Nursing Management of Care: Admissions, Transfers, and Discharge Notes and Discharge

Continuity of Nursing Care

• Nurses are responsible for ensuring continuity of care and the seamless sharing of information during the processes of admission, transfer, and discharge.
• The admission assessment serves as the foundation for nursing care, providing baseline data required to develop a comprehensive care plan.
• Continuity is maintained by comparing future assessments against baseline data to monitor a client's status and their specific response to treatments.
• Psychological and emotional considerations during admission include:
  • Clients often experience anxiety, fear of the unknown, and a perceived loss of independence or self-identity.
  • Children specifically risk experiencing separation anxiety if guardians cannot be present during the hospitalization.
  • Nurses must provide respectful and culturally sensitive care to ensure the client’s experience remains positive.

General Nursing Considerations

• Discharge planning is an interprofessional process that begins officially at the time of admission.
• Nurses must establish whether a client is capable of participating in the admission assessment. If a client is in distress or experiencing mental status changes, family members should provide the necessary information.
• The admission process is the starting point for establishing a therapeutic relationship with the client and their family.
• Nurses are tasked with promoting professional communication between all health care providers involved in the client's care.
• The nursing process guides the planning of teaching and interventions during the discharge phase.
• Standard hand-off communication tools, specifically $Introduction, Situation, Background, Assessment, Recommendation$ ($ISBAR$), are mandated for use during transfers and discharges.

The Admission Process

Equipment Preparation

• Before the client arrives, the following equipment must be placed in the room:
  • Appropriate documentation forms.
  • Equipment for measuring vital signs.
  • Pulse oximeter.
  • Hospital attire for the client.

Procedural Steps

• Introduce yourself and identify your specific professional role.
• Identify any language barriers and address them immediately.
• Explain the various roles of other care delivery staff the client will encounter.
• In semiprivate rooms, introduce the client to their roommate.
• Provide hospital attire and assist the client with changing as needed.
• Position the client comfortably.
• Apply the identification bracelet and an allergy band if necessary.
• Provide facility-specific brochures and informational materials.
• Offer information on advance directives and document the status in the medical record. If a physical copy is available, place it in the record.

Assessment and Data Collection

• Baseline Data: Includes vital signs, height, weight, and allergy status.
• Biographical Information: Identity and background details.
• Health History:
  • Reason for seeking health care and findings related to the present illness.
  • Current medications, including prescriptions, over-the-counter ($OTC$) drugs, and dietary or herbal supplements.
  • Prior illnesses, chronic diseases, surgeries, and previous hospitalizations.
• Family History: History of hypertension, cancer, heart disease, or diabetes mellitus.
• Psychosocial Assessment:
  • Use of alcohol, tobacco, recreational drugs, and caffeine.
  • History of mental illness, abuse, or homelessness.
  • Home situation and significant others.
• Nutrition Assessment:
  • Current diet and presence of chewing or swallowing problems (dysphagia).
  • Recent weight gain or loss.
  • Use of supplements and presence of dentures.
• Spiritual and Quality-of-Life: Religion, advance directives, and living wills.
• Review of Systems ($ROS$): Collection of subjective data regarding changes or altered function in each body system.
• Physical Examination: Collection of objective data through a head-to-toe examination.

Safety and Discharge Data

• Safety Assessments:
  • History of falls.
  • Sensory deficits such as vision or hearing impairments.
  • Use of assistive devices including walkers, canes, crutches, or wheelchairs.
• Early Discharge Information:
  • Family members present in the home and available transportation.
  • Relevant phone numbers and home medical equipment needs.
  • Requirements for home health care and presence of stairs in the home.

Inventory of Personal Items

• Personal items include clothing, jewelry, money, credit cards, assistive devices (eyeglasses, contacts, hearing aids, canes, dentures), cell phones, technology, and religious articles.
• Valuables should not be kept at the bedside; clients should be discouraged from doing so.
• Nurses must document all communication regarding items left in the room and items locked in the facility’s safe.

Client Orientation

• Orient the client and family to the room and facility, specifically addressing:
  • Call light and electric bed operation.
  • Telephone and television controls.
  • Overhead lighting operation.
  • Smoking policies and restroom locations.
  • Waiting areas, meal times, and dining/vending services.
  • Visiting policies and the usual timing for provider visits.

Transfer and Discharge Processes

Indications for Transfer and Discharge

• Level of Care Change: Client health status has improved (e.g., no longer needing intensive care).
• Different Setting Required: A different unit is needed for specific care (e.g., medical unit to surgical suite).
• Facility Specialization: The current facility cannot offer required care (e.g., transferring to a skilled facility after the acute phase of a stroke).
• Stability: The client no longer requires inpatient care and is ready to go home.

Discharge Planning and Education

• Assess the client's ability to return to their previous residence and the availability of home assistance.
• Evaluate the residence for necessary adaptations or equipment.
• Make referrals to social workers for community services and communicate health status to service providers.
• Identify that legally competent clients have the right to leave at any time (Against Medical Advice or $AMA$); in such cases, notify the provider, have the client sign forms, and provide teaching.
• Discharge Instructions: Must be printed in clear, concise language the client understands. The nurse must verify the client understands these instructions.

Standards for Discharge Education

• Identify home safety concerns.
• Review manifestations of potential complications and provide emergency contact numbers.
• Provide step-by-step instructions for continued treatments (e.g., dressing changes).
• Reinforce dietary restrictions and medication guidelines (including potential interactions and adherence).
• Specify the frequency and amount of therapies needed to support independence.

Procedural Responsibilities for Nurses

Transferring/Discharging a Client

• Confirm the receiving facility or unit is expecting the client and a bed is available.
• Communicate the transfer time and complete all documentation (medical records, transfer forms).
• Give a verbal report (in person or via phone).
• Confirm the mode of transportation (car, wheelchair, ambulance).
• Ensure the client is dressed appropriately and all valuables are accounted for.

Receiving a Transferred Client

• Ensure specialized equipment is ready.
• Inform the roommate of the incoming transfer.
• Notify the health care team of the client's arrival.
• Meet the client and family to complete admission and orientation.
• Assess the client's tolerance of the transfer and review documentation to implement interventions.

Documentation Requirements

• Transfer Documentation: Includes medical diagnosis, providers, demographics, health status overview, progress, immediate concerns, vital signs, medications ($including PRN$), allergies, diet/activity orders, adaptive equipment, and advance directives/code status.
• Discharge Documentation: Includes type of discharge ($provider prescription or AMA$), date/time, destination, escort/transportation mode, condition summary (e.g., steady gait), unresolved difficulties, follow-up procedures, and disposition of valuables/medications.

Questions & Discussion

Active Learning Scenario: Admission Assessment Components

• Health History Aspects:
  • Current illness.
  • Current medications (prescription, herbal, and over-the-counter).
  • Prior illnesses and chronic diseases.
  • Surgeries and previous hospitalizations.
• Psychosocial Evaluation Aspects:
  • Alcohol, tobacco, recreational drug, and caffeine use.
  • History of mental illness.
  • History of abuse or homelessness.
  • Home situation and significant others.

Application Exercise 1

• Question: After gathering assessment data and performing a review of systems for an older adult, what is the priority action?
• Answer: A. Orient the client to their room.
• Rationale: The priority is to prevent injury from unfamiliar surroundings. The client must know how to use the call light before being left alone.

Application Exercise 2

• Question: For a client with dementia, what is the priority nutrition evaluation component to determine from the family?
• Answer: D. Difficulty swallowing.
• Rationale: Dysphagia poses a life-threatening risk for aspiration, making it the highest priority over meal times, BMI, or food preferences.

Application Exercise 3

• Question: What are the responsibilities of the nurse at a transferring facility? (Select all that apply.)
• Answer: A, B, D, E.
  • A. Ensure the client has valuables.
  • B. Confirm the receiving facility has a room.
  • D. Give a verbal transfer report.
  • E. Complete a transfer form.
• Rationale: Assessing transfer tolerance (Option C) is the responsibility of the receiving nurse upon arrival.

Application Exercise 4

• Question: What should be included in a discharge summary for a client going home after knee arthroplasty? (Select all that apply.)
• Answer: B, C, E.
  • B. Follow-up care.
  • C. Instructions for diet and medications.
  • E. Contact information for home health care agencies.
• Rationale: Advance directives (Option A) and recent vitals (Option D) are prioritized in transfers between care providers, not home discharge summaries.