admission, transfer

What is patient admission?

The process of bringing a patient into a hospital or healthcare facility to receive care.

What is the goal of patient admission?

To make the patient feel safe, respected, and informed while beginning their care.

What does the nurse help the patient do during admission?

Feel safe and welcome, understand what will happen, complete necessary paperwork, become familiar with the room and hospital, receive an initial assessment, and begin the plan of care.

What are the main nursing responsibilities during admission?

Verify identity, obtain health history, check allergies and medications, obtain vital signs, assess physical and emotional needs, check safety risks, explain hospital routines, orient the patient, educate the patient, and document admission information.

What is the simple admission sequence?

Identify → Assess → Orient → Educate → Document.

What should the nurse verify during admission?

The patient's identity using facility policy.

What information should the nurse obtain during admission?

Health history, allergies, medications, vital signs, physical and emotional needs, and safety risks.

Why does the nurse check for safety risks during admission?

To identify risks such as falls and help prevent patient injury.

What should the nurse explain during admission?

The hospital routine, important hospital rules, room features, safety procedures, and how to get help.

What should the nurse show the patient during room orientation?

The call light, bed controls, bathroom, lights, television/phone if available, storage for belongings, emergency equipment, safety equipment, meals, and visiting rules.

What is the nursing process?

A step-by-step way nurses organize patient care.

What does ADPIE stand for?

Assessment → Diagnosis → Planning → Implementation → Evaluation.

What is Assessment?

Collecting information about the patient.

What is Diagnosis?

Identifying the patient's nursing problems or needs.

What is Planning?

Deciding what needs to be done, identifying patient needs, setting goals, and planning nursing care.

What is Implementation?

Carrying out the plan by providing treatments, medications, comfort, safety, and patient teaching.

What is Evaluation?

Determining whether the plan worked and checking how the patient is responding.

When is the nursing process used?

During admission, transfer, and discharge.

What does the nurse assess during admission?

Health history, vital signs, pain, allergies, medications, and physical and emotional condition.

What does the nurse do during planning for admission?

Identifies patient needs, sets goals, and plans nursing care.

What does the nurse do during implementation?

Provides treatments and medications, provides comfort and safety, and teaches the patient.

What does the nurse do during evaluation?

Checks how the patient is responding and updates the plan when needed.

What does HIPAA stand for?

Health Insurance Portability and Accountability Act.

What is HIPAA?

A law that includes rules that protect a patient's health information.

What is the main purpose of HIPAA?

To help keep a patient's private health information private.

What does PHI stand for?

Protected Health Information.

What can be included in PHI?

Name, address, medical history, diagnosis, medications, test results, medical records, and insurance information.

What should nurses do to protect patient information?

Keep information private, only access information needed for their job, avoid discussing patients in public areas, protect passwords, log out of electronic medical records, verify who receives information, and follow facility privacy policies.

What question should a nurse ask before sharing patient information?

"Does this person need to know this information?"

What does the HIPAA Privacy Rule generally require?

Covered organizations should make reasonable efforts to limit certain uses and disclosures of health information to the minimum necessary for the purpose.

What are common patient reactions to hospitalization?

Fear, anxiety, anger, loneliness, sadness, confusion, loss of independence, loss of privacy, sleep problems, and worry about money, family, work, or health.

Why can hospitalization cause patients to feel a loss of control?

Someone else may decide when they eat, help them bathe, wake them during the night, perform tests or procedures they do not understand, or make decisions about their care.

What is the nursing goal for patients reacting to hospitalization?

Help the patient maintain as much control, independence, dignity, and privacy as possible.

How can the nurse help a patient with anxiety?

Listen to the patient, explain what is happening, answer questions, and provide reassurance.

How can the nurse help a patient experiencing fear?

Give honest and simple information, encourage the patient to express concerns, and allow family/support persons when appropriate.

How can the nurse help with loss of independence?

Encourage the patient to do what they can safely do, offer assistance only when needed, and encourage choices.

How can the nurse help a lonely patient?

Encourage appropriate family contact, provide emotional support, and connect the patient with appropriate resources.

How can the nurse help a confused patient?

Reorient the patient, keep the environment calm, and make sure glasses or hearing aids are available when needed.

What should the patient know about the call light?

How to call the nurse and when to use it.

What should the patient know about bed controls?

How to raise/lower the bed and adjust the head or foot.

What safety instructions should the nurse give the patient?

Use the call light when help is needed, do not get out of bed alone if at risk for falling, keep the call light within reach, wear appropriate footwear, and tell the nurse if feeling dizzy, weak, or unsafe.

What is the purpose of room orientation?

To help the patient feel comfortable, informed, and safe in the hospital.

When does patient teaching begin?

As soon as the patient is admitted.

What should admission teaching include?

Room orientation, safety, hospital routines, medications and treatments, privacy and confidentiality, patient rights and responsibilities, and the plan of care.

What is teach-back?

A method of checking whether the patient understands teaching by asking them to explain or demonstrate the information in their own words.

What should the nurse ask instead of "Do you understand?"

Ask the patient to explain or demonstrate what they should do, such as "Can you show me how you would call for help?"

What is the main goal of admission teaching?

To help the patient feel safe, understand what is happening, participate in care, and know how to ask for help.

What is a patient transfer?

Moving a patient from one healthcare location to another.

What are examples of patient transfers?

Medical-surgical unit to ICU, ICU to medical-surgical unit, hospital to rehabilitation facility, hospital to skilled nursing facility, or hospital to another hospital.

What is the goal of patient transfer?

To make sure the patient's care continues safely.

What should the nurse do before transferring a patient?

Confirm the transfer order, explain the transfer, assess the patient, make sure the receiving unit/facility is ready, review medications and treatments, gather records, send test results, account for belongings, give a handoff report, and safely transport the patient.

What should the nurse consider when choosing transportation?

The safest method, such as a wheelchair, stretcher, or ambulance, and the patient's positioning, oxygen, IVs, drains, and other equipment.

What equipment may be needed during transfer?

Oxygen, IV fluids or IV pump, catheters or drains, mobility equipment, medications, necessary supplies, medical records, and transfer documents.

What information should be included in a transfer report?

Patient's name and diagnosis, current condition, allergies, medications, vital signs, recent changes, treatments, IVs/drains/oxygen, safety concerns, special needs, and what needs to happen next.

What question can help guide a transfer report?

"What would the next nurse need to know to safely care for this patient?"

What care may need to be completed before transfer?

Wound dressing changes, hygiene, brief changes, toileting, repositioning, medications that are due, pain management, and checking that the patient is stable.

What should the nurse do with patient belongings before transfer?

Gather belongings, handle valuables according to facility policy, and make sure glasses, hearing aids, dentures, and mobility devices go with the patient when appropriate.

What should be documented after transfer?

Time of transfer, patient's condition, transfer location, transportation method, report given, care provided, belongings sent, and changes in condition.

What is an easy way to remember transfer preparation?

TRANSPORT → EQUIPMENT → REPORT → CARE → BELONGINGS → DOCUMENT.

What is the key point about a patient transfer?

A transfer is not just moving the patient; it is transferring responsibility and important information.

What does the nursing process look like during transfer?

Assessment: What does the receiving nurse need to know? Planning: What needs to happen before the patient moves? Implementation: Prepare and safely move the patient. Evaluation: Did the patient arrive safely and was care continued correctly?

What is discharge planning?

Preparing the patient for what happens after leaving the hospital.

When should discharge planning begin?

Early during the patient's stay, not just on the day the patient leaves.

What should the nurse consider during discharge planning?

Where the patient will go, who will help, medications, follow-up appointments, equipment, diet, activity, wound care, transportation, warning signs, and when to seek medical help.

What does IDEAL stand for in discharge planning?

Include → Discuss → Educate → Assess → Listen.

What does Include mean in IDEAL?

Include the patient and family in discharge planning.

What does Discuss mean in IDEAL?

Discuss what life will be like at home.

What does Educate mean in IDEAL?

Explain medications, treatments, warning signs, and follow-up care.

What does Assess mean in IDEAL?

Ask the patient to explain the plan back in their own words.

What does Listen mean in IDEAL?

Listen to the patient's concerns, questions, and goals.

What should the nurse review before discharge?

Discharge instructions, medications, diet and activity restrictions, wound/treatment care, warning signs, follow-up appointments, transportation, equipment, written instructions, and questions.

What should the patient know before going home?

"What do I need to do when I get home?"

Why should nurses use simple language during discharge teaching?

So the patient can understand and correctly follow the instructions.

What are common challenges with hospital discharge?

Incomplete understanding, medication mismanagement, limited family/caregiver support, missed follow-up care, emotional stress, financial burden, and risk of readmission.

What is home health?

Healthcare services provided to patients at home who still need care.

What services can home health provide?

Nursing visits, wound care, medication management, and assessment of the patient's condition.

What does physical therapy (PT) help patients improve?

Walking, strength, balance, mobility, and the ability to safely move around.

What does occupational therapy (OT) help patients do?

Safely perform everyday activities such as bathing, dressing, eating, using the bathroom, and getting in and out of bed.

What can occupational therapy recommend?

Equipment that makes daily activities easier and safer.

What does speech therapy help with?

Speaking, understanding language, communication, and swallowing problems.

What does a social worker help with?

Safe discharge placement, financial concerns, transportation, community resources, family concerns, and long-term care or rehabilitation.

What does a case manager do?

Coordinates the patient's care and discharge plan.

What can a case manager arrange?

Home health, rehabilitation, skilled nursing facility placement, medical equipment, follow-up appointments, and insurance-related needs.

What does a dietitian/nutritionist do?

Helps patients who need special diets and assesses nutrition needs.

What diets might a dietitian help with?

Diabetic, low-sodium, renal, tube-feeding, and post-surgery nutrition.

What can a pharmacist help with during discharge?

Medication review, medication interactions, understanding medications, identifying duplicate medications, and medication questions.

What is a skilled nursing facility (SNF)?

A facility for patients who are not ready to live independently but do not need to remain in the hospital.

What care can an SNF provide?

Nursing care, rehabilitation, medication management, and wound care.

What is inpatient rehabilitation?

A setting for patients who need more intensive rehabilitation before returning home.

What is hospice care?

Care that supports patients approaching the end of life and focuses on comfort and quality of life.

What is palliative care?

Care focused on comfort and symptom management that can be provided while the patient is still receiving treatment for an illness.

Who makes referrals during discharge planning?

The healthcare team works together; the nurse identifies needs, communicates concerns, participates in planning, helps coordinate referrals, and teaches the patient and family.

What is the referral process to remember?

Patient needs → Identify the problem → Make referral → Arrange services → Teach patient → Follow up.

What was Mrs. Johnson's biggest safety concern after discharge?

Her risk of falling.

Which healthcare professional helps Mrs. Johnson improve walking and strength?

Physical therapist.

Who helps Mrs. Johnson learn how to safely bathe and dress?

Occupational therapist.

Who can help coordinate home health services and equipment?

The case manager or social worker, depending on the facility.

What should the nurse review before Mrs. Johnson leaves?

Medications, activity, wound care, safety, follow-up appointments, warning signs, and whether she understands the instructions.

What equipment might Mrs. Johnson need at home?

A walker, shower chair, raised toilet seat if needed, non-slip bath mat, and other equipment recommended by PT or OT.

What should Mrs. Johnson know about wound care?

Watch for increased redness, swelling, drainage, fever, and increasing pain.