Approaches to patient care

Wednesday, 2 February 2022

7:50 pm
 
APPROACHES TO PATIENT CARE
 
Think of the patient as an individual who:
 Needs help
 Have fears and worries about their illness or injury
 Has to be allowed to maintain identity
 Should be given privacy, dignity and maintain self-esteem
 Can continue to practice his own religious faith, customs and patterns of his nationality
 should be allowed to continue in his ways, habits, rituals and idiosyncrasies
 Should know what you are going to do
 
 
TO GIVE CARE TO THE PATIENT MEANS TO:
 Help patient maintain or improve physical fitness
 Provide a comfortable atmosphere
 Help in the prevention of injuries a accidents
 Help prevent patient from contacting
 
 
ADMISSION AND DISCHARGE
 
ADMISSION
The administrative process that covers the period from the time the patient enters the
institution do, or to the time the patient is settled.
 
 
DISCHARGE
 The official procedure for helping patients to leave the health care institution, including
teaching them how to care for themselves at home. It is the termination of care health
care agency.
 
 
TYPES OF ADMISSION
 Elective admission
 The admission itself may be delayed until a time is convenient for the client and
the doctor.
 Emergency admission
 This occurs through the emergency department. The client may be admitted to a
floor, a specialized unit, or a holding (observation) unit
  Same-day surgery or Out Patient procedure
 Technically, this is not an admission, with same
 day surgery or ambulatory surgery, the doctor will schedule a procedure that will
be performed at hospital. The client will-be-discharged home the procedure.
 Direct admission
 The client does not feel well, goes directly to the hospital and was advised to be
admitted or has spoken to or seen the doctor, who feels the need that the client
should be admitted.
 
 
HOSPITAL TEAM
1. Medical staff
 Doctors/specialists, medical students (interns, clerks)
 House case
 Private case
2. Nursing staff
 Nurses, nursing aides
3. Social services
 social worker
4. Ancillary services
 Laboratory, radiology, pharmacy,
 rehabilitation, nutrition, and maintenance
 Spiritual services
 Chaplain, nuns/sisters
 
 
ADMISSION PROCEDURE - in general
It depends on the policy of the healthcare facility; in some healthcare facilities the patient is
taken directly to the room and the actual admission process begins. In larger facilities
however, the admission process starts in the admitting office.
 
 
1. A preliminary interview of the patient is done to obtain the necessary medical and
financial information.
2. It is important for the family to remain with the patient for this interview.
3. If an ID bracelet is used, it may be placed on the patient's wrist time.
4. Complete the admission checklist
5. Fill in the date and time of admission
6. Method of admission - the way the patient came into the room.
7. Observations or unusual conditions noted
8. Chief complaint of the patient
9. Be brief but complete, and write legibly
 
 
ADMISSION PROCEDURE - client's unit
A. Before a patient is admitted, make sure the room is ready for his/her arrival
 Check necessary equipment:
  admission checklist
 pen or pencil
 patient's gown or pajamas (if the patient is to be put to bed)
 portable scale
 thermometer
 sphygmomanometer
 Stethoscope
 envelope for the patient's valuables
 
 
AREA/UNIT
 ICU - Generally reserved for the sickest people, those who require close nursing
supervision, or those who require a ventilator to help them breathe.
 CORONARY CARE UNIT - Like the ICU, but reserved for people with heart problem
 SURGICAL INTENSIVE CARE UNIT - For people who have had surgery
 IC INTENSIVE CARE UNIT - For children
 NEONATAL INTENSIVE-CARE BUNIT - For newborns
 SURGERY FLOOR - A general floor for people who need surgery
 MEDICAL FLOOR - A general floor for medical care
 NEUROLOGICAL OR NEUROSURGERY UNIT - People who have suffered a stroke
 ONCOLOGY UNIT - People with cancer
 ORTHOPEDIC UNIT - People with fracture, etc.
 
 
B. Help the patient become familiar with the new surroundings.
 Explain the facility's policy on visitors. Tell the patient when meals are served.
 Answer any questions he/she has about daily routine.
 Demonstrate how to use:
 intercom and signal cord system
 remote-control for television
 automatic bed controls
 
C. Screen or curtain off the bed or close the door to a private room.
 Ask the patient to put on a hospital gown, or a gown or pajamas brought from home.
 Assist the patient as needed.
 If the patient wants a family member to be present, invite the person in.
 
D. Assess the patient's general physical condition, appearance, and behavior as the admission
process is continued.
 Observe the patient for unusual conditions:
 cuts or bruises
 v' loss of function
 signs of weakness
 any prosthesis
 other physical complaints the patient may have.
 
E. Record vital signs and note for any unusualities from the baseline VS and refer.
 
F. Ask about previous hospitalizations, allergies, or diseases other than the one for which the
patient is being admitted
 
G. Record all information and observations on the admissions checklist. taken during admission
should be thorough with
 
H. records taken during admission should be through with
 
I. In acute care hospitals, the patient must provide a urine specimen.
 Assist the patient to the bathroom, or offer the bedpan or urinal as needed.
 Collect the urine specimen from the patient, and replace the cap.
 Label the specimen with the patient's name, doctor's name, and room number, and send it
to the laboratory along with the requisition for the admission urine test
 Always wash your hands after handling urine specimens
 
J. Make the patient comfortable.
 If the patient is ambulatory, he/she may wish to sit up and visit with family members.
 In an acute care hospital, the patient is put to bed.
 Raise the side rails if the nursing supervisor orders it, and it also ensures the safety of the
patient admitted—side rails may be needed if the patient cannot or should not get out of
bed unassisted, or if the patient's bed is not in the lowest position
 Give the patient water if it is allowed.
 Make sure the patient can reach the signal cord and anything else he/she might need
while you are not in the room.
 Remove the screen or curtains surrounding the patient, or open the door so others will
know you are finished.
 Tell family members they may return to the patient's room.
 
 
Helping Patients Adjust to the Healthcare Facility:
A. Every patient admitted to a healthcare facility is nervous, even if it is not a first admission.
 The strange surroundings
 The busy nursing staffs
 The sight of other patients may add to the patient's feelings of helplessness.
 If this is a first admission, the patient will not know what to expect.
 
 
B. Admission to a healthcare facility
 Temporary - patients are hospitalized for surgery or treatment of an acute illness
 permanent - patients are no longer able to take care of themselves. Whether temporary
or permanent, admission to a healthcare facility causes many changes in their lifestyle.
 Confusion and disorientation often occur when patients are first.
 They may feel they no longer have control over their lives.
  They may be physically powerless and almost complete dependent on strangers
for everyday care
 
 
C. GREETING THE PATIENT
The patient's first impression of the facility will depend on how he/she is greeted.
 Greet each patient in a friendly, cheerful manner.
 Introduce yourself, and take the patient to their room.
 If the patient has a friend or relative with him/her, invite them to accompany you to the
room
 
Patient's Chart
A database, a body of knowledge about the patient, the one source that has everything the
healthcare team needs to return the patient to daily activities of life. It contains information
describing the patient's previous and current medical conditions and healthcare that the patient
received and will receive from the healthcare team. It is document and to communicate the
patient's medical condition and treatment
 
 
 
COMPONENTS OF THE CHART
I. Patient's Data Sheet / Page
 Authorization for Examination and Admission
 Against Medical Advice (In Case of AMA, there is a sheet that is signed by the patient
for this)
 
2. Clinical History Page
To be filled up by the medical resident/intern/clerk
 Present complaint
 Family history
 Past history
 Present illness
 Physical examination
 Impression/tentative diagnosis
 Examiner's signature
 
3. Admitting Notes Page
To be filled up by the resident/intern/clerk
 Chief complaint
 Brief clinical history
 
4. Laboratory Results Page
All lab results will be pasted in this page (Serial hgb, hct. Platelet, protime monitoring)
 
5. Graphic Chart Page
 To be filled up by the nurse/nursing aide
 Contains the record of the patient's TPR, weight, activity, diet, urine, stool from the day
of admission
 
6. Vital signs sheet/page
 Done by the nurse/aide
 Recordings of the patient's BP, PR, RR, CR (if the patient is for Hourly VS and
I/O, there is a separate sheet for that, this is common in the ICU)
 
7. Medical Order page
 Doctor's page
 Nurse can write the order: telephone, verbal made by the doctor
 Countersign by the doctor asap
 
8. Intravenous fluid sheet/page
 filled up by the nurse
 Information about the IVF administered to the patient: start, follow-up,
incorporation, termination
 
9. Medication sheet/page
 Nurse (Use pen according to the time of duty)
 Red NOC shift
 Black AM shift
 Blue PM shift
 
10. Insulin sheet
 filled up by the nurse (if the patient is diabetic and needs glucose monitoring)
 Records HGT results, and medications given
 
Il. Nurses' notes
 Recordings of the nurse on the course of the patient's stay throughout his hospitalization
by shift
 
12. Discharge summary page (clinical summary)
 resident/intern/clerk
 Physical examination
 Treatment
 Course in the ward
 Final diagnosis
 Recommendation / discharge instructions
 Signature
Add-ons
13. Consultation report page - done by Resident/intern/clerk
 Patient is referred to another doctor for evaluation
 Patient must sign the consent for referral
14. Consent for surgery/minor
15. Consent for admission to ICU
 signatory provides 3 samples of signature
16. Pre-operative preparation slip / checklist
 Nurse has to sign after each procedure is done
17. Consent for restraint applications
18. Consent for chemotherapy
19. DNR order form
20. Doctor's fee charge slip / summary of services
 Nurse's responsibility to write the name(s) of the
 
 
TRANSFERRING PATIENT
A patient may be transferred from one room to another within the healthcare facility for several
reasons:
 Sometimes the transfer is made at the patient's request
 Medical staff may request it.
 The physician may request the patient be transferred from one level of nursing care to
another because of a change in the patient's condition that might require more or less
specialized care
 Transferred onto a regular medical floor when his/her condition improves
 Sometimes the nursing staff will transfer a patient closer to the nursing station where the
patient's condition can be supervised more closely.
 The patient may also be transferred if the room location or equipment in the room is
needed for a more critically ill patient.
 
NURSES' RESPONSIBILITIES:
1. Make sure all the patient's belongings are transferred with him /her
2. Collect the belongings and any equipment that will be moved
3. Check with the nursing supervisor before moving any equipment to another floor
4. Check drawers, closets, tables, windowsills, the bathroom, and bed covers for articles that
might be forgotten.
5. The nurse will collect the patient's chart and medicines
6. The ward clerk will make the necessary changes in the patient's records, billing charges, and
other forms.
7. post the transfer on the patient's chart.
 include the time
 room numbers transferred from and to
 the reason for the transfer
 the patient's attitude toward the move should also be charted
 
 
DISCHARGE
Termination of care from a health care agency. The doctor plans the discharge with the
patient and leaves a written order on the patient's chart.
 
 
 
NURSES' RESPONSIBILITIES
a) The nurse makes sure the discharge order has been written by the doctor.
b) The nurse will then make the necessary arrangements with other departments to prepare for
the patient's discharge.
c) The nurse will also make sure the patient has been given instructions by the doctor for home
care and understands the instructions
 
 
METHOD
M medications
E environment
T treatment
H health teachings
O outpatient referral
D diet
 
 Taking medications
 Exercise programs
 Physical therapy
 Changing dressings
 Giving injections
 Respiratory treatments that will be
 continued at home.
 
d) If possible, the nurse will give the patient a written copy of the instructions, such as a copy of
the diet or an appointment card for a return visit to the doctor
e) The family must be notified of the patient's discharge time so they can make arrangements for
transportation.
 
 
Chart the Patient's Discharge
1. the date and time the patient was discharged
2. the way the patient left the healthcare facility
3. Any special instructions, diet, or medications the patient is to continue after discharge.
4. A notation should also be made on the chart that the patient's personal belongings were sent
with the patient.
 
 
 
Against Medical Advice (AMA)
 The patient leaves prior to obtaining a written order. The nurse requests the patient to
sign the form.