NCM 109 RLE 2021- 2022 Second Semester

At the end of the lecture, through self-directed learning the students will be able to:
1. Interpret admission and discharge .
2. Assess patient ‘s health care needs based on a patient- centered approach
3. Execute nursing assessment by gathering patient information like health history, presenting
signs and symptoms.
4. Chart pertinent data on appropriate forms
5. Facilitate continuity of care to the patient after discharge

ADMISSION
 The point at which a person enters hospital as a patient.
 The point at which a person begins an episode of care—e.g., by arriving at an ER or in the triage
 The provision of patient centered services, which are accessible to the population without
compromising safety, quality and clinical standards, to the right people in the right location and
at the right time.
 The stay of a sick person in a health facility for the purpose of further observation , investigation
and treatment that can only be performed in the hospital setting.
 Patient generally reside at least overnight as inpatient in healthcare facility who is to provide
with room, board and continuous nursing service.

“ER LOG” shall document the following:

• Date and time of arrival • Chief complaint
• Patient complete detail(name, age, • Emergent status
gender, address, birthday) • Care received
• Care provider-attending physician, • Discharge time
nurse • Disposition
Other Documentations:
• Transfer form completed by attending • List of home medications
physician/provider • Test results
• ER Report if care of service is • Consent for treatment
completed- eg. Chest pain • Discharge Orders
• Physician Orders • Progress Notes

TRIAGE
 is a medical process of sorting out patients according to their need for care
  Patients with the most severe health problem receive immediate treatment.

DIFFERENT STEPS IN TRIAGE:

STEP 1 – ASSESSMENT
A registered nurse will take the medical history and perform a brief examination of presented
symptoms
STEP 2 – REGISTRATION
Triage staff gather information patient record and obtain consent for treatment. Both are
necessary to order diagnostic tests to enable the physician determine the best treatment
option.
STEP 3 – TREATMENT
Depending on patient condition, a registered nurse may start an intravenous (IV) line
A nurse or technician may also take blood or urine samples, or they may send for an X-ray or
other imaging test before a physician sees the client.
STEP 4 – RE EVALUATION
An Emergency physician or mid-level practitioner will re- evaluate condition after they receive
test results because the results may give them additional insight into the type of treatment
needed.
After re -evaluation, the attending physician determines whether the patient should be
admitted to the hospital or treated and sent home
STEP 5 – DISCHARGE
All patients receive written home-care instructions to follow when discharged.
The instructions describe how you can safely care for wound or illness, directions prescribed
medications and recommendations for follow-up medical care.

ADMISSION PROCEDURES
 In the absence of the Doctor's Admission Order Sheet or a doctor known to them, a walk-
in patient may be admitted through the Emergency Room
 Fill out a Patient Information Sheet. Information requested will be needed by the
attending physician and the hospital
  Indicate the accommodation of choice (suite, private room, semi-private - 2 patients per room,
or ward - 4 to 6 patients per room).

ADMITTING NURSE DUTIES

1. Facilitate admission of patients in a care setting and perform complete assessment of the
patient.
2. Accomplish admission form
3. Take patient vital signs (pulse, temperature, respiratory rate, height and weight).
4. Develop healthcare nursing plans in coordination with the clinicians or doctors.
5. Coordinate with other nursing staff and healthcare team to provide nursing care if for
admission.
6. Ensure compliance of admission nurse activities with the standards of quality healthcare.
At the time of arrival to the unit or clinical area, the nurse should:
1. Greet the patient
2. Introduce self
- accompany patient to room of choice
3. Give Patient / Significant Others Orientation:
- department policy rules and regulations
- patient’s room , facilities of the hospital, use of call system
-treatment schedule, visitor timings
2. Ensure safe and compassionate nursing care to patients
3. Completes patient’s admission chart
DISCHARGE PLANNING
 As transitional care, discharge planning begins when one is admitted to the hospital
 Prepares the client and his family so they don’t have to make a rushed decision about what
happens after they leave the hospital.
 Ensures them to have services and support to meet their needs during their recovery
HOSPITAL DISCHARGE
 The point of relieving a person from hospital setting who is admitted as inpatient from the
hospital
 Formal termination of patient service by attending doctor when treatment is over.

ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING

 Abilities for dressing; eating; toileting; bathing (tub, shower, sponge);
 ambulating (with or without aids such as a cane, crutches, walker, wheelchair;
 transferring (from bed to chair, in and out of bath, in and out of car);
 meal preparation; transportation; shopping
DISABILITIES/LIMITATIONS
 Sensory losses (auditory, visual); motor losses (paralysis, amputation) communication disorder
CAREGIVERS’ RESPONSES/ABILITIES
 Principal caregiver’s relationship to client; thoughts and feelings about client’s discharge;
expectations for recovery; health and copingabilities; comfort with performing needed care
FINANCIAL RESOURCES
 Financial resources and needs (note equipment, supplies, medications,special foods required)
COMMUNITY SUPPORTS
 Family members, friends, neighbors, volunteers; resources
HOME HAZARD APPRAISAL
 Safety precautions (stairs with or without handrails);
 lighting in rooms, hallways, stairways, night-lights in hallways or bathroom;
 grab bars near toilet and tub;
 firmly attached carpets and rugs);
 self-care barriers (lack of running water, lack of wheelchair access to bathroom;
 home, lack of space for required equipment, lack of elevator
NEED FOR HEALTH CARE ASSISTANCE
 Home-delivered meals; special dietary needs; volunteers for telephonereassurance, friendly
visiting, transportation, shopping
 assistance with bathing
 assistance with housekeeping
 assistance with wound

INFORMATION PROVIDED BY MEMBERS OF THE HEALTHCARE TEAM DURING THE DISCHARGE PROCESS
1. Client’s medical condition at the time of discharge
2. What kinds of follow-up care is needed, such as physical therapy
3. What medications to take, including why, when, and how to take them, and possible side effects to
watch for
4. Instructions on food and drink, exercise, and activities to avoid
5. What to expect at the new facility, if the patient is not going home

PATIENT EDUCATION AND SUPPORT DURING DISCHARGE

 Ensure that patients are able to understand their health, illnesses, medications, and treatments
to the best of their ability.

Discharge Process using METHODS

M-EDICATION
o Lanoxin 0.25mg/ once a day
Lanoxin is best to be taken without food
o Monitor apical pulse for 1 full min before administering. Withhold dose and notify
health care professional if pulse rate is less than 60bpm
E-XERCISE
o Take breaks if you feel tired. Do not over exert.
T-REATMENT
o e.g. Apply ointment to affected area
o Change dressing aseptically once daily
H-EALTH TEACHINGS
o When you leave hospital it may take some time for your appetite to return to normal.
Eating smaller meals and snacks regularly will help you build your appetite and intake
gradually
O-WHAT TO OBSERVE/ OPD
o Increasing shortness of breath and reduced tolerance of activity
o Follow up in RM. 204 of Marian Bldg. at 2pm. with Dra. Cruz
D-IET
o Low salt low fat diet-(limit salty foods, cut down on saturated fats, eat more fresh fruits
and vegetables )
S-PIRITUALITY/ SEXUAL ACTIVITY
o Ensure sense of hope and positivity
o Check with your doctor about when you can resume sexual activity
o
Recording is writing down all pertinent interactions with the client-assessing, diagnosing, planning,
implementing and evaluating.
Nursing documentation is a vital component of safe, ethical and effective nursing practice, regardless of
the context of practice or whether the documentation is paper-based or electronic.
Reporting is the verbal or written communication of data regarding the clients health status needs,
treatments, outcomes and responses.
Reporting facilitates clinical decision making, continuity of care and co-ordination among health team
members.

HOSPITAL FORMS FOR RECORDING

ARRANGEMENT OF FORMS (Ready made chart)
 Diet Request  Doctor’s Order
 Kardex  Nurses’ Progress notes
 Medication Reconciliation Form  Nursing Assessment Checklist
 Vital signs Form  Nursing Care Plan
 Intake and Output every shift/Hourly  Monitoring record
 Medication Record  IV Monitoring Record
 ABG Record  Blood Sugar Monitoring
 Laboratory Report Sheet  Patient Contraption Check list
 Request/Laboratory Forms  Multidisciplinary Patient and Family
Education

KARDEX
 Form of patient care summary updated every shift
 File system done by nurses that is separate from the patient chart for quick reference
 Accomplished upon patient admission in the area with patient information, such as patient
complete name, age, gender , religion, citizenship etc as well as chief complaints or reason for
admission, admitting physician, and admitting diagnosis
 The pages are written on in pencil and erased for any changes

MEDICATION RECONCILIATION
 Medication reconciliation is the process of comparing all of the medications a client is taking
(and should be taking) with newly ordered or changed medications.
 The comparison addresses duplications, omissions, and interactions.
 Reconciliation must occur during transitions in care and include client education on safe
medication use, and communications with other providers.
 The information is updated when the client’s medications change.
 The responsibility for conducting medication reconciliation often falls to the nurse.

VITAL SIGNS RECORD

 Vital signs are an objective measurement to help detect or monitor a medical problem
 It tells the physician the degree of derangement that is happening from the baseline
 Vital signs consist of temperature, pulse rate, blood pressure, and respiratory rate.
 “Pain as the fifth vital sign”
 Studies have found pulse oximetry sometimes helps to clarify the patient's physiological
functions
Temperature
 The human body temperature typically ranges from 36.5° C to 37.5° C. (97.7 to 99.5 degrees
Fahrenheit.)
 Axillary, rectal, oral, and tympanic membrane are the most commonly used methods to
record a body temperature.
 Digital and infrared thermometers are the devices most commonly used.
Pulse Rate
 Pulse is the heart rate, or the number of times your heart beats in one minute.
 The most common sites of measuring the peripheral pulses are the radial pulse, ulnar pulse,
brachial pulse in the upper extremity, and the posterior tibialis or the dorsalis pedis pulse
as well as the femoral pulse in the lower extremity.
 The radial pulse is the most frequently used site for checking the peripheral pulse, where
the pulse is palpated on the radial aspect of the forearm, just proximal to the wrist joint.
 Parameters for assessment of pulse include its rate, rhythm, volume, amplitude, and the
rate of increase, besides its symmetry
Rate-fastness Volume-force or strength
Rhythm-equal intervals between pulsations
Respiratory Rate
 The respiratory rate is the number of breaths per minute.
 Respiration can be affected by age, smoking, activity, disease, and illness.
 Bradypnea described as ventilation less than 12 breaths/minute
 Tachypnea described as respiratory rate more than 20 beats per minute
 Parameters important include its rate, depth of breathing, and its pattern rate of breathing.
 Hyperpnea is described as an increased depth of breathing
 Hyperventilation-breathing that is deeper and more rapid than normal. It causes a decrease
in the amount of a gas in the blood (called carbon dioxide, or CO2).
 Hypoventilation-The state in which a reduced amount of air enters the alveoli in the lungs,
resulting in decreased levels of oxygen and increased levels of carbon dioxide in the blood.
Blood Pressure
 Blood pressure (BP): measures the pressure of the blood against the artery walls.
 Pre-requisites before checking the blood pressure of the patient
 The patient should not have taken any caffeinated drink at least 1 hour before the testing
and should not have smoked any nicotine products at least 15 minutes before checking the
pressure.
 They should have emptied their bladder should be before checking the blood pressure. Full
bladder adds to the pressure readings
 It is advisable to have the patient be seated for at least 5 minutes before checking his/her
pressure.
 The patient’s back and feet should be supported, and their legs should be uncrossed.
Unsupported back and feet likewise crossed legs add to the pressure readings
 Cuff placement should be on a bare arm and not put over sweaters, coats, or other clothing.
 The arm should be supported at the heart level. Unsupported arm leads to 10 mmHg to the
pressure readings.
 Using the correct cuff size is very important. Smaller cuff sizes give falsely high, and larger
cuff sizes give a falsely lower blood pressure reading.
Pain Scale
 A chart that represents different levels of pain, from mild to severe
 Used by a healthcare provider with patients to effectively communicate pain intensity
Assess for objective signs of pain:
 Facial Expression-facial grimacing(suggests disgust or pain); frowning and sad face
  Vocalization-moaning, crying
 Body movements-guarding, resistance to moving
Types of Pain Scale
 Numerical rating: Usually based on a scale from zero to 10, this scale assigns a
measurable number to your pain level. Zero represents no pain at all while 10
represents the worst imaginable pain.
 Wong-Baker: Represented by faces with expressions, this scale follows the same
guideline as the numerical scale. Zero is represented by a smiley face, while 10 is
represented as a distraught, crying face. This scale is useful when rating pain in children
or adults with mild cognitive impairments.
 With this scale, you would point to each face using the words to describe the pain
intensity.
 Color Analog Scale uses colors, with red representing severe pain, yellow representing
moderate pain, and green representing comfort.
 The colors are usually positioned in a linear format with corresponding numbers or
words that describe your pain. The color analog scale is often used for children and is
considered reliable.

How to record the vital signs

 Enter results corresponding the dates and shifts of duty
 Pulse Rate (PR)& Respiratory Rate(RR)-record the results taken in beats and breaths /minute
respectively
 Blood Pressure (BP)- Blood pressure is represented by two numbers written as a fraction in
millimeters of mercury (mm Hg).
 The systolic reading is written as the numerator
 Diastolic pressure is written as the denominator.
 Pain Scale-record the level of pain from mild to severe as described
 How to Record the Vital Signs
 Temperature (T):
 Plot the result in the graphic sheet. Each vertical row has lines ; one line represents the point
result in centigrade
 Start by encircling 37 and connect each result with a straight line to the point with a dot
 If recording of temperature was missed by the previous shift, do not connect the dots, leave as
is. Plot the result with a beginning dot then continue connecting the dot with a straight line to
your next monitoring
 If the patient got febrile and an intervention was made like doing a sponge bath or
administering an antipyretic /doctor’s order and the temperature lowered, connect the result
with a dotted line and indicate the time the patient had fever/medication was given

INTAKE AND OUTPUT MONITORING

Intake-is any measurable fluid that goes into the patient's body
Intake includes:
 oral intake  intravenous fluids
 tube feedings  medications
  total parenteral nutrition  dialysis fluids
 lipids  flushes
 blood products

Output-Is any measurable fluid that are excreted or withdrawn from the patient.
This includes:
 urine
 liquid stools
 drainage from drains or chest tubes
 blood
 wound drainage

Intake and Output

 Determines the difference between the amount of fluids that goes in and the amount that is
out.
 Accurate recording of intake and output is vital to be able to calculate the fluid balance.
 If there is more intake than output, the patient is in a positive fluid balance.
 If there is more output than intake, the patient is in a negative fluid balance.
 Most charts include a running total.
 Routinely monitor fluid balance (1&0) for the following:
 All clients receiving tube feedings
 Clients with catheters
 Clients with urinary tract infections
 Clients with physician orders for fluid restrictions or orders to force (encourage) fluids
 Clients with specific physician orders for additional liquid (fluid)
 Clients who are known to be dehydrated or who are at risk for dehydration
 Clients with certain heart and kidney conditions that are at high risk for fluid imbalance
 Clients receiving intravenous fluids or parenteral nutrition therapy

STANDARD MEASUREMENTS FOR I&O

1 ounce=30ml
1tablespoon=15ml
1teaspoon=5ml
1 cup=180ml
1 glass=240ml

OTHER FORMS
 Medication Card Sample
 Referral form
 Sample Prescription
 Diagnostic Imaging Request Form
 Pulmonary Request Form
  Indication for Transfusion
 Consent for Operation/ Procedure/ Treatment
 Schedule for Operation
 Advanced Directives Form (Allow Natural Death)
 Request Form for the Pastoral Care for the Sick

ADVANCE HEALTH CARE DIRECTIVES

 A variety of legal and lay documents that allow persons to specify aspects of care they wish to
receive should they become unable to make or communicate their preferences.
 In an advance directive, the patient and the family always have the option to change their
decision. For example, clients who are terminally ill may have decided not to have ventilator
support, they have the right to change their mind or take more time to make the decision

The two types of advance health care directives:

 The living will provides specific instructions about what medical treatment the client chooses to
omit or refuse (e.g., ventilatory support) in the event that the client is unable to make those
decisions.
 The health care proxy, also referred to as a durable power of attorney for health care, is a
notarized or witnessed statement appointing someone else (e.g., a relative or trusted friend) to
manage health care treatment decisions when the client is unable to do so

Multidisciplinary Patient and Family Education Record

 Purpose-tofacilitate positive patient health outcomes by promoting healthy behavior involving
the patient/family/significant other in patient care decisions
 Patient and family education is collaborative and interdisciplinary process appropriate to the
plan of patient care in which they are involved. Considerations shall be given to:
 Cultural and religious practices
 Emotional barriers
 Physical and cognitive limitations
 Desire and motivation to learn
 Financial implication of care choices
 Length of stay

NURSING RECORDS AND REPORTS

(medical record, health record, and medical chart)
 HEALTH RECORD is the systematic documentation of a single patient’s medical history and care
across time.
The medical record includes a variety of types of "notes" entered over time by health care
professionals, recording observations and administration of drugs and therapies, medication
orders, test results, x-rays reports, etc
 REPORTS are oral or written exchanges of information shared between caregivers in a number
of ways
TYPES OF NURSING REPORT
1. Change of Shift Reports-
  A report given by a primary nurse to the nurse who assumes responsibility for continuing
care of the patient. The change of shift report might be given in written form or orally.
 It provides basic identifying information such as patient condition, current appraisal of
each patients’ health status, current order by the physician, changes of medication,
intravenous fluids, diet, activity level.
 Summary of each newly admitted patient.
 Report on patients who have been transferred or discharged.
2. Telephone Reports
 Telephones can link healthcare professionals immediately and enable nurses to receive and
give critical information about patients in a timely fashion.
 Report the patients’ current vital signs and clinical manifestation investigation etc.
3. Incident Reports
 It is a tool used by heath agencies to document the occurrence of anything out of the
ordinary that results in harm to a patient, employee or visitor

CHARACTERISTICS OF GOOD RECORDING AND REPORTING:

 Accuracy: Information should be correct to prevent serious mistakes. It should be always
complete with accurate signature. Do not use nick names.
 Conciseness: Use a few words as possible to give the necessary information.
 Thoroughness: Even a concise record or report must contain complete information
 Up to date: Recording should be done on time. A definite time and routine for the reporting
make more time and routine for the reporting makes more efficient management. Delay in
recording can result in serious omissions and delay the work.
 Organization: Communicate all the information in a logical format or order.
 Confidentiality: The information should be confidential.
 Objectivity: Presentation of facts not personal feelings, to give true picture.

IMPORTANCE OF RECORDS AND REPORTS:

FOR PATIENTS:
 Legal evidence
 It avoids duplication of treatment measures
 It avoids duplication of diagnostic and procedural measures
 It will assist in continuity of patient care
 It helps in health insurance of the patient
PURPOSE OF RECORDS
1. Supply data that are essential for program planning and evaluation
2. Provide the practitioner with data required for the application of professional services for the
improvement of family’s health
3. Tools of communication between health workers, the family, & other development personnel
4. Help in the research for improvement of nursing care
5. Records from and on behalf of medical patients is a critical component of healthcare,
particularly when that data needs to be analyzed to provide the best and most proper care.
6. It is a written and legal recording of the interventions that concern the patient and it includes a
sequence of processes.
7. It is established with the personal record of the patient, which constitutes a base of information
on the situation of his health.
PURPOSES OF KEEPING RECORDS
 Communication
 Education
 Assessment
 Documentation of continuity and justification of case
 Research
 Auditing
 Legal documentation
 Individual case study

NURSES RESPONSIBILITY FOR RECORD KEEPING AND REPORTING

1. Keep under safe custody of nurses
2. No individual sheet should be separated
3. Not accessible to patients and visitors
4. Strangers is not permitted to read the record
5. Records are not handed over to the legal advisors without written permission of the
administration
6. Handed carefully
7. The patient has a right to inspect and copy the record after being discharged
8. Failure to record makes a nurse guilty of negligence
9. Medical record must be accurate to provide a sound basis for care planning
10. Errors in nursing charting must be corrected promptly in a manner that leaves no doubts about
the facts
11. In reporting information about criminal acts obtained during patient care, the nurse must
reveal such information only to the police, because it is considered a privileged communication

ADMISSION ORDER

Please admit to a room of choice under the service of Dr. Sugay. Please secure consent for admission
and management.
 Diet as tolerated
 For Complete Blood Count, sodium, potassium
 Ferrous Sulphate 1 capsule three times a day
 Folic Acid once a day
 Vital signs every 4 hours
  Monitor fetal heart tones every 4 hours and Intake and Output every shift
 Monitor amount of blood and number of pads consumed every shift
Dr. Sugay

Reference Materials:

Berman, Audrey, Kozier, Barbara, ( Eds.) (2010) Kozier and Erbs fundamentals of Nursing,concepts,
process, and practice upper Saddle River, N. J. : Pearson Prentice Hall

FEU- NRMF Medical Center , Hospital forms

RLE Manual Book for Level 2