Practical Guide for Nursing : Admitting the Patient

ADMITTING THE PATIENT

Admission

It is the preparation of a patient and the admission records to enter the hospital.

Purpose

To establish diagnosis by examinations, observations and tests.

To provide treatment and comprehensive care to the patient.

To provide necessary treatment and care which cannot be available or possible at home.

Supplies

1.     In out patient department (OPD)

2.     Supplies for taking vital signs.

3.     Supplies for conducting physical examination.

4.     OPD admission slip.

5.     In ward

6.     Patient' s case sheet with nurse' s notes/ records in it.

7.     Supplies for making admission bed.

8.     Supplies for giving admission bath.

9.     Supplies for conducting physical examination.

Nursing Activity

In OPD

1.     When the patient comes, receive with courtesy and offer a stool to sit. If very ill, place on the examination table or stretcher.

2.     Fill the particulars, name, age, sex, religion, address, husband' s or father' s name, occupation and date of admission on the admission slip.

3.     Check vital signs and observe general condition to determine the patient' s condition.

4.     Get the patient examined and admission slip completed by the doctor.

5.     Direct the patient or relative to the Medical Records Room to get the case sheet prepared.

6.     Inform the concerned ward nurse, so that she can complete the preparation to receive the patient in the meantime.

7.     As soon as the patient or relative comes with case sheet from Medical Record Department (MRD), attach the admission slip with the case sheet. Let the doctor write orders in the order sheet.

8.     Carry out the stated orders and emergency investigations.

9.     Take the patient along with case sheet to the ward and

a.     endorse to the ward nurse.

In Ward

1.     When the patient comes, take the case sheet and receive patient in the admission bed.

2.     If the patient is very ill, inform to the doctor incharge immediately.

3.     Complete the admission register and other admission records side by side.

4.     Make general observation (refer Nursing Activity Point 4 of the procedure 'Observing the Patient') from head to toe, take height, weight and vital signs.

5.     Give bath to the patient, if dirty, wash hair. If the patient is well enough, this may be done in the bathroom, if not it is done in the bed. Refer procedures 'Bathing a Patient in Bed' and 'Attending Hair Care'.

6.     Dress the patient in clean hospital clothes, comb the hair and make him or her comfortable.

7.     Subsequently learn the patient' s habits, interests, hobbies and health history.

8.     Hand over the patient' s belongings and valuables to the relative or ward in charge(nurse) for safe custody.

9.     Assist the doctor in examining the patient and carry out the orders and investigations.

10.                        If the patient is admitted for operation or any treatment requiring anaesthesia, take the consent.

11.                        If the patient wants hospital diet, prepare the diet slip, have it signed by the doctor and send to the dietician.

12.                        See for the following before the relative leaves for home.

a.     Any personal supplies which need to be brought from home.

b.     Any medicines to be brought from the market.

c.      The relative has got the visitor' s card and food pass, if the patient wants home diet.

13.                        Introduce the patient to the other patients on either side, orientate with bathroom, lavatories, doctor incharge, ward routines and any other necessary things.

14.                        If the patient is mentally upset due to worries of home, disease or some other reason, give psychological support accordingly.

Recording

1.     In OPD - Record

2.     The vital signs, any observations made, any stat orders and emergency investigations carried out.

3.     Any instructions given to the patient and /or family.

4.     In Ward - Record

5.     The observations made, height, weight , vital signs, socio-economic and cultural data, nursing needs identified, consent, medical orders and investigations carried out.

6.     Any instructions given to the patient and /or family.