C9 Admission and Discharge Nursing Flashcards

Vocabulary flashcards covering core terms, protocols, and clinical standards for patient admission, transfer, and discharge.

Admission Process Start

The clinical process that begins immediately when the patient arrives on the healthcare unit.

Emergency Admission

An admission type required immediately for life-threatening conditions, such as severe respiratory distress.

Direct Admission

An admission that occurs when a patient is admitted straight to the healthcare facility from a primary care provider's office or clinic.

Approved Patient Identifiers

Reliable criteria used to identify a patient, specifically their full name, Date of Birth (DOB), and Medical Record Number (MRN).

Initial Assessment Priority

The immediate clinical priority during the initial nursing assessment, which is assessing Airway, Breathing, and Circulation (ABCs).

Baseline Vital Signs

Initial measurements established during admission to establish a clinical baseline for monitoring changes and guiding ongoing safe care.

Medication Reconciliation

The process of comparing home medications (including OTCs, herbs, and supplements), provider orders, and pharmacy lists to screen for omissions, duplications, incorrect doses, and interactions.

Medication Discrepancy Action

The safety priority of contacting the primary care provider to verify and clarify any missing or discrepant home medications.

Allergy Assessment Documentation

The required recording of the specific allergen name, the type of reaction (e.g., hives, difficulty breathing), and the severity of the reaction.

Routinely Screened Sensitivities

Sensitivities evaluated during initial screening, including medication allergies, food allergies, latex sensitivity, and environmental allergies.

Primary Fall Interventions

Safety measures including placing the bed in a low position, ensuring the call light is within reach, providing appropriate footwear, and assisting with ambulation.

Fall Risk Factors

Patient characteristics that increase fall risk, such as older age, history of falls, weakness, altered mental status, sedating medications, poor vision, and orthostatic hypotension.

Pressure Injury Inspection Sites

Key areas requiring careful skin inspection, including the sacrum, heels, elbows, bony prominences, skin folds, and existing wounds.

Wound Documentation Elements

Required details documented for existing wounds, including exact location, size, appearance, drainage, and stage or category.

Admission Safety Screening Risks

Conditions evaluated during safety screening, including risks of falls, pressure injuries, aspiration, infection, suicide/self-harm, elopement, seizures, and bleeding.

SBAR Framework

A structured communication model standing for Situation, Background, Assessment, and Recommendation.

Real-time Documentation

Immediate clinical recording that establishes an accurate record of facts and supports structured interprofessional communication for safe continuity of care.

Comprehensive Health History

An assessment history containing reason for admission, past medical/surgical history, allergies, medications, immunizations, family history, social history, and functional status.

Teach-Back Method

An interactive teaching method using return demonstration to confirm patient understanding and promote safe self-management.

Discharge Planning Timing

The care planning process that ideally begins upon admission to the healthcare facility.

Transfer Handoff Responsibility

The primary responsibility during unit transfers to provide a comprehensive SBAR handoff report ensuring safe transition of care.

Room Orientation Safety Action

An environmental safety step involving demonstrating how to use the call light system and placing it directly within the patient's reach.

Level of Consciousness (LOC) Assessment

An assessment that establishes neurological baseline status and guides necessary safety interventions and communication strategies.

Latex Allergy Immediate Action

The immediate protocol of applying a latex allergy alert band and ensuring a latex-safe environment.

Continuity of Care Discharge Elements

Essential review components prior to leaving the facility, including discharge instructions, home medications, follow-up appointment schedules, and emergency red flags.

Seizure Precautions

Safety interventions implemented upon arrival, including setting up functional suction equipment, testing bedside wall oxygen, keeping the bed low, and padding side rails.