ADMITTING CLIENT TO A HEALTH

CARE AGENCY
Purpose:
 To establish a positive, initial and relationship with the
client, his relatives or close friends
 To orient the client to the immediate environment and the
services that are available.
 To acquire data base or information which generally includes
a health history, comprehensive subjective and objective data
related to the current health, and physical assessment.
 To enable the nurse to collaborate with the client to discuss
his/her needs and expectations for care.
ASSESSMENT:
 Determine the name, sex, age religion, civil status, admitting
diagnosis or primary symptoms of the client and the name of
the attending physician
 To orient the client to the immediate environment and the
services that are available
 To acquire data base or information which generally includes
a health history, comprehensive subjective and objective data
related to the current health and physical assessment.
 To enable the nurse to collaborate with the client to discuss
his/her needs and expectations for care.
POSSIBLE NURSING DIAGNOSIS
 Anyone who must leave the security of his previous pattern
of living for care and treatment in a health care agency is
likely to be experiencing any of the following nursing
diagnosis:
 Fear
 Anxiety
 Altered Family Process
 Self-care deficit
 Disturbance in self-concept
 Social Isolation
EQUIPMENT:
 Thermometer
 Sphygmomanometer
 Stethoscope
 Scales for weight and height
 Instruments used for physical Assessment.
 Pen light
 Tongue depressor
 Etc.
PROCEDURE:
 Greet the client and the accompanying relative. Introduce
yourself
 Provide privacy
 Let the client sit in a comfortable position and take the data
and complaint
 Tell the client what will be happening and what to expect
 Obtain the client’s temperature, pulse, respiratory rate,
blood pressure, weight and height
 Notify the physician in charge and introduce the client to the
doctor
 Change street clothes to hospital gown.
 Prepare the client for physical examination and assist the physician
 Carryout STAT orders
 While waiting for the physician’s orders, notify the department
about the client to be admitted. Give pertinent information to the
nursing staff
 Document on the client’s chart all necessary data
 Request client’s admission kit from the pharmacy
 Bring the client to the department through wheelchair or
stretcher at the same time orienting the client and relatives on
some hospital rules like visiting hours, hospital places like
pharmacy, accounting office and nurse’s station as you pass them
on your way to his room.
 Upon reaching the department, introduce the client to the
nurse in charge.
 Orient the client to his/her room as well as the use of the
equipment such as signal device (buzzer), adjustable bed.
Etc., explain meal times and visiting hours
 Endorse client’s condition and other pertinent data to the
nurse in charge
FDAR- FORMAT FOR DOCUMENTATION
F- Focus
D- Data
A- Action
R- Response
SAMPLE DOCUMENTATION
DATE TIME FOCUS NURSES NOTES
1/20/2020 3:30 PM HYPERTHERMIA D:Admitted this 18 year old female under the
service of Dr. Tan (PC); patient is awake,
conscious and coherent.----------------------
Subjective data: “Init kayo akong paminaw,
labad pud akong ulo”--------------------------
Objective data: Temperature 38 ºC, pain scale of
8/10-------------------------------------------------
3:30 PM A: Vital signs checked and recorded.-----------
TSB, done---------------------------------------
Seen and examined by Dr. Carpio (ROD); with
orders made.--------------------------------------
3:40 PM Paracetamol (Biogesic) 500 mg 1 tab, P.O. given.
Started venoclysis of D5 LR 1 liter at 120 cc/hr
infusing well at left metacarp al vein.------------
R: Subjective data: “ Ok na akong paminaw
maam dili na init ug dili na labad akong ulo.
Objective data: temp 37.2 ºC; pain scale of 2/10
Transported to room per wheel chair, with no
other unusualities noted. Endorsed to ward
NOD. Anne Curtis Smith, St. N., DMSFI
ABBREVIATIONS
 ABG- ARTERIAL BLOOD GAS
 abd-abdomen
 ABP- ARTERIAL BLOOD PRESSURE
 ADH- antidiuretic hormone
 ADL- ACTIVITIES OF DAILY LIVING
 AGN- acute glomerulonephritis
 AIDS- acquired immunodeficiency syndrome
 ALL- ACUTE LYMPHOCYTIC LEUKEMIA
 AKA- ABOVE THE KNEE AMPUTATION
 aPTT- activated partial thromboplastin time
 BMR- BASAL METABOLIC RATE
 BLS- BASIC LIFE SUPPORT
 BP- BLOOD PRESSURE
 CRT- CAPILLARY REFILL TIME
 Ca+- Calcium
 CBR- complete bed rest
 CBR s̅ BRP- COMPLETE BED REST WITHOUT BATH
ROOM PRIVELEDGES
 MHBR- MODERATE HIGH BACK REST
 ECG- ELECTROCARDIOGRAM
 HCVD- HYPERTENSIVE CARDIOVASCULAR DISEASE
 I & O- INTAKE AND OUTPUT
 I & D- INCISION AND DRAINAGE
 JP DRAIN- JACKSON-PRATT DRAIN
 IVF- INTRAVENOUS FLUID
 IV- INTRAVENOUS
 IM- INTRAMUSCULAR
 ID- INTRADERMAL
 KVO- KEEP VEIN OPEN
 LBW- LOW BIRTH WEIGHT
 MRI- MAGNETIC RESONANCE IMAGING
 NICU- NEONATAL INTENSIVE CARE UNIT
 ICU- INTENSIVE CARE UNIT
 CT SCAN- COMPUTED TOMOGRAPHY SCAN
 DM- DIABETES MELLITUS
 DKA- DIABETIC KETOACIDOSIS
 PO- PER OREM
 NPO- “NOTHING BY MOUTH”
 IVTT- INTRAVENOUS TREATMENT THERAPY
 q- every
 VS- VITAL SIGNS
 Tx- TREATMENT
 Dx- diagnosis
 S/Sx- signs and symptoms
 Rx- prescription
 r/t- related to
 s/t- secondary to
 r/o- rule out
 s/p- status post
 STAT- immediately
 CV- CARDIOVASCULAR
 ID- INFECTIOUS DISEASE
 MI- MYOCARDIAL INFARCTION
 MVA- MOTOR VEHICULAR ACCIDENT
 SOB- SHORTNESS OF BREATH
 BM- BOWEL MOVEMENT
13 Principles of Sterile
Technique
1. Only sterile items are used within the sterile field.
2. Sterile persons are gowned and gloved.
3. Tables are sterile only at table level.
4. Sterile persons touch only sterile items or areas. Unsterile
persons touch only unsterile items or areas.
5. Unsterile persons avoid reaching over sterile field. Sterile
persons avoid leaning over unsterile areas.
6. Edges of anything that encloses sterile content are considered
unsterile.
7. Unsterile persons avoid sterile areas.
8. Sterile field is created as close as possible to the time of use.
9. Sterile areas are continuously kept in view.
10. Sterile persons keep well within sterile area.
11. Sterile persons keep contact with sterile areas to a minimum.
12. Microorganisms must be kept to irreducible minimum.
13. Destruction of integrity of microbial barriers results in
contamination.