Section 5 Summary

Study Guide Summary

Admission, Transfer, and Discharge Guidelines

1. Admission
   - Definition: The formal process of placing a patient in a healthcare facility for treatment.
   - Process:
     - Collect patient demographics and medical history.
     - Obtain informed consent for treatment and procedures.
     - Conduct initial assessments, including vital signs and physical exams.
     - Prepare the patient’s room with necessary supplies and equipment.

2. Transfer
   - Definition: Moving a patient from one unit within or from one facility to another.
   - Key Steps:
     - Ensure the patient is stable enough to transfer.
     - Communicate with the receiving unit regarding the patient’s condition and any special needs.
     - Complete and send necessary documentation (transfer forms, medical history).
     - Accompany or assist the patient during the transfer.

3. Discharge
   - Definition: The process of releasing a patient from a healthcare facility to their home or another facility.
   - Components:
     - Conduct discharge planning early in the admission process.
     - Provide patients with discharge instructions, including medication management, follow-up appointments, and home care instructions.
     - Ensure that all paperwork is complete and that the patient has transportation arranged.

4. Continuity of Care
   - Ensuring that patient care is seamlessly continued from one setting to another (e.g., from hospital to home health care) to improve outcomes and patient satisfaction.

HIPAA Overview

- Definition: The Health Insurance Portability and Accountability Act of 1996 establishes national standards for the protection of health information.
- Key Points:
  - Protects patient privacy by restricting access to health records.
  - Requires patient consent for the sharing of medical information.
  - Mandates safeguards for electronic health records (EHR).
  - Allows patients to access their own health records.

Common Patient Reactions to Hospitalization

1. Disorientation:
   - Symptoms include confusion regarding time, place, and identity.
   - May result from unfamiliar environments or medications.

2. Separation Anxiety:
   - Feelings of fear and apprehension due to separation from family, friends, and familiar settings.
   - Common in children and elderly patients.

3. Other Reactions:
   - Depression: Feelings of sadness or hopelessness.
   - Anxiety: Worry about health status, treatments, or recovery.

Nursing Interventions Related to Hospitalization

1. Empathy:
   - Recognizing and understanding patients' feelings to build trust and rapport.
   - Actively listen to concerns and provide reassurance.

2. Interventions:
   - Provide emotional support and clear information about procedures and treatments.
   - Encourage family involvement to alleviate anxiety.
   - Monitor patients for changes in mood and behavior.

PCT Responsibilities

1. Performing an Admission:
   - Gather patient information (e.g., allergies, medications).
   - Take and record vital signs.
   - Ensure the room is prepared and stocked with necessary supplies.
   - Introduce the patient to the care team and explain the admission process.

2. Preparing for Transfer:
   - Confirm patient stability and readiness for transfer.
   - Pack the patient’s personal belongings.
   - Ensure that the receiving unit has all required documentation.
   - Transport the patient safely to the new unit, ensuring comfort and safety.

3. Preparing for Discharge:
   - Review discharge instructions with the patient and family.
   - Confirm follow-up appointments and medication plans.
   - Assist with transportation arrangements and answer any last-minute questions.

Patient Hygiene and Care Procedures

1. Personal Hygiene:
   - Essential practices for maintaining cleanliness and preventing infections.

2. Bath Procedures:
   - Vary based on patient condition (e.g., full bath, sponge bath, bed bath).
   - Use appropriate techniques to ensure patient comfort and dignity.

3. Oral Hygiene:
   - Importance of maintaining oral care to prevent complications like pneumonia and oral infections.

4. Pressure Injury Prevention:
   - Repositioning patients regularly, using special mattresses and conducting skin assessments.

5. Skin Care:
   - Regular cleaning, moisturizing, and protecting skin from injury.

6. Making Beds:
   - Techniques for both unoccupied and occupied beds to maintain cleanliness and comfort.

Medication Administration

1. Factors Affecting Response:
   - Age, weight, gender, genetics, and existing medical conditions can influence drug efficacy and side effects.

2. The Six Rights of Medication Administration:
   - Right Patient: Verify patient identity using two identifiers.
   - Right Drug: Confirm the medication matches the order.
   - Right Dose: Ensure the correct dosage is administered.
   - Right Route: Check the method of administration (e.g., oral, IV).
   - Right Time: Administer medication at the correct time.
   - Right Documentation: Document the administration promptly and accurately.

3. Routes of Administration:
   - Oral: By mouth, most common.
   - Sublingual/Buccal: Under the tongue or in the cheek.
   - Topical: Applied directly to the skin.
   - Rectal: Administered via the rectum.
   - Intravenous (IV): Directly into the bloodstream.

Nutrition and Hydration

1. Importance of Water:
   - Vital for hydration, nutrient transportation, and temperature regulation.

2. Feeding Assistance:
   - Understand the different types of feeding tubes (e.g., NG tube, PEG tube) and their use.
   - Assist patients with eating, considering any dietary restrictions.

3. Intake and Output Calculation:
   - Track fluid intake (oral, IV) and output (urine, drains) to monitor hydration status.

Bowel and Urinary Care

1. Bowel Elimination:
   - Techniques for promoting regular bowel movements, including dietary modifications and physical activity.
   - Administration of enemas when necessary.

2. Catheterization:
   - Steps for catheterization, including sterile techniques for male and female patients.
   - Importance of monitoring for complications such as infection or blockage.

3. Ostomy Care:
   - Education on stoma care, skin protection, and recognizing complications like leakage or infection.

Respiratory Care

1. Postoperative Care:
   - Importance of deep-breathing and coughing exercises to prevent pneumonia and promote lung expansion.

2. Oxygen Therapy:
   - Monitoring patients on oxygen therapy for proper usage and to prevent complications such as hypoxia.
   - Understanding the different delivery methods (nasal cannula, face mask).

3. Tracheostomy Care:
   - Procedures for maintaining a tracheostomy, including suctioning and cleaning the site.

Key Terms
- Admission: Entry into a healthcare facility for treatment.
- Continuity of Care: Ensuring seamless patient care transitions.
- Discharge: Release of a patient from healthcare services.
- Empathy: Understanding and sharing the feelings of patients.
- Urinal: Device for urination for bedridden patients.
- Ostomy: Surgical opening for waste elimination.
- Hypoxia: Condition of insufficient oxygen in tissues.
- Incentive Spirometer: Device used to encourage deep breathing.