THE ADMISSION PROCESS

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11

Chapter

Admission, Discharge,

Transfer, and Referrals

W O R D S T O K N O W

admission basic care facility clinical résumé continuity of care discharge

discharge planning extended care facility home health care intermediate care facility orientation

progressive care unit referral

skilled nursing facility stepdown unit transfer

transfer summary transitional care unit

L E A R N I N G O B J E C T I V E S

On completion of this chapter, the reader will

● List four major steps involved in the admission process.

● Identify four common psychosocial responses when clients are admitted to a health agency.

● List the steps involved in the discharge process.

● Give three examples of the use of transfers in client care.

● Explain the difference between transferring clients and referring clients.

● Describe three levels of care that nursing homes provide.

● Discuss the purpose of a Minimum Data Set.

● Identify two contributing factors to the increased demand for home health care.

EVERYONEexperiences health changes. Several levels of health care are available, depending on the seriousness of the condition (see Chap. 4). Some people recover with self-treatment or by following health instructions from nurses or other health care team members.

This chapter describes skills used in caring for clients who become seriously ill, are injured, or have chronic health problems that require admission and temporary care in a facility such as a hospital. This chapter also addresses nursing skills involved in subsequent discharge, transfer, or referral of clients to community agencies that provide health care.

Admissionmeans entering a health care agency for nursing care and medical or surgi- cal treatment. It involves the following:

• Authorization from a physician that the person requires specialized care and treatment

• Collection of billing information by the admitting department of the health care agency

• Completion of the agency’s admission data base by nursing personnel

• Documentation of the client’s medical history and findings from physical examination

• Development of an initial nursing care plan

• Initial medical orders for treatment

The various types of admissions are listed in Table 11-1.

164 U N I T 4 ● Performing Basic Client Care

Medical Authorization

Before admission, a physician determines that a client’s condition requires special tests, technical care, or treat- ment unavailable anywhere other than in a hospital or other health care agency. Some clients are scheduled for nonurgent care, such as some types of surgery, on a mutu- ally agreeable date and time. Most clients, however, see a primary care or emergency department physician just before admission. The physician advises both the client and nursing staff to proceed with the admission process.

The Admitting Department

In the admitting department, clerical personnel begin to gather information from the prospective client or his or her family. They initiate the medical record with data obtained at this time. They prepare a form with the client’s address, place of employment (if the client works), insurance company and policy numbers, Medicare infor- mation, and other personal data. The hospital’s business office uses this information for record keeping and billing.

Clients who are extremely unstable or in severe dis- comfort may bypass the admitting department and go directly to the nursing unit. Personnel eventually will direct someone from the family to the admitting depart- ment on the client’s behalf or go to the client’s bedside to obtain needed information.

Generally the admissions clerk prepares an identifica- tion bracelet for the client, which contains the client’s name, an identification number, and, in some cases, a bar code for computerized scanning purposes. Someone in the admitting department or the admitting nurse applies the bracelet (Fig. 11-1). For the client’s safety, he or she must wear the bracelet throughout the stay. Other than asking a client’s name, the bracelet is the single most important method for identifying the client. If the iden- tification bracelet is missing or has been removed, the nurse is responsible for replacing it as soon as possible.

Once personnel have collected preliminary data, they notify the nursing unit and escort the client to the site where he or she will receive care. They deliver the form initiated in the admitting department to the nursing unit along with a plastic card called an Addressograph plate.

The card identifies the pages within the client’s medical record. Nurses use it to stamp laboratory test request forms, forms that accompany a laboratory specimen, and charge slips for special items such as dressing supplies used in the client’s care.

Nursing Admission Activities

Preparing the Client’s Room

When the admissions department informs the nursing unit that the client is about to arrive, nurses check the room to ensure it is clean and stocked with basic equip- ment for initial care (Box 11-1). They later provide per- sonal care items such as soap, skin lotion, toothbrush, toothpaste, razor, paper tissues, and denture containers for clients who do not have them. They place oxygen administration equipment, a stand for supporting intra- TYPES OF ADMISSIONS

TABLE 11-1

TYPE EXPLANATION EXAMPLE

Inpatient

Planned (nonurgent) Emergency admission Direct admission Outpatient

Observational

Length of stay generally more than 24 hours Scheduled in advance

Unplanned; stabilized in emergency department and transferred to nursing care unit

Unplanned; emergency department bypassed Length of stay less than 24 hours; possible

return on a regular basis for continued care or treatment

Monitoring required; need for inpatient admission determined within 23 hours

Acute pneumonia

Elective or required major surgery Unrelieved chest pain, major trauma

Acute condition such as prolonged vomiting or diarrhea

Minor surgery, cancer therapy, physical therapy

Head injury, unstable vital signs, premature or early labor

FIGURE 11-1

•

Applying an identification bracelet.

C H A P T E R 1 1 ● Admission, Discharge, Transfer, and Referrals 165

venous fluids, and anything else required at the time of initial treatment.

Welcoming the Client

One of the most important steps in admission is to make the client feel welcome. On arrival, the admitting nurse greets the client warmly with a smile and handshake. He or she wears a name tag, introduces himself or herself, and also introduces clients sharing the room. Being treated courteously helps relax the client. A client who feels un- expected or unwanted is likely to have a poor, and last- ing, first impression of the unit.

Orienting the Client

Orientation(helping a person become familiar with a new environment) facilitates comfort and adaptation. When orienting a client, the nurse describes the following:

• The location of the nursing station, toilet, shower or bathing area, and lounge available to the client and visitors

• Where to store clothing and personal items

• How to call for nursing assistance from the bed and bathroom

• How to adjust the hospital bed

• How to regulate the room lights

• How to use the telephone and any policy about divert- ing incoming calls to the nursing station during the night

• How to operate the television

• The daily routine such as meal times

• When the doctor usually visits

• When surgery is scheduled

• When laboratory or diagnostic tests are performed Some hospitals provide booklets with information about the agency, such as gift shop hours, newspaper deliveries, and location of the chapel or name of the chaplain. Such booklets, however, should never replace a nurse’s individualized explanations.

Safeguarding Valuables and Clothing

Nurses give certain items, such as prescription and non- prescription medications, valuable jewelry, and large sums of money, to family members to take home. If this is not

possible, the nurse must carefully observe the agency’s policies.Some institutions provide clients who are not expected to stay longer than 24 hours with a locker to store personal effects. The nurse may place the clients’

valuables in the hospital’s safe temporarily. He or she notes in the medical record the type of valuables and how they have been safeguarded. It is best to be as descriptive as possible. For example, rather than indicating that the nurse placed a ring in the safe, it is better to describe the type of metal and stones in the ring.

Losing a client’s personal items can have serious legal implications for both the nurse and health care agency.

The client may sue, claiming the belongings were lost or stolen because of careless handling. Therefore, it is best to have a second nurse’s, supervisor’s, or security person’s signature on the envelope containing secured valuables.

One method for avoiding discrepancies between the items entrusted to the nurse and those eventually returned is to make an inventory (Fig. 11-2), which both nurse and client sign. The nurse gives one copy to the client and attaches another copy to the chart. When adding items or returning them to the client, the nurse revises the list, and BOX 11-1 ● Basic Room Supplies

Each bedside stand is generally stocked with

❙ Wash basin

❙ Soap dish

❙ Emesis basin

❙ Water carafe

❙ Bedpan and urinal

FIGURE 11-2

•

Inventory of the client’s personal belongings.

166 U N I T 4 ● Performing Basic Client Care

the client signs the new inventory. Problems with theft or loss may occur without subsequent documentation.

The nurse identifies client-owned equipment, such as a walker or wheelchair, with a large, easily read label.

Doing so helps prevent confusing such equipment with that of the facility. Most agencies have places in the client’s room for storing street clothing.

Because clients remove eyeglasses and dentures occa- sionally, such items may be lost or broken. Generally the health care agency is responsible for replacing these items if negligence of the staff causes accidental damage or loss.

Helping the Client Undress

To facilitate a physical examination, the client must undress. If the client cannot undress without the nurse’s help, the nurse does the following:

• Provides privacy

• Has the client sit on the edge of the bed, which has already been lowered

• Removes the client’s shoes

• Gathers each stocking, sliding it down the leg and over the foot

• Helps the client lie down if weak or tired

• Releases fasteners such as zippers and buttons and removes the item of clothing in whatever way is most comfortable and least disturbing. For example, the nurse folds or gathers a garment and works it up and over the body. He or she has the client lift the hips to slide clothes up or down.

• Lifts the client’s head to guide garments over it

• Rolls the client from side to side to remove clothes that fasten up the front or back

• Covers the client with a bath blanket after removing the outer clothing, or puts a hospital gown on the client, explaining that hospital gowns fasten in the back Compiling the Nursing Data Base

At admission, the nurse begins assessing the client and col- lecting information for the data base (Fig. 11-3). Although

the registered nurse is responsible for the admission assess- ment, he or she may delegate some aspects to the practical nurse, nursing student, or other ancillary staff. Physical assessment skills, which include taking vital signs, are discussed in more depth in Chapters 12 and 13.

Skill 11-1 describes the basic steps in admitting a client.

Additions or modifications to the procedure depend largely on the client’s condition and agency policies.

Initial Nursing Plan for Care

Once all admission data are collected, the nurse devel- ops an initial plan for the client’s care as soon as possi- ble but no later than 24 hours following admission (see Chap. 2). The initial plan generally identifies priority problems and may include the client’s projected needs for teaching and discharge planning. The nurse revises the care plan as more data accumulate or the client’s con- dition changes.

Medical Admission Responsibilities

The nurse notifies the physician once the admission pro- cedure is completed. The physician provides medical orders for medications and other treatments, laboratory and diagnostic tests, activity, and diet. He or she also obtains a medical history and performs a physical exami- nation within 24 hours of admission. The physician may delegate this task to another member of the medical team such as a medical student, intern, or resident.

The medical history and physical examination gener- ally include identifying data, reason for seeking care, history of present illness, personal history, past health history, family history, review of body systems, and con- clusions (Box 11-2). If the physician is unsure of the actual medical diagnosis, he or she uses the term rule outor the abbreviationR/Oto indicate that the condition is sus- pected, but additional diagnostic data must be obtained before confirmation.

Common Responses to Admission

Nurses and physicians must remember that no matter how often they have admitted clients, it is a unique and emotionally traumatic experience for each client. Leaving

FIGURE 11-3

•

Beginning to compile the nursing data base.

Stop • Think + Respond BOX 11-1 What aspects of admission could the registered nurse delegate to a practical nurse, nursing student, or nursing assistant? What are the responsibilities of the nurse who has delegated admission tasks?

C H A P T E R 1 1 ● Admission, Discharge, Transfer, and Referrals 167

the security of home and entering an unfamiliar envi- ronment compound the stress of physical illness and con- tribute to emotional and social distress.

Although specific responses to admission are unique, common reactions include anxiety, loneliness, decreased privacy, and loss of identity. In addition, the nurse may identify one or more of the following nursing diagnoses as a consequence of admission:

• Anxiety

• Fear

• Decisional Conflict

• Situational Low Self-esteem

• Powerlessness

• Social Isolation

• Risk for Ineffective Therapeutic Regimen Management Anxiety

Anxiety is an uncomfortable feeling caused by insecu- rity. The North American Nursing Diagnosis Associa- tion (NANDA, 2005, p. 9) has defined it as “a vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source is often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individ- ual to take measures to deal with threat.”

Many adults do not manifest their anxiety in obvious ways. Observant nurses may note that adults appear sad or worried, are restless, have a reduced appetite, and have trouble sleeping (see Chap. 5). Because adults have a greater capacity to process information than children,

it is helpful to acknowledge their uneasiness and to pro- vide explanations and instructions before any new expe- rience. Nursing Care Plan 11-1 provides an example of how to use the nursing process when planning the care of a client with anxiety.

Loneliness

Loneliness occurs when a client cannot interact with family and friends. Although nurses can never replace significant others, they act as temporary surrogates and should make frequent contact with the client. To help combat loneliness, many hospitals and nursing homes have adopted liberal visiting hours. They also are lifting age restrictions to allow more contact between children and their sick relatives.

Decreased Privacy

Privacy is at a premium in most health care agencies.

Providing private rooms for all hospitalized clients is becoming a trend because of Health Insurance Portability and Accountability Act(HIPAA) legislation (see Chap. 9).

Although most prefer a private room, not all clients have one; in fact, clients may have little more than a few feet that they can consider their personal space. For most, it is stressful to share a room with a stranger. To ensure privacy, the nurse closes room doors unless safety issues require observation. Doors may be open at the client’s request, but this results in being observed by many people who pass by at all hours.

Nurses demonstrate respect for and protect each client’s right to privacy. They always shield clients from the view BOX 11-2 ● Components of a Medical History and Physical Examination

Identifying Data

❙ Age, gender, marital status

❙ General appearance

❙ Circumstances surrounding physician involvement

❙ Reliability of client as historian

❙ Others providing information about the client’s history Chief Complaint

❙ Reason for seeking care (from client’s perspective) Present Illness

❙ Chronologic description of onset, frequency, and duration of current signs and symptoms

❙ Outcomes of earlier attempts at self-treatment and medical treatment Personal History

❙ Occupation

❙ Highest level of education

❙ Religious affiliation

❙ Residence

❙ Country of origin

❙ Primary language

❙ Military service

❙ Foreign travel or residence (date, location, length)

Past Health History

❙ Childhood disease summary

❙ Physical injuries

❙ Major illnesses and surgeries

❙ Previous hospitalizations (medical or psychiatric)

❙ Drug history

❙ Alcohol and tobacco use

❙ Allergy history Family History

❙ Health problems in immediate family members (living and deceased)

❙ Longevity and cause of death among deceased blood relatives (especially parents and grandparents)

Review of Body Systems

❙ Results of physical examination Conclusions

❙ Primary diagnosis (from chief complaint and physical examination)

❙ Secondary diagnoses reflecting stable or pre-existing conditions possibly affecting client’s treatment

168 U N I T 4 ● Performing Basic Client Care

of others when giving personal care. If a client’s door is closed or the curtains are pulled, the nurse knocks and asks permission to enter. If the health care agency has a place where clients can find solitude, such as a chapel or reading room, the nurse includes this information in the admission orientation.

Loss of Identity

Admission to a health care facility may temporarily deprive a person of his or her identity. For example, clients required to wear hospital gowns tend to look somewhat alike. As a result, personnel may treat clients impersonally—simply as a face or a warm body with no name. This attitude makes clients feel like they are receiving care but without caring.

Nurses learn and use the client’s name. They use first names only at the client’s request. They encourage clients to display pictures or other small personal objects that reaffirm their unique life and personality. Many long-term care facilities urge clients to dress in their own clothing and invite them to furnish their rooms with personal items from home.

Regardless of where or why clients are admitted, the goal is to keep the admission as brief as possible and to dis- charge clients to home or to another health care facility of their choice as soon as possible. Discharge(termination of care from a health care agency) generally consists of discharge planning, obtaining a written medical order, completing discharge instructions, notifying the business office, helping the client leave the agency, writing a sum- mary of the client’s condition at discharge, and request- ing that the room be cleaned.

Discharge Planning

Discharge planningis a process that improves client out- comes by (1) predetermining his or her postdischarge needs in a timely manner, and (2) coordinating the use of appropriate community resources to provide a contin- uum of care. If effective, discharge planning shortens the hospital stay, decreases the cost of in-hospital care,