Admissions, Transfers, and Discharge in Nursing 🩺

Admissions Responsibilities

Comprehensive Admission Assessment

• Essential baseline data for nursing care plan.
• Snapshot of patient's current health status.
• Foundation for personalized care plan.
• Enables comparison with future assessments.
• Nurses can adapt plans based on evolving needs.

Addressing Patient Anxiety

• Anxiety, fear, and loss of independence are common.
• Children may experience separation anxiety.
• Respectful and culturally sensitive care is crucial.

Steps in Admission Process

1. Introduce yourself and your role
2. Explain roles of other staff members
3. Introduce the client to their roommate (if applicable)
4. Provide and assist with hospital attire
5. Position the client comfortably
6. Apply identification bracelet and allergy band
7. Provide facility brochures and information
8. Inform about advanced directives
9. Document advanced directives status

Example Introduction

• "Hello, my name is Julie and I'm a registered nurse. I'll be your nurse today."
• "In addition to me, doctors, physical therapists, occupational therapists, and pharmacists will be involved in your care."

Assessment and Data Collection

Baseline Data

• Vital signs, allergy status
• Biographical information
• Reason for seeking healthcare
• Health history (current illness, medications, past surgeries, etc.)
• Family and psychosocial history
• Nutrition and spiritual health

Safety Assessments

• History of falls, sensory deficits, use of assistive devices

Discharge Information

• Family members, transportation, medical equipment needs

Tips for Collecting Data

• Be organized, efficient, and respectful.
• Use a standard assessment form.
• Document findings accurately.

Inventorying Personal Items

• Clothing, jewelry, money, assistive devices, medications, technology.
• Discourage keeping valuables at bedside.
• Document choice of safekeeping.

Orientation to Room and Facility

• Call light operation
• Electric bed operation
• Telephone and television services
• Overhead lighting control
• Smoking policy
• Restroom locations
• Waiting areas
• Meal times and dietary services
• Visiting policies

Indications for Transfer and Discharge

Reasons for Transfer/Discharge

1. Change in level of care needed
2. Need for specialized care not available in current facility
3. Patient ready for home or lower-level care setting

Discharge Planning

• Assess home suitability and need for home adaptations.
• Referral to social worker for community services.
• Effective communication with community service providers.
• Involve patient and family in planning process.

Discharge Education

1. Identify safety concerns at home.
2. Review symptoms of potential complications.
3. Provide contacts for providers and community resources.
4. Step-by-step instructions for home treatments.
5. Dietary restrictions.
6. Directions for medication adherence.

Equipment and Items at Discharge

• Personal belongings, valuables, medications, assistive devices, medical records.
• Ensure comfort and safety in transportation.

Nurse's Responsibilities

Transferring or Discharging a Client

1. Confirm receiving facility's readiness.
2. Communicate transfer time.
3. Complete and transfer documentation.
4. Provide verbal transfer report.
5. Confirm client’s transportation mode.
6. Ensure client is dressed appropriately.
7. Account for all client valuables.

Receiving a Transferred Client

1. Prepare specialized equipment.
2. Inform client’s roommate (if applicable).
3. Inform other healthcare team members.
4. Meet client on arrival and complete admission process.
5. Assess client’s condition post-transfer.
6. Review transfer documentation.
7. Implement timely nursing interventions.

Transfer Documentation

1. Medical diagnoses and care providers
2. Demographic information
3. Overview of health status and care plan
4. Immediate concern alterations
5. Essential care/assessments within next hours
6. Recent vital signs and medications
7. Allergies
8. Diet and activity orders
9. Specific equipment or adaptive devices
10. Advance directives and emergency status
11. Family involvement and healthcare proxy

Discharge Documentation

1. Type of discharge (provider prescription or AMA)
2. Date, time, and mode of transportation
3. Discharge destination (home, long-term care facility)
4. Summary of patient's condition at discharge
5. Unresolved difficulties and follow-up procedures
6. Disposition of valuables, medications, and prescriptions

Discharge Instructions

• Written instructions in patient’s language
• Dietary instructions
• Step-by-step home procedure instructions
• Signs of complications to report
• Contacts for providers and community services
• Plans for follow-up care and therapies

Example of Documentation for Understanding Discharge Instructions

• Document patient’s ability to repeat and demonstrate instructions.
• Include nurse’s signature and date.

Thank you for your attention. For more informative audio notes on various nursing topics, consider subscribing.