 self-care 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.)
● Describe medcation 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 nurseing 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.
LEAVING THE HEALTHCARE FACILITY AGAINST MEDICAL
ADVICE
Occasionally, a client leaves the healthcare facility without
permission. Such action is called against medical advice
(AMA).
● Report to the team leader any client who says he or
she is leaving the healthcare facility AMA.
● A client who leaves AMA is asked to sign a dated
release form that absolves the providers and the
facility of all responsibility in the event that the
client suffers complications.
● A licensed nurse witnesses the client’s signature. The
primary provider also writes a note documenting the
AMA discharge.
● If the client refuses to sign, the refusal must be
noted on the form. The form is then signed by at
least two witnesses.
● The nursing student should not witness any legal
papers, including the AMA form.
Note: Discharge planning and teaching begin on admission.
The client and caregivew are taught to care for the surgical
wound, in preparation for discharge. A return demonstration
allows the nurse to determine if teaching has been effective
and to review points of concern.
IN PRACTICE: NURSING CARE GUIDELINES 45-4
DISCHARGING THE CLIENT
● Verify the discharge order
● Check for new orders
● Check orders for take-home medications, special
treatments, or special equipment.
● Check orders for last-minute procedures, laboratory
tests, or x-ray examinations.
● Make sure the person has a place to go.
● Coordinate transportation if necessary. You may
need to make a telephone call to request an
ambulance or taxi service or to contact a neighbor.
Social Services may need to assist.
● Determine what type of clothing the client is best
suited to wear. (If he or she is being discharged to
extended care, pajamas or a robe may be
appropriate, rather than street clothes).
● Assist the client with packing and dressing for
discharge.
● Check the closet and bedside stand for personal
items. Have the client sign the property sheet,
verifying that he or she has all personal property.
Check and have the client sign the property record.
● Arrange for a small utility cart for easy conveyance
of belongings to the exit.
● Secure release of any valuables checked into the
vault.
● Go over discharge orders and instructions,
medication orders, and follow-up appointments with
the client.
● If the client is leaving the facility with actual
medication, go over them with the client to make
sure the instructions are understood and the
medications are correct. If generic names are on the
bottles, make sure they are also on the discharge
information.
● Have the client sign the discharge form and make
sure he or she gets a copy.
● Notify necessary departments of the discharge. This
is often done electronically.
● Escort the client from the clinical unit to the door.
Use a wheelchair. Assist the client into the car or
taxi.
● Write or input a discharge note in the chart or the
electronic record.
Key Concept: Sometimes, a client walks off the unit to go
home or to leave the facility without being discharged. This
client is considered AWOL (absent without leave).
● In many facilities, this client would be officially
discharged AMA at midnight.
● If the client who is AWOL returns after midnight, or
the next day, he or she usually needs to be
readmitted, using the complete admission process.
This is considered a new admission for the client. (In
some cases, insurance will not cover the client who
goes AOL and then returns to the facility.)
Long-term facilities usually identify vulnerable clients who
are unlikely to leave without permission. These clients wear a
WanderGuard or special transmitter.
● These transmitters alert personnel if the client tries
to leave, so staff can intervene.
● This is important for safety particularly if the client is
confused or otherwise vulnerable.
● In addition, some areas are locked to prevent
vulnerable or dangerous clients from wandering
away or going AWOL.
COMMUNICATIONS AMONG HEALTHCARE TEAM MEMBERS
In admission, transfer, and discharge, as in other areas, the
nurse must know how to interact effectively with other
members of the healthcare team.
Primary Healthcare Providers’ Orders
● This is one form of communication among members
of the healthcare team.
 ● The primary healthcare provide may be a physician,
but may also be another primary care provider, such
as an osteopathic physician, an advance practice
nurse, or a physician’s assistant.
● These orders are most often communicated via
computer, but may be handwritten in some cases.
● The provider depends on the nurse to interpret
these orders correctly, to make accurate
observations concerning the client, and to document
those observations.
● The orders give instructions to nurses, and nursing
protocols specify methods to be used. The provider
may give verbal instructions to explain written ones.
● The team leader or charge nurse must understand
the orders and request clarification for any confusing
order.
● Some orders are absolute and positive; others may
require the nurse’s judgment.
● The nurse may need to decide when (or if) to give a
PRN (as needed) medication, for example.
● Judgment is needed to decide which nursing
procedures may be safe to perform without an
order, and which procedures require clear and
specific orders from the physician.
○ For example, a nurse can place a client on
fall precautions, but usually the provider
must remove such an order. Protocol and
agency procedures give specific guidance to
nursing staff.
Verbal Orders
● In rare situations, it may be necessary for the
provider to give verbal orders.
● These orders are legal, but must be signed by the
provider as soon as possible.
● If given in person, the verbal order is abbreviated
VORB (verbal order, read back).
● If given by telephone, a verbal order is called a
telephone order, TORD (telephone order, read back).
○ All orders are read or stated back to the
provider, to make sure the nurse has heard
and recorded the order accurately.
○ These must then be documented as VORB
or TORB.
● It is rare today to receive verbal orders, other than in
an emergency, because providers can enter orders
into the electronic record from any computer.
Nursing Alert: The nursing student, nursing assistant, or unit
secretary should never take verbal orders, whether in person
or by telephone. Only a licensed nurse (usually an RN) has
legal authority to take verbal orders.
Telephone Communication
● Nurse should give his or her name and the name of
the person being called.
● If the nurse calls a primary care provider, it may be
necessary to explain to the office nurse what the call
is about and whether or not it is an emergency.
○ Office nurses usually screen calls to
conserve time.
● The SBAR (situation, background, assessment,
recommendations) method of communication is
used to oragnize information when calling a primary
provider.
● The nurse should not chew gum while on duty when
conducting business by telephone.
● Do not cover the receiver and continue a
conversation with someone else.
● If a caller must be put on hold, be sure to follow
telephone etiquette as outlined below.
Answering the Telephone
● This is one of the duties of the nurse.
● When answering a telephone, be sure to give the
name of the department along with your name and
position, so callers know whom they are speaking.
○ Example: “Station Main 2 West (state your
name), nursing student speaking.”
○ The caller then knows if you can help or if
someone else is needed.
The following are keys to proper telephone usage:
● Answer promptly— it may be an emergency.
● Ask “How may I help you?”
● Know how to use the telephone system, including
transferring calls and placing the caller on hold.
● Ask callers if it is ok to put them on hold or if they
would like to call back or leave a message.
● If someone is on hold, go back every minute to see if
he or she still wants to hold or if someone else can
help him or her.
● Offer to take a message; write messages carefully.
● Do not give out any client information without a
signed release.
● Do not make personal calls or send personal emails
from the nursing unit.
Taking Messages
● Write down messages carefully.
● Do not try to remember them.
 ● Repeating the message to the caller helps clarify the
message.
● Write the date, time, and your name on all messages
you take. Deliver messages promptly.
Making Emergency Calls
● Sometimes a nurse must make an emergency
telephone call.
● Give all necessary information.
● Remain calm. The prime responsibility of the caller in
an emergency is to get assistance, but the caller will
not be effective unless he or she is calm and gives all
the necessary information.
Nursing Alert: Be sure you know the emergency numbers and
code names used in your facility. Example:
● “Mr. Red” - code name for fire
● “Dr. Blue” / code blue - common code name for
cardiac arrest
● “Pink Alert” - used for an infant abduction.
When calling, give the exact location and nature of the
emergency and your name.
Computer Use in the Healthcare Facility
1. In most facilities, all staff members document care in
the electronic record.
● This way allows information about the client to be
quickly and easily accessed by all authorized
healthcare personnel.
● This includes admission information, medical history,
progress notes, test results, physical examinations,
care plans, medications ordered and given, and
discharge planning.
● Information regarding clinic visits and previous
hospitalizations is often available as well. It is vital
for you to learn to operate safely and competently
your facility’s computer system.
2. Confidentiality about clients is vital.
● Make sure no unauthorized person can access client
information.
● Remember that the chart (whether computerized or
on paper) is a legal document.
● All information in the client record may be called
into court, and nurses may be asked to testify. Think
about this whenever you make an entry into the
client’s record.
Nursing Alert: Remember to protect the client’s privacy when
using the computer.
● The nurse must always log off when finished
accessing information or documenting client care.
● In addition, be careful to keep the screen protected,
so unauthorized people (including other clients)
cannot read confidential client information.
● A nurse may be dis-carged for inappropriately
accessing a client’s record.
KEY POINTS
● The admission process helps establish how clients
feel about admission and potentially helps
determine the effectiveness of admission to any
healthcare facility.
● Measures are taken to preserve the client’s privacy
and maintain confidentiality.
● Clients may have serious concerns about their
physical condition and about unfamiliar procedures
in the healthcare facility.
● All clients must be carefully identified and must wear
an ID band. In addition, special ID bands are worn for
allergies, fall risk, and sometimes for other
situations.
● Baseline vital signs readings, pulse oximetry, pain
level, height, and weight are important components
of the admission information.
● Nurses perform an initial nursing assessment.
● No matter what type of healthcare facility or
program will be serving the client, some sort of
admission procedure is required.
● Clients’ belongings must be properly identified and
listed; valuables are sent home or to the facility’s
vault.
● Careful documentation of admission is important to
establish a baseline and ti give information to other
members of the healthcare team.
● Any existing wounds or pressure areas on admission
must be carefully documented.
● When a client is transferred, the procedure must be
explained to the client; belongings, records, and
medications must be transferred with the client.
● Safety in transporting the client is essential.
● Continuity of care is enhanced when thorough and
accurate reporting occurs between nursing shifts.
● Discharge teaching begins on admission. All teaching
is individualized and must be documented.
● All client belongings and valuables must accompany
the client at discharge.
● The client is escorted to the door. Usually, clients are
required to ride in a wheelchair to their
transportation (to reduce the risk of accident).
● Some clients sign out of the healthcare facility
against medical advice (AMA) or leave without
 permission (AWOL). This must be carefully
documented.
● A nurse has the challenge to make a positive
impression when answering the telephone.
THE KEY PRINCIPLES OF EFFECTIVE DISCHARGE PLANNING
Effective discharge planning is crucial to care continuity.
● The NHS now encompasses a huge breadth of
alternative services to hospital admission, including
inreach and outreach services, and rapid-access
clinics, which are aimed at increasing the pace of
discharge or transfer.
● Furthermore, it is now recognised that each clinical
area involved in the discharge of a patient, from the
pharmacy to the transport services, must collaborate
to reduce overlap, waste and frequent frustrations.
The 10 Steps of Discharge Planning
For simple discharges carried out at ward level, the process
should be standardised throughout an entire hospital.
1. Start planning before or on admission
● In elective care, planning can commence before
admission and may take the form of a screening tool,
risk assessment, or care pathway.
● The principle is to anticipate potential delays and
manage those in a proactive manner. With the
advent of the Liverpool Care Pathway and the
renewed focus on end-of-life issues, care pathways
exist to facilitate rapid discharge for patients at the
end of life on admission to acute services.
● In emergency, unscheduled care, advance planning is
not possible, so robust systems to gather patient
information must be in place– pivotal sources
include the GP, primary care team, and carers.
2. Identify whether the patient has simple or complex
needs.
● Identifying the patient pathway from admission or
before should enable you to recognise when simple
becomes complex.
● A simple discharge is one that can be executed at
ward level with the multidisciplinary team (MDT);
funding issues, change of residence or increased
health and social care needs make the discharge
complex.
3. Develop a clinical management plan within 24 hours of
admission
● Most patients admitted by junior medical staff will
have an outline management plan. The extent of
MDT involvement may be minimal depending on the
time of admission.
○ Example: admissions after 5 pm will be
reviewed by the team the next day on the
ward round. Ward rounds, therefore,
become inextricably linked to management
plans. Ultimately, a management plan
should engage and focus the whole MDT
with the patient to plan the aspects of care
required leading to discharge.
4. Coordinate the discharge or transfer process
● Although most clinical areas have developed systems
in which coordinators are allocated to discharge
planning, there is a lot of disparity between these
roles.
● Some use clerical staff to coordinate simple tasks,
while others hold the role of discharge coordinator
full time.
● Communication, MDT working and assessment are
three key roles for discharge coordinators.
5. Set an expected date of discharge within 48 hours of
admission
● This has prioved incredibly tough to implement and
embed within organisational philosophy.
● The patient’s discharge date should be estimated as
early as possible to guide the discharge-planning
process; the date can then be refined with
reassessment of the patient’s progress against the
clinical management plan.
● The estimated discharge date has three purposes:
○ Strategic: to predict overall hospital
capacity;
○ Operational: to assess progress and
outcomes of clinical plans;
○ Individual: for patients to understand
expectations, limitations, and what is
required from them in the discharge-
planning process.
6. Review clinical management plan daily
● Provided the clinical management plan was
commenced on admission, the review with the
patient should be relatively straightforward.
● Review, action, progress (RAP) is the process
suggested by the National Leadership and Innovation
Agency for Healthcare.
● The important aspect is to update the plan with the
MDT nad the patient.
7. Involve patients and carers
 ● This is aimed at managing patient/carer expectations
and understanding potential complexities or
challenges.
● It mainly involves therapy and social care partners,
who should be guided by the clinical referrals and
actions in the clinical management plan.
● Patient choice with regard to utilising supporting
services in intermediate care, care pathways and/or
dementia care will need to be taken into careful
consideration.
● Involvement is a core principle, not a one-off action.
● Involving patients take experience and patience, and
often necessitates a series of meetings with the
patient, carers, MDT, and social care.
8. Plan discharges and transfer to take place over seven
days
● This relies on engagement from services that
support discharge, such as therapy, X-ray, transport,
district nursing and intermediate care.
● Only with the support of seven-day working from
hospital and community services will continuity over
seven days of the week be possible.
9. Use a discharge checklist 48 hours before transfer
● The checklist has proven difficult to sustain.
● The principle is not new; what is new is the concept
of having a single checklist across a
trust/organisation and ensuring it is developed with
primary and social care involvement.
● The point is not to replicate information but to
ensure that amid the heightened activity in the
planning stage and pre-discharge, vital aspects of the
planning are not missed.
10. Make decisions to discharge and transfer patients each
day
● Nurse-led discharge will never replace the role of the
MDT and senior clinical decision-makers such as
consultants but well thought-out implementation
will support MDTs to deliver services over seven
days.
● It is crucial that nursing grasps the opportunity to
develop this new way of working.
Conclusion
● Discharge planning is a complex activity, particularly
in the context of new services offered outside
hospital, like intermediate care, and having a
population with more older people, who often have
extremely complex care needs.
● However, effective discharge planning is crucial to
ensure timely discharge and continuity of care.
● It also helps healthcare providers use limited
resources most effectively and unnecessary
readmissions to be avoided.
CARE TRANSITIONS FROM HOSPITAL TO HOME: IDEAL
DISCHARGE PLANNING IMPLEMENTATION HANDBOOK
Introduction
● Discharge from hospital to home requires the
successful transfer of information from clinicians to
the patient and family to reduce adverse events and
prevent readmissions.
● Engaging patients and families in the discharge
planning process helps make this transition in care
safe and effective.
The IDEAL Discharge Planning strategy highlights the key
elements of engaging the patient and family in discharge
planning:
● Include the patient and family as full partners in the
discharge planning process.
○ Always include the patient and family in
team meetings about discharge. Remember
that discharge is not a one-time event but is
a process that takes place throughout the
hospital stay.
○ Identify which family members or friends
will provide care at home and include them
in conversations.
● Discuss with the patient and family five key areas to
prevent problems at home:
1. Describe what life at home will be like. Include
home environment, support needed, what the
patient can or cannot eat, and activities to do or
avoid.
2. Review medications. Use a reconciled medication
list to discuss the purpose of each medicine, how
much to take, how to take it, and potential side
effects.
3. Highlight warning signs and problems. Identify
warning signs or potential problems. Write down the
name and contact information of someone to call if
there is a problem.
4. Explain test results. Explain test results to the
patient and family. If test results are not available at
discharge, let the patient and family know when they
should hear about results and identify who they
should call if they have not heard the results by that
date.
5. Make follow up appointments. Offer to make ○ Schedule at least one meeting specific to
follow-up appointments for the patient. Make sure discharge planning with the patient and
that the patient and family know what follow-up is family caregivers.
needed.
● Educate the patient and family in plain language What is the IDEAL Discharge Planning process?
about the patient’s condition, the discharge process, ● The IDEAL Discharge Planning strategy focuses on
and next steps at every opportunity throughout the engaging the patient and family in the discharge
hospital stay. process from the hospital to home. You can
○ Getting all the information about a incorporate elements of the IDEAL Discharge
condition and next steps on the day of Planning process into your current discharge
discharge can be overwhelming. Discharge process. This process incorporates the IDEAL
planning should be an ongoing process elements from admission to discharge and includes
throughout the stay, not a one-time event. at least one meeting between the patient, family,
During the hospital stay, you can: and discharge planner to specifically address the
■ Elicit patient and family goals at patient’s and family’s questions and concerns.
admission and note progress
toward those goals each day.
What to do? Who does it?
■ Involve the patient and family in
nurse bedside shift report or At initial nursing assessment
bedside rounds.
■ Share a written list of medicines ● Identify the caregiver Bedside nurse
every morning. who will be at home
with the patient
■ Go over medicines at each
administration: What is it for, how ● Let the patient and Bedside nurse
to take it, and possible side effects. family know that they
■ Encourage the patient and family can use the white
to take part in the care practices to board in the room to
supprt their competence and write questions or
concerns
confidence in caregiving at home.
● Assess how well doctors and nurses explain the ● Elicit the patient and Bedside nurse
diagnosis, condition, and next steps in the patient’s family’s goals for the
care to the patient and family and use teach back. hospital sta
○ Provide information to the patient in small
● Inform the patient and Bedside nurse
chunks and repeat key pieces of
family about steps
information throughout the hospital stay. toward discharge
○ Ask the patient and family to repeat what
you said back to you in their own words to Daily activities
be sure that you explained things well.
● Listen to and honor the patient and family’s goals, ● Educate the patient All clinical staff
and family about the
preferences, observations, and concerns.
patient’s condition at
○ Invite the patient and family to use the every opportunity and
white board in the room to write questions use teach back
or concerns.
○ Ask open-ended questions to elicit ● Explain medicines to All clinical staff
questions and concerns. the patient and family
and use teach back
○ Use the Be Prepared to Go Home Checklist
and Booklet (Tools 2a and 2b) to make sure ● Discuss progress All clinical staff
the patient and family feel prepared to go toward goals
home.
● Involve the patient All clinical staff
and family in care
 ● In another study, nearly 20 percent of Medicare
practices
patients were rehospitalized within 30 days after
Prior to discharge planning meeting discharge. Of the readmitted patients, half the
(1 to 2 days before discharge planning meeting; for short patients had no claim filed for a visit with a physician
stays, this may occur at admission) during the 30 days following the discharge, and
about 70 percent of surgical patients were
● Identify and discuss Hospital identifies one
rehospitalized with a medical problem. The authors
the patient and person: Nurse, patient
family’s questions and advocate, or discharge estimate that the cost of these unplanned
concerns about going planner hospitalizations in 2004 was $17.4 billion.
home ● The following were identified as the best practices
among others:
● Schedule discharge Hospital identifies one
○ A focus on improving clinical quality and
planning meeting with person: Nurse, patient
patient care with the belief that reductions
the patient, family, advocate, or discharge
and hospital staff planner in readmissions will naturally occur as a
result of these improvement efforts.
○ Attention to discharge planning from the
Rationale for the IDEAL Discharge Planning Strategy
first day of patients’ stay, typically within 8
● Patient and family engagement creates an
hours of admission. This includes staff
environment where patients, families, clinicians, and
assessment of patients’ risk factors, needs,
hospital staff all work together as partners to
available resources, knowledge of disease,
improve the quality and safety of hospital care.
and family support.
● Patient and family engagement encompasses
○ Care coordination after discharge. Two
behaviors by patients, family members, clinicians,
hospitals scheduled followup appointments
and hospital staff, as well as the organizational
for most of their patients prior to discharge.
policies and procedures that support these
Because of limited resources, the two other
behaviors.
hospitals made followup appointments on
● For discharge to be most effective, communication
an ad hoc basis for the neediest patients. All
between clinicians, the patient, and family needs to
hospitals coordinated with home health
happen throughout the hospital stay. Education and
agencies and connected patients to
learning is a two-way path:
community resources.
○ The patient and family needs to learn from
○ Empowering patients through educational
clinicians about the condition and next
activities throught the stay to help patients
steps.
understand their conditions; manage their
○ Clinicians need to learn from the patient
diet, activities, medications, and care
and family about their home situation (both
regimens; and know when to seek care.
whathelp and support they can count on
and the barriers they may face in taking
What are the key challenges related to discharge?
care of themselves) and to learn what
Several important challenges have been identified in
questions they have after they get home.
providing high-quality care as patients leave the hospital:
Clinicians also need to make sure that
● Discontinuity between inpatient and outpatient
patients and family members really
providers. Hospital discharge summaries often fail to
understnad the next steps in their care.
reach outpatient providers, and when they do, they
neglect to provide important administrative and
What is the evidence for improving discharge planning?
medical information.
● Nearly 20 percent of patients experience an adverse
○ In one study, only 34% of primary care
event within 3 weeks of discharge, according to one
physicians received the discharge
study. Of these adverse events, three-quarters could
information needed to continue managing
have been prevented or ameliorated. Common
their patients within 48 hours of discharge.
complications post-discharge include adverse drug
Also, patients have multiple providers,
events, hospital-acquired infections, and procedural
making continuity of care more difficult
complications.
between inpatient and outpatient settings.
 ● Changes or discrepancies in medication lists before
and after a hospital stay. To make sure there is an
accurate medication list at hospital discharge,
hospital providers need to take a complete and
accurate medication history at the time of
admission, keep track of changes to medications
administered throughout the hospital stay, and
reconcile medication lists at discharge. Patients
prescribed high-risk medications or complex
medication regimens may be at higher risk of
adverse drug events.
● Inadequate preparation for discharge. Quality of
discharge teaching is the strongest predictor of
discharge readiness. Patients may not be properly
informed about food choices, medication side
effects, danger signs, and when to resume activities.
Also, studies have shown a disconnect between the
information that patients and families belive they
need to know and what providers think patients
need to know.
● Disconnect between provider information-giving
and patient understanding. Studies have
demonstrated that providers may not relay
information to patients in a way they can
understand. Key instructions at discharge should be
given in plain language, use both verbal and
audiovisual instruction, be repeated by multiple
providers (e.g., physician, nurse, and pharmacist),
and be confirmed using a teach-back method where
patients are asked to repeat back what they
underood about their discharge instructions in their
own words.
● Burden of care assumed by patients and families
after discharge. Patients are responsible for
administering new medications, tracking symptoms,
participating in physical therapy, and following up
with their outpatient physician. Many patients do
not have sufficient social and family support to
perform these activities effectively. Also, patients
may feel overwhelmed and unprepared to take an
active role in their health care without adequate
information, and in some cases, coaching.
How to prevent adverse events after discharge?
● Many of the challenges described above can be
attrubuted to problems in discharge planning.
● Discharge planning is the process of identifying and
preparing for a patient’s anticipated health care
needs after they leave the hospital. Hospital staff
cannot plan discharge in isolation from the patient
and family.
● Comprehensive discharge planning involving the
patient and family contributes to positive patient
outcomes, such as reductions in unplanned
readmissions and increases in patient and caregiver
satisfaction with the health care experience.
● However, it is often difficult for hospitals to conduct
comprehensive discharge planning given the
shortened length of stays for most hospital
admissions. That is why it is critical to involve and
educate the patient and family throughout the
hospital stay.
● Ensuring safe transitions from hospital to home
requires a systematic approach that includes the
patient and family in the discharge process. At this
time, no consensus exists on the single best method
to prevent adverse events after discharge. However,
there is promising evidence related to specific
interventions.
○ For example, various medication
reconciliation approaches have shown
promise in improving clinical outcomes,
although more research is needed to verify
these findings.
○ Other promising interventions include using
discharge checklists to standardize the
discharge process and making structured
post-discharge phone calls to patients.
○ Similarly, evidence is mounting for
interventions that incorporate structured
discharge communication. In this type of
approach, specially trained staff meet with
patients before (and sometimes after)
discharge to reconcile medications, instruct
patients and caregivers in self-care
methods, prepare patient-centered
discharge instructions, and facilitate
communication with outpatient physicians.
MULTIPLE CHOICE QUIZLET:
Potter & Perry Chapter 30 - Vital Signs (WITH RATIONALE)
https://quizlet.com/260665880/potter-perry-chapter-30-
vital-signs-flash-cards/

Vital signs - Pottery and Perry Test Bank (WITH RATIONALE)

https://www.studocu.com/en-us/document/long-island-
university/fundamentals-of-nursing/vital-signs-pottery-and-
perry-test-bank/7548648

Vital signs NCLEX questions (WITH RATIONALE)

https://quizlet.com/519939380/chapter-25-vital-signs-nclex-
questions-flash-cards/

Vital signs terminology flashcards

https://quizlet.com/23318575/fundamentals-of-nursing-vital-
signs-flash-cards/

Admission, Transfer, and Discharge (WITH RATIONALE)

https://quizlet.com/412739918/chapter-13-admission-
transfer-and-discharge-flash-cards/

https://quizlet.com/530233019/chapter-11-admission-
transfer-and-discharge-flash-cards/

WITHOUT RATIONALE
https://quizlet.com/454784398/ch-11-admission-transfer-
and-discharge-flash-cards/