Fundamental Nursing Skills and Concepts

1. Fundamental Nursing Skills and Concepts Chapter 10 PAGE 117

3. Admission to the Health Care Agency Authorization from a physician- admission must be determined by a physician either for the clients condition, testing that may be needed, special care or treatment that can only be carried out in that particular health care setting. The admitting dept.- initiates a medical record. Gathering of information from or about the client for record keeping and billing purposes.

4. Admission to the Health Care Agency Collection of billing information, done be admitting dept.. The ID bracelet may be put in place here or later in the pts. room by the admitting nurse. Completion of the admission procedure- the bracelet is very important and contains the name of the pt. , Id #, pts. doctor, and the pts. room #. It will stay in place throughout the hospital stay. Other than, asking the patients name, the bracelet is the single most important method of identifing the patient.

5. Admission to the Health Care Agency Addressograph card- identifies all pages of the pts. chart. So it is important that it is correct. Room change- card must be changed. In the hospital setting now sticky labels with clients info printed on them are now furnished to Id. clients paperwork as well as belongings.

6. Nursing admission activities Nurse checks to see that the room is clean, well stocked with basic equipment. Oxygen equipment available. IV standard in place. Nurse welcomes patient, smile, greets the client, gives a handshake. Nurse wears name badge so it can be easily read and introduce self. Double occupancy room, please do not overlook introducing room mate.

7. Orienting the Client to the Room The location of the nursing station Where to store clothing and personal items How to call for nursing assistance How to adjust the bed, equipment in environment How to regulate the room lights

8. Orienting the Client to the Room How to use the phone How to operate the television The daily routine, schedule such as meal times, activities When the physician visits When surgery or diagnostic testing is performed Answer any questions, this will make him more comfortable

9. Valuables and clothing Clothing usually remains in pts. room, but valuables should be encouraged to make a return trip home with the family or loved ones. Always document what was sent home with the name of the person taking it home on the inventory check list. If sending valuables home is a problem, observe the agency’s policy on safeguarding valuables. Hospital safe is used – be descriptive of object- 1 yellow metal ring with a clear stone or red stone. You are not a gemologist so do not assume it is a diamond or ruby. Just put down what you see. A second nurse, supervisor, or security personnel should be in attendance when the nurse and patient co-sign an inventory list. A copy to the patient, another attached to the chart.

10. Valuables and clothing Inventory list of patients belongings on page 120. Patients name should be labeled on all personal equipment, such as walkers, c-pap machines, wheelchairs. Special cups for dentures should be labeled. Please take care of eyeglasses and hearing aids also. If negligence is proven in loss, the agency replaces.

11. Helping patient to undress Provide for privacy Bed in low position Remove shoes Remove the most comfortable way in the least disturbing fashion. Remove unaffected side last, but, dresses it first. Apply hospital gown if possible. Page 120 lays steps used.

12. Admission to the Health Care Agency Documentation of client’s medical history- some of these skills may be delegated out. Such as v/s, weight, and admission questions may be done by the receiving nurse who is the LVN. The patients condition and the agency’s policy may deviate the procedure. Documentation of client’s physical examination

13. Admission to the Health Care Agency Development of an initial nursing care plan- completed within 24 hours following admission. Initial plan generally identifies the clients priority problems and may include the projected needs for teaching prior to discharge. Revise as needed. Initial medical orders for treatment, lab and dx. tests, activities and diet are done -medical hx. obtained and a physical exam within 24 hours is done and documented. An associate may be delegated to do so but it must be done with in 24 hours. Medical hx. and physical exam generally include, identifing data, chief complaint, history of present illness, personal history, past health history, family history, review of body systems and conclusions.

14. Con’t. Page 121 identifies the 8 components of a medical history. Conclusions are reached, if not, physician may document rule out, ( R/O ) , this is for suspected diagnosis and more testing is required to determine the diagnosis.

15. Initial Nursing Plan For Care Admission data is collected Nurses develops an initial plan of care within 24 hours Skill 10-1 describes basic steps in admitting a client page 132. Identifies the client’s priority problems Identifies the projected needs for teaching prior to discharge The nurse revises the care plan as the client’s condition changes.

16. Specific Responses to Admission Anxiety Fear Decisional conflict Situational Low Self-esteem Powerlessness Social Isolation Risk for Ineffective Therapeutic Regimen Management

17. Admission Responses Anxiety-uncomfortable feeling caused by insecurity. Always explain, instruct or teach, to inform the patient what is going to happen. They have a fear of the unknown, so keep them informed for more cooperation. Also you will find it takes less pain medication to combat there pain if they are well informed. Nursing care plan on page 122. Loneliness-occurs when a client cannot interact with family and friends. Admission limits interaction with family and friends. Make frequent contact with the client. Many facilities recognize that their clients need more liberal times for their loved ones to visit. Contact with those that are young is very important. Check with your facility to see if age limits are enforced.

18. Admission Responses Decreased privacy-ensure privacy by closing doors. It is common courtesy to knock before entering a clients room. You need to demonstrate respect and ensure protection of each patients rights to privacy. On admission inform the client of where they may retreat for solitude, such as the chapel, reading room, solarium. Smoking areas now are limited to none available. Loss of identity-a healthcare facility may temporarily deprive a person of his or her identity. Client may feel like they are receiving care, but no caring. Learn and call all patients by their name. The goal is to keep the admission as brief as possible and to discharge patients back to their homes as soon as possible.

19. Discharge a client Skill 10-2 page 135

20. The Discharge Process page 124 Obtain authorization for medical discharge- by obtaining a written medical order

21. The Discharge Process page 124 Provide discharge instructions- page 124, planning for discharge actually begins when patients are admitted. Use the acronym METHOD, table 10.2. The nurse reviews the teaching that was done, gives the prescriptions to be filled, advises to make an office visit appointment, gives the client a written summary of discharge instructions, patient signs, carbon copy is attached to patients chart. Notify the business office of discharge- need to make sure all insurance info. is complete, authorizations signed for release of medical info. for reimbursement or financial arrangements have been completed

22. The Discharge Process page 124 Gather the client’s belongings Arrange the client’s transportation if needed Escort the client at the time of discharge

23. The Discharge Process page 124 Write the discharge summary-of patients condition at the time of discharge Request room be terminally cleaned. The room is terminally cleaned, stripped of linen cleaned with disinfectant, restocked with basic equipment and the admissions department notified of a ready room.

24. The Discharge Process page 124 Authorization, physician writes discharge order, prescription and any follow up instructions.

25. The Discharge Process page 124 Leaving against medical advice or AMA, this is when a patient leaves before the physician authorizes the discharge. The nurse negotiates with the patient or family. To no avail, notify the nursing supervisor and the physician of the patients wishes. Patient still determined the nurse asks the patient to sign a special form. The AMA form releases the physician and health agency from future responsibility for any complications that may occur. Patient refuses to sign, cannot be detained. Document the AMA form was presented, explained and refused to be signed and this is all noted in the patients medical record.

26. Transferring patients page 125 Involves discharging from one unit or agency and admitting him to another without going home. Maybe to a step down unit or progressive care unit or a unit that requires less intensive nursing care. Nursing guidelines 10-1 page 126.

27. Admission to Other Nursing Facilities Extended Care Facilities-Health care agency that provides long-term care. Provides care for people who are unable to care for themselves but do not require hospitalization Skilled Nursing Facilities-Provides 24-hour nursing care under the direction of a registered nurse. Must be referred by a physician and require specific technical nursing skills such as :

28. Admission to Other Nursing Facilities (1) observation during an acute or unstable phase of illness. (2) enteral feedings or IV fluid administration. (3) bowel or bladder retraining. (4) administration of injectable meds. (5) sterile dressing changes. This facility must provide: rehabilitative services, physical therapy, occupational therapy, pharmaceutical therapy, dietary services, diversional activities, therapeutic activities, routine and emergency dental services.

29. Con’t. Those who have Medicare are entitled to 20 days of full coverage and 80 days of partial coverage per year for skilled care. Some folks have private insurance policies to cover costs that medicare doesn’t, but for those that go beyond 100 days they bear the cost personally, until all their resources are used and those of their spouse. Then when they are considered indigent they can apply for medicaid or its equivalent in their respective state.

30. Admission to Other Nursing Facilities Intermediate Care Facilities-Provides health care for people who require institutional care due to a physical or mental condition, but not 24 hour nursing care. They need supervision, assistance with meds, bathing and dressing. They tend to wander or are confused. Medicare provides no reimbursement for ICF. The costs are assumed personally or by state welfare programs like medicaid. Basic Care Facilities- BCF-Agency that provides extended custodial care. Provides shelter, food, laundry services in group home settings. ADL’S carried out on own.

31. Minimum Data Sets (MDS) Assess level of care using a standardized form. Repeated at 3 month intervals. MDS required assessments are listed on page 128. Problems that are identified an MDS’s are reflected in the nursing plan of care. These defeciencies must be addressed and focused on for the care of that client.

32. Client Referral Selecting a nursing home, page 128 A referral- sending someone to another agency or special services. Table 10-3 Common Community Services

33. Client Referral Continuity of care, care remains uninterrupted despite change in caregivers. Home health care- care provided in the home by a home health agency employee, either a nurse, LVN or RN, aide or therapist. Medicare and insurance companys reimbursements are limiting hospital stays, so this adds to the need for extended care to be carried out in patients homes. There is also a greater number of older Americans that can use these types of services. This type of nursing service help shorten the time spent in the acute care facility. Display 10-3 responsibilities of Home Health Nurses