Admission, Transfer, and Discharge

Admission, Transfer,
and Discharge
LEARNING OBJECTIVES
1. Explain the steps of admitting a client to the hospital. 8. Describe the process and rationale for medication recon-
2. List client data that are included in documentation when ciliation across the continuum of care.
admitting a client to the hospital, including the plan of 9. Outline steps for transferring a client to another unit
care, goals, and outcome criteria. within the hospital or to the home.
3. Describe the disposition process for safeguarding client’s 10. Discuss discharge procedures when a client leaves the
valuables. hospital.
4. State what is meant by advance directives. 11. Describe expected outcomes for clients being discharged
5. List documents that may be included in the client’s from the hospital, including meeting criteria in the initial
admission record (Patient’s Bill of Rights, Advance plan of care.
Directives, DNAR, etc.). 12. Complete discharge documentation including client’s
6. Propose two solutions for clients who are unable to adapt achievement of criteria established in the initial plan of care.
to the hospital environment. 13. Describe three solutions for clients leaving the hospital
7. Identify essential “hand-off” information to be communi- against medical advice.
cated when client care is transferred to another caregiver, 14. Outline discharge procedures that must be completed
setting, or home. when a client leaves the hospital against medical advice.
CHAPTER OUTLINE
Theoretical Concepts Gerontologic Consideration . . . . . . . . . . . . . . . . . . . . . . . . . .
Admission, Transfer, and Management Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Delegation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adaptation to Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Communication Matrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
•
UNIT 1 Admission and Transfer . . . . . . . . . . . . . . . . . . . . . . Critical Thinking Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . .
•
UNIT 2 Height and Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . Scenario 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
•
UNIT 3 Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scenario 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
•
UNIT 4 Admission to Home Care . . . . . . . . . . . . . . . . . . . . NCLEX® Review Questions . . . . . . . . . . . . . . . . . . . . . . . . . . .
UNIT • Admission and Transfer

1 UNIT • Discharge
3
Nursing Process Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nursing Process Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Admitting a Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discharging a Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transferring a Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discharging a Client Against Medical Advice (AMA) . . . .
UNIT • Height and Weight

2
Nursing Process Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
UNIT • Admission to Home Care
4
Nursing Process Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Measuring Height and Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . Nurses’ Role in Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Admission, Transfer, and Discharge
Identifying Eligibility for Medicare Reimbursement . . . . . . . Maintaining Nurse’s Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Completing Admission Documentation . . . . . . . . . . . . . . . . . . Assessing for Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
TERMINOLOGY
Adaptation ability to adjust to a change in environment. Empathy the vicarious experience of another’s situation.
Admit the process of signing a client into the hospital. Home care assistance nursing care given in the client’s home.
Ambulatory able to walk, or not confined to bed. Ident-A-Band a band, usually worn on a client’s wrist, with
Assessment critical evaluation of information; the first step the client’s name and medical record number.
in the nursing process. Limitation the state of being limited or restricted.
Behavior a person’s total activity—actions or reactions, Maladaptation inability to adjust to a change in environment.
especially conduct that can be observed. Potential possible but not yet realized.
Caring thoughtful attentiveness accompanied by responsibility. Procedure a particular way of accomplishing a desired result.
Client Care Plan a plan for care of a specific client or one Reconcile to resolve discrepancies.
designed especially for one client. Stress a state of agitation that renders the body out of
Comfort to ease physically; relieve, as of pain. balance.
Communication transmission of knowledge, information, or Supervise to direct or inspect performance; to oversee.
messages to another person. Termination the spatial or temporal end of something; a limit
Diagnostic test a test used to determine a diagnosis or to deter- or boundary.
mine the cause and nature of a pathological condition. Therapeutic having healing or curative powers.
Disability a disabled state or condition; incapacity. Transfer to convey or shift from one person or place to
Discharge to let go, as in discharging a client from the hospital. another.
DMEe durable medical equipment. Transition the process or an instance of changing from one
DRG diagnosis-related group. A system to classify all types of form, state, activity, or place to another.
clients to determine how much Medicare pays the hospital, Verbalize to express in words (written or spoken).
since clients within each category are similar clinically and Volunteer a person who performs or gives his or her services
are expected to use the same level of hospital resources. of his or her own free will.
ADMISSION, TRANSFER, AND Admission Protocol

DISCHARGE • Advance directives are made available to clients.
Admission to the hospital can be a positive event if handled • The Client’s Bill of Rights is presented to each client.
with attention and empathy. On the other hand, it can be a • The admission assessment is completed by a registered
negative experience if it is impersonal or mechanized. nurse within a specified time after admission.
Impressions formed by clients during the admission process • All clients must be clearly identified by a legible
can affect their attitude toward and ability to adapt to their identification band.
total hospital experience, so the nurse should consider this an • When consent forms are required (for invasive
important aspect of client care. procedures), they must be signed by an adult or
guardian who is mentally competent. The adult must
Admission to the Hospital give voluntary consent, understand the risks and
benefits of the treatment, and have the opportunity to
The process of admitting a client to a healthcare facility varies
ask questions.
among institutions, such as nursing homes, clinics, and hospi-
tals. Regardless of the size or type of facility, the admission
process assists in the provision of safe, effective care. Because
the nurse–client relationship begins with admission, the nurse
should have a thorough understanding of the standard admission Initial laboratory procedures and x-rays (according to
process for the particular facility. client’s DRG admitting diagnosis, surgeon, or anesthesiolo-
Clients who present to the emergency department (ED) are gist’s orders) are usually completed before admission. The
stabilized, then discharged, or admitted to the hospital by a client may be provided a copy and/or explanation of an admis-
general practitioner or specialist who writes, faxes, or tele- sion plan outlining the client’s projected clinical course.
phones admitting orders. In some cases, the nurse calls the ad- Preadmission instructions discourage the client from bringing
mitting physician for these orders. valuables to the hospital.
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If a client enters the hospital in an emergency situation, he or time, a professional nurse performs a more thorough history
she may feel insecure or fearful because there has been little time and physical assessment, determines a priority of needs, and
to make plans concerning family, travel, finances, or employ- initiates an individualized plan of care.
ment. When a client enters the hospital for elective treatment The client is informed about telephone use, clergy availabil-
or surgery, both the nurse and client have more time for orienta- ity, recreational area and lounge use, mealtimes, visiting hours,
tion and preparation for the hospital experience. The initial and other hospital schedules. Some hospitals have printed book-
contact with the nurse leaves a lasting impression, so it should lets describing this information. The client is also familiarized
be conducted in an unrushed, organized, and respectful manner. with the immediate environment, including the space for be-
When the elective client arrives at the hospital, the first longings, the bathroom, and operation of the nurse call system
contact is usually with the admitting receptionist, who assigns a inside the bathroom. The nurse also demonstrates operation of
hospital number and interviews the client. If preadmission forms the bedside nurse call system, television, radio, and bed controls.
were mailed to the client, the information is verified by the re- The more information the client receives, the more control he
ceptionist at this time; otherwise, the client must answer ques- or she has over the environment.
tions about age, address, financial or insurance status, next of kin, Clients are discouraged from bringing items of monetary or
religion, employment, and consent for treatment. If the client sentimental value to the hospital (e.g., money, credit cards,
cannot answer these questions because of age or condition, a rel- jewelry, photographs, documents). If they are brought, the
ative usually gives the information. A parent or guardian must do client may send them home with a family member or friend or
this for a child. At this time, the client receives an identification place them in the agency vault per security personnel, or the
bracelet or Ident-A-Band. This bracelet includes the client’s client may retain them, assuming total responsibility and sign-
name, hospital number, and admitting physician’s name. ing a “Release from Responsibility” form. Valuables retained in
the agency vault are inventoried and witnessed, and the client
Admission to the Nursing Unit is given a receipt. Safeguarded items may be withdrawn from
When admission to the hospital is complete, the client is the vault upon presentation of the receipt and completion of
either directed to the nursing unit or escorted by a volunteer. the “Request for Release of Valuables” form. Prosthetic devices
The client may be met by a staff nurse assigned to admission such as hearing aids, dentures, and glasses are also considered
for that day or by a delegate who will orient the client to the to be valuables, but these are retained by the client.
unit and obtain baseline assessment data. Within a specific Upon admission, a comprehensive list of the client’s home
medications is obtained (prescribed, OTC medications, and sup-
plements), including route, dose, and frequency of use. A list of
allergies to foods, drugs, devices, and materials is also obtained.
The physician then orders continuation or discontinuation of
Client may be admitted to the hospital in a wheelchair. Vital signs are obtained during the admission procedure.
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home medications during hospitalization. If the client brings test the client has received, as these may indicate the need for
medications or supplements to the hospital, they should be veri- follow-up assessment or intervention. Similarly, when the
fied by the hospital pharmacist, then placed in the client’s med- client returns from x-ray or other procedures, the nurse consid-
ication drawer or sent home (according to agency policy). No ers intervening events (e.g., medications administered) that
medication should be kept at the client’s bedside unless there is may influence care decisions. This information, as well as any
a specific physician’s order that it be placed there. special instructions for client care, is included on the “hand-off”
In some circumstances, upon a physician’s order, a client’s communication form.
labeled and pharmacist-verified home medication may be Clients are frequently transferred from one unit to another
stored in the client’s medication drawer and then administered within the same facility as their condition fluctuates. When a
by nursing staff in lieu of a hospital-dispensed preparation. client is moved, all records, charts, medications, MAR, belong-
In this case, the medication administration record (MAR) re- ings, and personal hygiene and special equipment are transferred
flects that the client supplies the particular medication and the with him or her. A complete hand-off report is given to the
hospital does not charge for dispensing it. receiving unit’s nursing staff. The new unit’s receiving nurse has
Because clients may not be sure of their role while in an obligation to validate all information relayed about the client,
the hospital, many hospitals have adopted versions of the to perform an independent client history and physical assess-
American Hospital Association’s Client’s Bill of Rights. This bill ment, and to handle the client’s transfer as a “new admission” to
includes the client’s rights to obtain information about the the receiving unit. The client also has a right to receive an orien-
client’s illness or injury, to refuse medication or treatment, to tation to the new setting just like that provided in the previous
participate in his or her own care, to know the rationale and setting. Sometimes clients are transferred within the same unit
risks of the treatment, and to receive courteous care. (e.g., from a semiprivate to a private room or vice versa) for vari-
The Patient Self-Determination Act requires all Medicare and ous reasons. While these transfers are readily accomplished
Medicaid recipient hospitals to provide clients with informa- within a short time frame, communication about such transac-
tion regarding their rights to reject medical treatment and to tions may be delayed, and confusion about a client’s identifica-
complete advance directives. An advance directive is a document tion or location may result in the client’s injury. Always ensure
the client creates that reflects goals, values, and preferences for that the client’s chart reflects the client’s current room number
health care. A “Living Will” specifies medical treatments the and that all departments participating in the client’s care are
client wants or does not want at the end of life (e.g., feeding informed about the client’s transfer to a new room number.
tube, mechanical ventilation). Another form of advance direc- A client’s transfer to another facility, and sometimes to
tive is the “Durable Power of Attorney,” which designates an another unit within the same facility, closes the current hospital
individual to make decisions for the client when the client is record just as if it were a “discharge.” A new record is established
unable to make them for himself or herself. These documents when the client arrives at the new receiving unit (equivalent to
vary from state to state. Copies of advance directives are placed a new hospital admission). In these circumstances, a copy of the
in the client’s chart. Additionally, many states mandate that an client’s records may or may not accompany the client; therefore,
agency inquire about a client’s requests concerning resuscita- a thorough report of the client’s pretransfer hospital course and
tion. Competent clients who have been informed about their current health status must be thoroughly communicated to
diagnosis and prognosis may be asked to execute a “Do Not receiving personnel in order to facilitate continuity of care.
Attempt Resuscitation” directive at the time of admission.
Following such a request, the physician attaches an order to the Discharge From the Hospital
client’s record, and the order is then reevaluated according to
From the time of admission, healthcare team conferences help
agency policy.
to identify ongoing needs and to make arrangements for the
client’s reintegration into the community setting. This dis-
Transfer to Another Unit charge planning process takes into consideration the physical,
When a client is admitted through the ED, the nurse must emotional, and psychosocial needs of the client, family, and
carefully review the ED record for any treatment or diagnostic caregiver. Sometimes hospitalization introduces the client to a
lifelong need to chronically adapt to declining physical health
and to chronically affiliate with the healthcare system. The
nurse must be empathetic to the client’s response at discharge
and approach the client with all possible options for continued
“Hand-Off” Process care, educational and financial resources, and any other services
Each healthcare facility must define and implement a to assist the client to adapt to a chronic situation. The final
consistent process by which relevant details about client responsibilities of the discharge process are to terminate the
care are communicated among hospital personnel nurse–client relationship and evaluate the discharge process.
throughout the continuum of care. This process must
allow opportunity for clarifying information in a time
frame that is consistent with safe care for the patient
Discharge Against Medical Advice (AMA)
If, for a variety of reasons, a client decides to leave the hospital
Source: The Joint Commission National Patient Safety Goals. NPSG. 02-05-10 against medical advice (AMA), it is imperative that the nurse
(www.jointcommission.org). notify the physician, especially if the client is still undergoing
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diagnosis and ongoing treatment. Most hospitals have AMA these nurses attend workshops, keep abreast of new equipment
protocols that include a mental status evaluation and possible and procedures, and continue to read nursing journals on a reg-
psychiatric consult or detention proceedings. ular basis. If home equipment is not functioning properly, the
A competent client, of course, has the right to refuse treat- nurse should inform the client, call the medical equipment
ment, but the nurse must still advocate for the client by provider, fill out an incident report, and not use the equipment.
attempting to determine the reason for the client’s decision to Home health nurses are also responsible for care provided
leave and explaining that diagnosis and/or treatment have not by unlicensed personnel and LVN/LPNs. It is the responsibility
been completed. An AMA discharge form should be signed by of the nurse to know the competence level of the staff, evalu-
the client and witnessed. This form usually includes follow-up ate their skill level, provide in-service instruction on new
instructions, prescriptions, and documentation that there may equipment or skills, and instruct them only within their spe-
be negative consequences of premature discharge. cific scope of practice.
It is extremely important to maintain open communication
with physicians and professionals in other disciplines provid-
ADAPTATION TO HOME CARE ing care to clients in the caseload. Cell phones and e-mail
The home healthcare industry has experienced drastically allow for quick response time and improved communication.
reduced payments and fewer reimbursable visits as a result of Another legal issue is the need for appropriate client docu-
the Balanced Budget Act of 1997. Now home healthcare agen- mentation that supports the need for home care services. If
cies are required to complete data collection information documentation is not accurate, timely, and complete, the
forms. The Outcome and Assessment Information Set client’s reimbursement may be denied. This can lead to hours
(OASIS) was instituted in February 1999, and the newest of time attempting to recover the costs of service, or it could
form, OASIS C, was implemented in January 2010. lead to legal repercussions. Maintaining appropriate client
The OASIS items were designed to enable systematic mea- records protects the nurse, client, and agency in cases under
surement of client home healthcare outcomes, with appropri- investigation. Writing legibly, using correct grammar and
ate adjustment for client risk factors affecting those outcomes. English, and being succinct and descriptive provide a good
The items have specific definitions used to measure changes in legal stance if necessary. Writing notes at the time care is deliv-
client’s health status between two or more time points. ered is essential so that information is not forgotten. Many
OASIS addresses sociodemographic, environmental, sup- agencies have documentation forms on a computer, so the
port system, health status, functional status, and health service nurse can enter data as he or she provides care.
utilization characteristics of the client. Data are collected at The purpose of the unit “Admission to Home Care” in this
the start of care, 60 days after initial care, and at discharge. chapter is to present clinical skills appropriate for the home
Additional data are collected if the client has a significant setting. Many of these skills are exactly the same as those pre-
change in condition that requires emergent hospitalization. sented in other sections of this book. Some skills require minor
In addition to measuring client outcomes, OASIS data have change for adaptation to the home environment.
the following uses: The use of the nursing process is just as important in home
care as it is in the hospital. Nursing care plans are required by
• Client assessment and care planning for individual adult Medicare regulations and are also used as a justification for
clients skilled nursing services by private insurers. Information regard-
• Agency reports on various client characteristics such as ing admission to home care is presented in the nursing process
demographic, health, or functional status at the start of care format to assist in organizing nursing actions and evaluating
• Internal Home Health Agency (HHA) performance health care.
improvement
Plan of Treatment
The information collected through OASIS is much more A plan of care for home health care based on previous hospi-
comprehensive, particularly in the area of the client’s health talization admission findings. Centers for Medicare and
history. Medicaid Services (the federal office that administers the
Medicare program) requires that all agencies certified to pro-
Legal Issues in Home Care vide home health care to Medicare clients complete the
Home health nurses are at risk for potential legal liability. OASIS forms and the home health certification and plan of
Nurses work alone in the home care setting and do not have the treatment form (form CMS-485) within 7 days. These forms
advantage of calling on a colleague to collaborate on a client must be completed on admission to home health care and
situation. This situation leaves the nurse vulnerable to legal signed by a physician. The plan of treatment is effective for
risks. Home health nurses must be extremely skilled in handling 60 days. If the client’s condition changes, an updated plan
equipment of all types, as well as performing specialized proce- must be signed and submitted to the Medicare office every
dures without the assistance of another nurse. It is critical that 60 days.
In addition to form CMS-485 and the OASIS forms, the
documentation includes the home care agency’s admission
worksheet, nursing care plan, medication profile, plan of treat-
ment, and consent for admission and service.
96
Documentation Medicare requires the nurse to make a home visit at least

Charting must follow the nursing care plan and cover the areas every 14 days to reassess client and family needs and to revise
listed in the OASIS C docmentation system. OASIS C is an the care plan. One visit each month is to discuss the treatment
assessment instrument used to collect specific information plan with the family. The nurse also accompanies the home
when a person is receiving Medicaid or Medicare and requires health aide once a month for a supervised visit.
the services of a home health agency. OASIS C is a key com- Home health nurses must meet the national standards of
ponent of Medicare’s partnership with the home care industry care as published by the American Nurses Association. The
to foster and monitor client outcomes and assist with quality best preparation for home health nursing continues to be a
improvement. Oasis C data items include sociodemographic, sound base of nursing skills coupled with a broad knowledge of
environmental, support system, health status, and functional agency procedures and protocols.
status attributes of adult clients. Information gathered in the
OASIS C form is forwarded to the state, where it goes to the
Centers for Medicare and Medicaid Services. There, the infor- CULTURAL AWARENESS
mation is used for reimbursement purposes for the specific With the increasing number of clients from culturally diverse
home health agency. This prospective payment system went backgrounds, it is imperative that nurses be culturally sensi-
into effect in October 2000. Several forms must be completed tive. Cultural generalizations should only be utilized as a start-
for each client. ing point, since differences exist within each culture and
An in-depth assessment identifies areas in which client among individuals.
status differs from optimal health or functional status and is Several areas where cultural diversity is common include
used as the basis of client care planning. Many agencies use handshakes, use of eye contact, violation of personal space,
standardized care plans and individualize them for each facial expressions, and gestures.
client. The American healthcare system emphasizes medical science
Since interventions are implemented by the client, family, and care, informed consent, self-care, advance directives, and risk
and part-time caregivers, all are involved in the treatment management. In contrast, clients of other cultures may prefer to
plan. The nurse or the case manager is responsible to coordi- rely on faith in God, beliefs, hope, and acceptance of fate as their
nate and evaluate the care. The physical therapist can assume primary coping mechanisms. A medical interpreter’s assistance
the role of case manager when the client is receiving rehabili- may be sought to help bridge these two sets of values and to help
tation services only. the client understand the hospitalization experience. The nurse
Because home health aides provide care without direct daily should be aware of different cultural responses to Western proto-
supervision of a nurse, agencies usually hire only experienced cols (e.g., Chinese-Americans believe the number 4 is unlucky
nursing assistants (in most states, those who have worked in a because it sounds like the Chinese word for death; if possible, do
hospital or nursing home). Home health aide certification is not assign 4 as a room number).
voluntary in some states and required in others. In many states,
the training is completed after nursing assistants have obtained Source: Pagana, KD (2009, July). Mind your manners multiculturally. Nurseweek:
a CNA certificate. Mountain West, 18–22.
NURSING DIAGNOSES
The following nursing diagnoses may be appropriate to include in a client care plan when the components are related to admission, transfer, and
discharge of a client.
NURSING DIAGNOSIS RELATED FACTORS
Anxiety Actual or perceived threat to self-concept, threat to biologic integrity, unfamiliar

environment and treatments, change in socioeconomic status
Fear Known or unknown outcome of hospitalization, medical or surgical diagnosis, and
treatments
Grieving Loss of function, change in lifestyle, lack of social support system, change in social role or
economic status
Ineffective Health Maintenance System impairment, surgery, musculoskeletal impairment, visual disorders, external devices
Powerlessness Actual or perceived lack of control over situation, imposed regimens, lack of privacy
Social Isolation Hospitalization, chemical dependency, altered appearance
CLEANSE HANDS The single most important nursing action to decrease the incidence of hospital-based infections is hand hygiene.
Remember to wash your hands or use antibacterial gel before and after each and every client contact.
IDENTIFY CLIENT Before every procedure, introduce yourself and check two forms of client identification, not including room number.
These actions prevent errors and conform to The Joint Commission standards.
97
UNIT • 1
Admission and Transfer
Nursing Process Data

ASSESSMENT Data Base IMPLEMENTATION Procedures
• Determine client’s understanding of reason for • Admitting a Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
hospitalization • Transferring a Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Observe and record client’s physical, emotional, and mental
status.
EVALUATION Expected Outcomes
• Observe and record client’s ability to adapt to the hospital
environment. • Client adapts to hospital environment.
• Observe for disabilities or limitations. • Client participates in the individualized plan of care.
• Obtain a list of medications client is currently taking (pre- • Client understands rationale for and accepts transfer to a
scribed, OTC, and supplemental), including dose, route, new care unit.
and frequency of use. • Client is transferred to new unit without complication.
• Identify any food, drug, device, or device material allergies.
• Assess the client’s level of comfort. Critical Thinking Application . . . . . . . . . . . . . . . . . . . .
• Assess client for potential discharge needs. • Expected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Assess condition prior to transfer. • Unexpected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Obtain a thorough “hand off” report of client’s progress and • Alternative Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
status at shift report, when receiving from another unit, or
when returning from any test or procedure.
Pearson Nursing Student Resources
PLANNING Objectives Find additional review materials at
nursing.pearsonhighered.com
• To obtain a preliminary nursing history/assessment
Prepare for success with NCLEX®-style practice questions
• To assist client to adapt to hospital environment with and Skill Checklists
minimal distress
• To encourage the client to participate in his or her own
plan of care
• To provide a comfortable and aesthetically pleasing
environment for the client
• To provide the client with some control over his or her
immediate environment
• To provide the client with an opportunity to verbalize his or
her feelings about hospitalization
• To facilitate safe and individualized continuity of care at all
transition points throughout the continuum of care.
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Admitting a Client
Equipment
Admission kit with personal hygiene articles
Clinical Alert
(if indicated)
The Joint Commission Performance Measurement
Hospital gown Initiative requires that all clients admitted with a diagnosis
Thermometer of myocardial infarction, community-acquired pneumonia,
Blood pressure cuff and stethoscope (or automated unit) or heart failure be assessed for tobacco dependence and
that smoking cessation advice/counseling be provided.
Hospital Nursing History and Assessment form
Client’s chart or access to electronic documentation Source: www.jointcommission.org
Labeled containers for client’s dentures, etc.
Procedure 9. Obtain client’s health history and complete the

1. Refer to client’s chart to determine reason for hospital- physical assessment (performed by the professional
ization and note any orders to be initiated immediately nurse).
(e.g., oxygen administration). Rationale: Timely initia- 10. Complete score assessments for fall and pressure ulcer
tion of tests or treatments reduces hospitalization time risk status.
and costs. 11. Obtain a complete list of medications client is currently
2. Notify physician of client’s admission and obtain orders taking (prescribed, OTC, and supplements) including
if not already done. dose, route, and frequency. Rationale: The physician
3. Check client’s Ident-A-Band and have client state reconciles this list by continuing or discontinuing each
name and date of birth (according to agency policy). medication and by ordering new ones.
4. Introduce yourself to the client and begin to establish 12. Place allergy and other alert bands on client’s wrist if
a therapeutic nurse–client relationship. indicated.
5. Orient client to hospital room, various controls, and 13. Initiate client’s care plan: Identify individual client’s
routines. Rationale: Reduces anxiety about problem areas and needs.
hospitalization. 14. Reassess client’s level of comfort and ability to adapt to
6. Provide labeled container for client’s prosthetic items hospitalization.
(e.g., dentures). 15. Complete client teaching for all unfamiliar procedures
7. Assist client to don hospital gown. or interventions.
8. Perform preliminary nursing assessment (may be 16. Document information on appropriate forms in chart.
obtained by a delegate).
Obtaining a Health History • History of food, drug, device, or device materials

allergies and nature of reaction
• Past medical history or health problems, including
those for which client was not hospitalized • Medications (prescribed and OTC) and
supplemental products including dose, route, and
• Signs and symptoms of current problems according
frequency used
to client’s perceptions
• Risk analysis for discharge (anticipated needs)
• Client’s knowledge of illness (understanding of
present illness) and expectations of care • Special data base for elderly client: level of
independence, ability to complete activities of daily
• Lifestyle patterns: diet, elimination pattern, exercise,
living (ADLs), side effects of medications, history of
habits (i.e., smoking, alcohol intake), sleep patterns
recent loss of loved one, management of chronic
• Relationships and social support systems; conditions
emergency contacts
• Values, beliefs, religious or spiritual practices
99
COMMUNITY
HOSPITAL
NURSING HISTORY / ASSESSMENT
White areas may be completed by patient / family.
Shaded areas must be completed by nurse / N.A.
PATIENT’S NAME
INFORMATION PROVIDED BY DISBURSEMENT VALUABLES KEPT BY PATIENT

CONFIDENTIAL INFORMATION
OF VALUABLES
Patient Family Friend Unable to Obtain
DATE OF ADMISSION TIME OF ADMISSION Patient
ROUTE OF ADMISSION Home

Ambulatory Wheelchair Stretcher Security
ORIENTATION
TO UNIT
Floor Brochure Channel 50 / 52 Call Light Bed Control
VITAL SIGNS
Emergency Light Telephone Visiting hr Mealtime STATED ACTUAL STATED ACTUAL
HEALTH PERCEPTION / HEALTH MANAGEMENT PATTERN WEIGHT Kg. WEIGHT Kg. HEIGHT cm HEIGHT cm
DESCRIBE YOUR USUAL STATE OF HEALTH BP Temp. PULSE RESPIRATION
Excellent Good Fair Poor °C
WHY ARE YOU BEING ADMITTED TO THE HOSPITAL?
ADVANCE DIRECTIVE INFORMATION
Do you have an Advance Directive?
Please list any medical problems or previous surgeries below. Include (Also may be called a Living Will) Yes No
pacemakers, artificial joints, or diabetes.
If so, is it on file at this facility. Yes No
PROBLEM / SURGERY DATE
If not, will you bring / send a copy? Yes No
If you do not have an Advance Not
Directive, do you want one? Yes No Sure
Do you want help with this? Yes No
See Progress Note for additional comments. Date & Time:
IMMUNIZATIONS
Influenza Pneumonia
Pacemaker Artificial Joint Diabetes Are you an Organ Donor? Yes No
MEDICATIONS – List medications, including aspirin, laxatives, birth control pills, If necessary, would you consent to a
cough medicines, vitamins, herbal supplements, non-prescriptions, all prescriptions. blood transfusion? Yes No
NAME DOSE FREQUENCY LAST DOSE ALLERGIES
NAME (Drug or Other) DESCRIBE REACTION
Latex Rubber Yes No Unknown

Shellfish Yes No Unknown
X-Ray Dye Yes No Unknown
EDUCATIONAL NEEDS ASSESSMENT

WHAT DO YOU KNOW ABOUT YOUR PRESENT ILLNESS?
DISCHARGE PLANNING NEEDS COMMUNITY

COMMUNITY AGENCIES CURRENTLY USED
Home Health Meals on Wheels Assistance Program

HOSPITAL
NURSING HISTORY / ASSESSMENT
Other DO YOU WANT INFORMATION ABOUT YOUR
ILLNESS, TREATMENT, OR MEDICATIONS? Yes / family.
White areas may be completed by patient No
WHO IS AVAILABLE TO HELP YOU WHEN YOU RETURN HOME?
WHAT INFORMATION WOULD
Shaded YOUmust
areas LIKE? be completed by nurse / N.A.
ACTIVITY / EXERCISE PATTERN
DO YOU ANTICIPATE ANY PROBLEM CARING FOR YOURSELF WHEN YOU RETURN HOME?
PHYSICAL LIMITATIONS PHYSICAL AIDS GENERAL SAFETY
HOSPITAL HOME N/A
No Yes Explain: Hearing Yes No High Risk for Fall (HRFF)
Sight Yes No Glasses Any one indicator checked indicates HRFF

DO YOU UNDERSTAND WHAT YOU HAVE
BEEN TOLD SO FAR? Yes No Contacts History of Falls
EMERGENCY CONTACTS Speech Yes No
IS THERE A CULTURAL OR LANGUAGE BARRIER?
Hearing Aid Impaired Mobility
NAME RELATIONSHIP TELEPHONE # No Mobility
Yes Explain: Yes No
Dentures Impaired Cognition
FUNCTIONAL ABILITY LEVEL Partial Sensory Deficit
0 = Self Care Complete Incontinence or Urgency
Interpreter Name
1 = Requires equipment Cane Age over 75
Phone # 2 = Requires supervision or assistance
Walker Any other reason for which
Areas within BOLD lines may contain information written elsewhere on the chart.3If=that
Requires equipment & supervision / assistance
is the case, the health card team judges
1229-1 (1/01) please indicate where the information may be found (Example: “See ODSU 4 =Form”).
Total care required Wheelchair
the patient to be at risk
Prosthesis
Feeding Dressing
Bathing Bed Mobility
Sample nursing history/assessment form (a). Ambulating Toileting
Central Line Yes No Type Dialysis Access

PAIN MANAGEMENT (Cognitive—Perceptual Pattern) ELIMINATION PATTERN
Have you experienced any discomfort / pain Yes No

Last Bowel Movement
in the past 24 hours?
Normal Bowel Pattern Yes No
If yes, how did you treat this pain?
Regular Yes No
Laxatives / Enemas Yes No
Was the treatment of pain / discomfort effective? Yes No
Problems Urinating Yes No
ROLE / RELATIONSHIP-SEXUALITY / REPRODUCTIVE PATTERN

Do you have any emotional, family, or home concerns that need to be addressed during this hospitalization? Yes No
Possibly pregnant? Yes No Last Period Do you feel safe in home? Yes No
Comments:
VALUE / BELIEF PATTERN
Do you have any special request with regard to your religious beliefs while you are in the hospital? Yes No
Comments:
NUTRITION / METABOLIC PATTERN
Special Diet at Home Yes No Specify

Food Allergies Yes No Specify

NUTRITION SCREEN
READ THE QUESTIONS BELOW. CIRCLE THE NUMBER IN THE YES COLUMN FOR THOSE THAT APPLY TO YOU. NO YES
Without wanting to, have you lost 10 pounds or more within the last 6 months? 0 1
Do you have a pressure sore or non-healing / infected wound? 0 1
Have you had daily nausea, vomiting, or diarrhea lasting more than 5 days? 0 1
Has your food intake declined within the past 3 months due to chewing / swallowing problems? 0 1
Have you been hospitalized for an illness or a surgery for more than 7 consecutive days within the past 3 months? 0 1
Total the nutritional score (all “yes” answers) and enter in the computer. At nutrition risk = any “yes” answer. (Score 1–5) TOTAL:
Do you have any concerns that have not been discussed? No Yes Please explain below:
RN SIGNATURE DATE TIME
1229-2 (1/01)
Sample nursing history assessment form (b).
100
Transferring a Client
Equipment
Wheelchair or gurney
Covering for client
Client’s records, chart MAR, and care plan
Client’s valuables receipt
Special equipment (e.g., walker)
Personal belongings
Procedure
1. Verify physician’s order if needed. Rationale:
Physicians order client transfers from and to hospital
units. They do not always order transfers within
a unit.
2. Contact admitting office to arrange for transfer.
3. Communicate with transfer unit to determine the best
time for transferring client.
4. Identify client and inform client of impending transfer.
Rationale: Discussing the rationale for transfer
Clients may be admitted or transferred on a gurney.
facilitates adjustment to the new unit. 13. Notify appropriate departments (dietary, pharmacy)
5. Gather equipment, belongings, and records. as required by hospital protocol when transfer is
6. Obtain necessary staff assistance for transfer. completed.
7. Transfer client to wheelchair or gurney unless client is 14. Notify x-ray and laboratory if tests were scheduled or
remaining in bed for the transfer. Use protective belts results are pending.
and rails as indicated.
8. Cover client to provide warmth and to avoid exposure Clinical Alert
during transfer. Healthcare facilities must accurately and completely
9. Notify receiving nurse when you arrive on the unit. reconcile medications and other treatments at every
transition of care: change in setting, service, practitioner,
10. Introduce client to new staff who will be caring for the or level of care (National Patient Safety Goal # 8).
client that day. Reconciliation at every transition point helps avoid medi-
11. Give complete report to staff, using the client care cation errors such as omissions, duplications, dosing er-
plan medication reconciliation list, MAR and Kardex. rors, or drug interactions.
Give information concerning client’s current status,
Source: www.jointcommission.org
individualized care needs (e.g., bed alarm), client
problems/alerts, and when next medications or treat-
ments are due. Note any completed or pending test Clinical Alert
results. If necessary, give phone report to receiving When a client is moved to another bed or room within
nurse. Rationale: Complete “Hand-Off” communica- the same unit, make certain the room/bed number is
changed on the client’s chart, MAR, and all other docu-
tion maintains continuity of care after transfer and
ments at the time the client is transferred. All appropri-
promotes client safety.
ate departments must receive transfer notification.
12. Notify physician when client’s transfer is completed.
DOCUMENTATION for Admitting and Transferring

• Admission procedures/orientation provided • Inventory and dispensation of client’s valuables and home
• Adaptation to hospitalization medications
• Client’s health history and physical assessment including • Transfer time, destination, mode of transfer, transporter’s
risk assessment scores name, and client’s status
• Individualized care plan and progress toward goal • Name of receiving unit’s staff to whom report was
achievement. given
• Client-signed documents added to the chart (e.g., advance
directive)
101
Legal Considerations
Misidentification of Clients Does Not Ordinarily Occur in Absence of Negligence
This client underwent an apparently uncomplicated hysterectomy. She was placed in Bed B of a semiprivate room to
recover.
Several hours later, the client occupying Bed A in the same room was moved elsewhere in the facility, but hospital
staff failed to note the move in its records. Two shifts of nurses also failed to note the move.
The next day, the nurses on the unit directed the orderly to the room to find the woman who had previously been
in Bed A to transport her to the lab for an ultrasound.
The hysterectomy client in Bed B, who wore a traditional hospital ID bracelet and whose name was posted on her
bed, protested that she had just come from surgery, had been instructed not to move without direction, and that she
knew of no scheduled test. Nevertheless, the orderly persisted without checking the client’s identity.
The client testified that she felt excruciating pain and nearly passed out, but the orderly proceeded to take her to
the lab. The lab commenced the procedure, and after client complaints, finally determined her true identity and re-
turned her to her room, but failed to notify the attending nurse of the mistake.
The client suffered an incisional dehiscence and hernia, necessitating further surgery. Based on evidence at trial,
the jury found the hospital had a “lackadaisical attitude” toward client identification procedures, evincing a “reckless
and wanton disregard of the rights of the client.” Potentially, this would allow an award of punitive damages in excess
of actual damages determined.
Source: Scribner v. Hillcrest Medical Center (1992).
CRITICAL THINKING Application

Expected Outcomes
• Client adapts to hospital environment. • Client understands rationale for and accepts transfer
• Client participates in the individualized to a new care unit.
plan of care. • Client is transferred to new unit without complication.
Unexpected Outcomes Alternative Actions

Client has difficulty adapting to hospital environment. • Assess physiologic, emotional, or cultural basis for
difficulty.
• Consult case manager, interpreter, clergy, or other assistant
to facilitate client’s adaptation.
Foreign client appears depressed, refuses • Understand client’s cultural acceptance of fate and fear
to participate in the plan of care. that the diagnosis actually caused the disease process.
• Explore client’s concept of hot/cold balance; assist in meal
planning accordingly.
• Emphasize essentials of care and discharge planning as
many feel the hospital is a place to die.
• Be flexible regarding timing of meals and other aspects of
care as much as feasible.
Client is anxious about transfer. • Orient client to new setting and elicit client’s perception of
reason for transfer.
• Correct misperceptions regarding transfer and continuity of
care.
• Explain that transfer decision is based on client’s clinical
progress and that new unit will be appropriate to provide
client’s current care needs.
Upon transfer, client’s personal belongings • Check with transferring unit for retained items.
are lost. • Check with security personnel for client’s registered items.
• File a variance report if belongings are not located.
102
UNIT • 2
Height and Weight

• Check the need for daily or weekly body weight measure- • Measuring Height and Weight . . . . . . . . . . . . . . . . . . . . . . . .
ments.
• Determine appropriate method for obtaining client’s weight EVALUATION Expected Outcomes
(standing scale, bed scale).
• Determine client’s ability to stand for height measurement. • Height and weight are obtained and recorded.
• Obtain previous height and weight measurements to com- • Client’s weight, depending on disease state and therapy,
pare with expected norms or to establish a base for identify- shows expected losses, gains, or stabilization.
ing trends.
Critical Thinking Application . . . . . . . . . . . . . . . . . . . .
PLANNING Objectives • Expected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Unexpected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To identify excess or deficit of fluid balance
• Alternative Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To establish baseline data to monitor response to drug
therapy (e.g., diuretic)
• To determine weight-based drug dosages Pearson Nursing Student Resources
• To determine nutritional status in relation to body require- Find additional review materials at
ments nursing.pearsonhighered.com
and Skill Checklists
103
Measuring Height and Weight

Equipment
5. If bedscale is used, account for weight of linens, etc.
Balance beam scale (for clients who are able to stand Rationale: Extraneous variables, such as linens, extra
without assistance)
pillows, etc., result in inaccurate client measurements.
Bed scale (for clients who are confined to bed or who are
6. Change wet gown or heavily saturated dressings before
unable to stand) or
weighing the client.
Bed scale (built into the bed)
Floor scale (for clients in wheelchairs) Procedure
Paper towel
1. Transport client to scale or bring scale to bedside.
2. Balance scale so that weight is accurate. (See Table 1 for
Preparation desirable weight based on sex and height.)
1. Perform hand hygiene and check client ID. 3. Place a clean paper towel on scale and ask client to re-
2. Weigh client in the morning before breakfast. Ask move shoes.
client to void before weighing. 4. Assist client to stand on scale.
3. Use the same scale each time you weigh the client. 5. Move weights until the weight bar is level or balanced.
Rationale: For consistency in weight from day to day,
6. Record weight on appropriate record.
keep variables the same as possible.
7. Ask client to face front so back is toward scale’s bal-
4. Make sure the client wears the same type of clothing
ancing bar.
(e.g., gown or robe) for each weighing.
8. Instruct client to stand erect.
Weigh client in the morning, before eating or drinking, using Instruct client to stand erect to measure height.
the same scale each time.
104
Bed scale is used to weigh clients who are on complete bed rest.
9. Place L-shaped sliding height bar on top of client’s head.

10. Read client’s height as measured.
11. Record height on appropriate record.
12. Discard paper towel (if used) and assist client back to room.
Scales accommodate wheelchairs for weighing clients. 13. Perform hand hygiene.
TABLE 1 Weight Chart (Desirable Weights in Pounds, According to Frame—in Indoor Clothing)
Small Medium Large Small Medium Large
WOMEN Height Frame Frame Frame MEN Height Frame Frame Frame
Feet Inches Pounds Pounds Pounds Feet Inches Pounds Pounds Pounds
4 10 92–98 96–107 104–119 N/A N/A N/A N/A
4 11 94–101 98–110 106–122 N/A N/A N/A N/A
5 0 96–104 101–113 109–125 N/A N/A N/A N/A
5 1 99–107 104–116 112–128 N/A N/A N/A N/A
5 2 102–110 107–119 115–131 5 2 112–120 118–129 124–141
5 3 105–113 110–122 118–134 5 3 115–123 121–133 129–144
5 4 108–116 113–126 121–138 5 4 118–126 124–136 132–148
5 5 111–119 116–130 125–142 5 5 121–129 127–139 135–142
5 6 114–123 120–135 129–146 5 6 124–133 130–143 138–156
5 7 118–127 124–139 133–150 5 7 128–137 134–147 142–161
5 8 122–131 128–143 137–154 5 8 132–141 138–152 147–162
5 9 126–135 132–147 141–158 5 9 136–145 142–156 151–170
5 10 130–140 136–151 145–163 5 10 140–150 146–160 155–174
5 11 134–144 140–155 149–168 5 11 144–154 150–165 159–179
6 0 138–148 144–159 153–173 6 0 148–158 154–170 164–184
6 1 N/A N/A N/A 6 1 152–162 158–175 168–189
6 2 N/A N/A N/A 6 2 156–167 162–180 173–194
6 3 N/A N/A N/A 6 3 160–171 167–185 178–199
6 4 N/A N/A N/A 6 4 164–175 172–190 182–204
Height is in feet and inches, including shoes. Weight is in pounds, including indoor clothing. Assumption: Male indoor clothing with shoes weighed seven pounds.
Female clothing with shoes weighed four pounds. Identify clothes client wore for accurate weight.
For girls between 18 and 25, subtract 1 pound for each year under 25.
Source: Blue Cross/Blue Shield of Delaware, 1997; American Heart Association.
105
DOCUMENTATION for Height and Weight

• Time of day height and weight were measured • Type and identifying number of scale used for weighing
• Client’s height and weight measurement recorded on • Weight of any attached equipment shoes or clothing that
client’s chart and MAR adds to client’s actual weight

Expected Outcomes • Client’s weight shows expected losses, gains, or
• Height and weight are obtained and recorded. stabilization.

Client cannot be weighed accurately because of attached • Analyze unexpected weight loss or gain by assessing other
mechanical devices. factors, such as fluid intake and urinary output, presence
of edema, lung sounds.
• Remove attached device momentarily to obtain accurate
weight.
Client’s weight varies more than expected from one • Check time of day weight was measured.
day to the next. • Check if same scale was used for both weighings.
• For equipment reliability, check client’s weight with
another scale and compare findings.
• Check what clothing or linen was on the client when
weighed on both days.
• Check MAR for medications that alter fluid balance
(e.g., diuretics).
• Check I & O record for sources of fluid loss or gain.
106
UNIT • 3
Discharge

• Verify order for client’s discharge. • Discharging a Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Identify discharge destination (home, rehabilitation unit, etc.). • Discharging a Client Against Medical
• Assess client’s feelings about discharge. Advice (AMA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Review care plan to determine client’s progress toward goal
achievement during hospitalization. EVALUATION Expected Outcomes
• Identify client’s teaching needs for discharge and report
findings to multidisciplinary team. • Client understands discharge process and is not exhibiting
anxiety.
• Assess for any unaddressed need for healthcare assistance in
the home. • Client remains in the hospital until discharged by the
physician.
• Determine that discharge needs have been addressed by
case manager, dietitian, occupational or physical therapist,
social worker, or other specialist. Critical Thinking Application . . . . . . . . . . . . . . . . . . . .
• Verify that client is ready for discharge. • Expected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Try to determine reason for client’s intent to leave the • Unexpected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
hospital against medical advice. • Alternative Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLANNING Objectives Pearson Nursing Student Resources

• To collaborate with the multidisciplinary team Find additional review materials at
• To prepare client for discharge and complete discharge nursing.pearsonhighered.com
planning Prepare for success with NCLEX®-style practice questions
• To assist in the discharge of a client whose condition neces- and Skill Checklists
sitates lifestyle changes or care at another facility
• To allow the client to verbalize feelings about discharge and
to identify the client’s strengths and needs
• To inform client of risks involved in leaving the hospital
against medical advice (AMA)
107
Discharging a Client
Equipment
3. Along with care team, determine that client is ready for
Client’s record
discharge.
Hospital Discharge Instructions form
4. Ensure that all laboratory work, x-rays, treatments, and
Copy of discharge medication order list and any new procedures are completed before discharge.
physician’s written prescription
5. Determine that client understands instructions for self-
Educational pamphlets/instructions care, including medications and follow-up arrangements.
Telephone numbers and information regarding follow-up 6. Complete client teaching if applicable.
appointments or special referrals
7. Notify client’s caregiver to arrange transportation.
Adaptive aids (e.g., walker, toilet seat extender) needed
8. Obtain adaptive aids or other supplies that can be dis-
on discharge (may be dispensed by the hospital)
pensed by the hospital (e.g., dressings, potty extender).
Client’s home medications retained, hospital dispensed
9. Provide opportunities for client to discuss impending
liquids, MDIs (metered dose inhalers), if continuation
discharge.
is prescribed.
Materials for dressing changes (if indicated), antiembolic
Procedure
stockings, or any additional items previously dispensed
for individual client use 1. Identify client.
Transport vehicle for discharge 2. Review details of discharge with client.
3. At discharge, the client’s list of medications received
Preparation during hospitalization is reconciled by the physician and
prescriptions are written for new medications to be
1. Determine that physician’s discharge orders have been
taken if indicated. The physician should document rea-
written.
sons for discontinuing or omitting certain medications
2. Notify client’s interdisciplinary team of discharge order. upon discharge from the hospital, such as a beta-blocker
and aspirin for the post–myocardial infarction client.
4. Review any teaching and answer questions about
medications, diet, bathing, any activity restrictions
(e.g., lifting, sexual activity, driving), physical/wound
care, use of special equipment or supplies, and follow-up
appointments.
5. Explain how to recognize complications and what to do
if they occur.
6. Complete written instructions on Discharge Instructions
form using lay terminology that client can understand.
7. Have client sign Discharge Instructions form and pro-
vide the client with a copy.
8. Place copy of client’s signed Discharge Instructions form
and discharge medication order list on client’s chart.
9. Assist client to retrieve safeguarded valuables per hospi-
tal policy.
10. Terminate relationship with client. Rationale:
Providing an opportunity for the client to express feel-
ings and impressions contributes to a positive termina-
tion.
11. Follow hospital procedure for client discharge, including
time and method of leaving hospital unit.
12. Document time and method of client’s discharge, desti-
nation, individual accompanying, and any supplies, pre-
scriptions, and forms sent with client.
13. Notify appropriate departments of client’s discharge.
Clients are discharged in a wheelchair for their safety.
108
Discharging a Client Against Medical Advice (AMA)

Equipment
Client’s record 7. Place signed AMA form in client’s record and provide a
Form for discharge against medical advice (AMA) copy to the client along with prescriptions, self-care and
follow-up instructions, etc.
Procedure 8. If the client refuses to sign the AMA form, note this on the
form, have it witnessed, notify appropriate hospital per-
1. Immediately notify physician and nurse manager if
sonnel, and file a variance report. Rationale: This ful-
client insists on leaving the hospital prematurely.
Rationale: If the nurse judges that the client is endan-
fills legal requirements if the client insists on discharge
AMA without signing form.
gered by leaving AMA, the physician should be notified
immediately. 9. Document client’s verbatim statement in nurses’ notes
indicating reason for leaving.
2. Ascertain why the client wants to leave the hospital
prematurely. 10. The client is not escorted by hospital personnel, but
leaves the hospital on his own or with family or friends
3. Explain reasons that continued hospital care is neces-
whose names should be documented on the client’s chart.
sary (e.g., diagnosis, treatment).
11. Notify client’s caregiver and hospital security if there is
4. Explain risks of leaving hospital AMA (e.g., incomplete
concern for the client’s welfare or safety.
testing or treatment).
12. Notify appropriate people when the client leaves (physi-
5. Inform client that some insurance companies may not
cian, case manager, nursing supervisor, risk management
pay for hospitalization if the client leaves AMA. Refer
personnel).
client to his or her insurance plan.
6. Request client to sign the AMA form if he/she still in- Clinical Alert
sists on leaving AMA. The nurse witnesses and cosigns Refer to agency standard operating procedures (SOPs)
the document. Rationale: This form states that the for specific instructions related to client admission,
hospital is relieved from responsibility for any ill effects transfer, or discharge.
which may result from AMA discharge.
DOCUMENTATION for Discharging a Client

• Day-to-day preparatory activities for discharge such as • Discharge criteria not met and reason criteria were not met
teaching, return demonstrations as identified on client’s care plan
• List Copy of Discharge Instructions form, discharge med- • Client’s signed Release from Responsibility for Discharge
ication order list, and client teaching/instructions provided (AMA) form, instructions provided, name of individual
• Discharge data (time, destination, how discharged, and accompanying client out of the hospital, and client’s tele-
accompanied by whom) phone number and address for follow-up call or visit by
• Client’s own medications, physician-written prescriptions, social worker
special equipment taken home by client • Individuals notified of client’s discharge AMA

Exected Outcomes
• Client understands discharge process and is not exhibiting • Client remains in the hospital until discharged by the
anxiety. physician.

Client is anxious about discharge to an extended care unit. • Reinforce physician/hospital’s recommendation for
extended care.
• Provide time for client and caregiver to recognize that the
goal is to increase client’s strength and independence.
Client wants to leave the hospital AMA. • Attempt to identify client’s reasons for wanting to leave
AMA.
• Notify client’s physician.
(Continued)
109

• Consult hospital policy and procedures regarding AMA
before releasing client.
• Negotiate possible alternative to leaving hospital (e.g.,
child care arrangements, employment concerns).
• Encourage discussion about risk of leaving/benefits of
remaining hospitalized.
• Notify charge nurse, or supervisor, case manager and social
worker, or clergy to discuss situation with client.
• In case of a minor or mentally incompetent client, contact
hospital attorney ASAP.
• Have client sign hospital AMA form.
• If client will not sign AMA form, have another nurse
witness refusal, and chart details of discharge.
110
UNIT • 4
Admission to Home Care

• Assess client’s financial eligibility for home care service. • Nurse’s Role in Home Care . . . . . . . . . . . . . . . . . . . . . . . . . .
• Observe client’s physical, emotional, and intellectual status. • Identifying Eligibility for Medicare Reimbursement . . . . . . .
• Observe client’s ability to adapt to the home setting. • Completing Admission Documentation . . . . . . . . . . . . . . . .
• Assess the client’s level of comfort. • Maintaining Nurse’s Safety . . . . . . . . . . . . . . . . . . . . . . . . . .
• Determine client’s understanding of the health status and • Assessing for Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . .
any limitations.
• Assess home condition and safety factors prior to client
returning home.
EVALUATION Expected Outcomes
• Examine equipment for safety features.
• Assess nurse’s safety for making home visits. • Client adapts to home setting with minimal difficulties.
• Client and family participate in the plan of care.
• Safe environment is provided for client.
PLANNING Objectives
• Nurse’s safety is maintained during home visits.
• To assist client to adapt to home care with minimal distress
• To encourage client and family to participate in the plan Critical Thinking Application . . . . . . . . . . . . . . . . . . . .
of care • Expected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To provide a comfortable and safe environment for the client • Unexpected Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To maximize client’s outcomes after discharge from hospital • Alternative Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• To provide the necessary and appropriate home care treat-
ment modalities
• To provide a safe environment for the nurse Pearson Nursing Student Resources
Find additional review materials at
nursing.pearsonhighered.com
and Skill Checklists
111
Nurse’s Role in Home Care

Equipment Procedure
Discharge Planning Records 1. Introduce self to client, family, and health caregiver.
OASIS C Forms 2. Describe services that will be provided, including time
H485 Forms frames and use of ancillary personnel, including role of
Consent Forms each member of the health team.
Agency Forms 3. Assess home for safety issues.
4. Determine client’s eligibility for services.
5. Complete OASIS C forms and CMS-485 forms, in
Preparation addition to relevant forms based on assessment (pressure
1. Obtain appropriate documents from healthcare facility. ulcer forms, mental status, sensory status, etc.). Develop
a. History and physical examination client care plan.
b. Diagnosis 6. Review client’s or caregiver’s responsibility for care dur-
c. Treatments ing absence of agency staff.
d. Medications 7. Provide telephone numbers for agency, emergency services,
e. Subjective and objective discharge notes. and, if appropriate, the RN (will vary among agencies).
f. Physical or occupational therapy during home care. 8. Review medication names, doses, and time of adminis-
g. Hospital follow-up care appointments. tration and side effects that should be reported to the
h. Caregiver status (i.e., family member or home health physician.
aide).
9. Review and have client or caregiver demonstrate any
2. Obtain all OASIS C documents to be completed during treatments that will be completed when agency person-
initial visit. nel are not in home.
3. Contact discharge planner at facility to determine 10. Develop a nurses’ worksheet and care plan to be re-
date, time of discharge, method of transfer to home, viewed each visit. Rationale: To ensure all activities
and availability of health caregiver when client reaches have been completed and documented.
home. NOTE: Worksheet to include assessment findings, flow
4. Contact client, health caregiver, or family to arrange sheets (ADLs, pain assessment, medications, etc.), vital
time for initial visit. signs, education provided, IVs. Care plan update.
Identifying Eligibility for Medicare Reimbursement

Procedure
1. Complete OASIS C forms. a. Registered nurse performs specific functions:
a. Integrate information with CMS-485 data. Client teaching
b. Complete all sections of document. Rationale: Dressings or irrigations
Denial of service can result if documentation Catheterization
incomplete. Parenteral therapies
c. Complete forms within 7 days. Medication administration and teaching
d. Ensure information from forms is transcribed accu- b. Physical therapist performs certain functions:
rately onto CMS-485 forms. Rationale: To prevent Gait training
denial of service. Therapeutic exercises
2. Check required criteria for Medicare coverage eligibil- Ultrasound, diathermy, TENS
ity. Rationale: This prevents administering care for Restorative therapy
which reimbursement will not be received. c. Speech therapist performs certain functions:
Therapy for clients with certain diagnoses (e.g., cere-
3. Identify client as homebound. brovascular accident, laryngectomy)
a. Client’s condition severely restricts leaving the home. Selected diagnostic and evaluative services
b. Leaving the home requires considerable effort and 5. Provide supplemental services from home health aide,
assistance of another person. social worker, or occupational therapist; care is reim-
c. Special transportation is necessary. bursed by Medicare only when one of the three skilled
d. Absences from the home are infrequent and short. services is required.
4. Check that home service is considered skilled. To a. Supplemental services may be obtained even if one of the
be skilled, service must be under the supervision of a skilled services is not needed; however, Medicare does
registered nurse or a physical therapist. not reimburse, and client is responsible for payment.
112
Clinical Alert
The Outcome and Assessment Information Set (OASIS- Guidelines for Home Care
B1) and the Discharge Form in the OASIS paperwork is • Take as little with you into the home as possible.
more extensive than previously gathered information
• Use appropriate nursing protocols in home setting.
on documentation forms. Be careful to complete all
sections of the form. • Perform hand hygiene on entering and leaving home.
• Maintain clean technique in the home.
• Know CDC infection control guidelines.
b. Home health aide services are reimbursable only if plan
• Review state and federal guidelines and protocol for
of care is established and supervised by registered nurse.
reimbursement.
Personal care (activities of daily living [ADLs])
Light housekeeping (e.g., food preparation, client’s
laundry)
Selected semiskilled care (e.g., passive range-of-motion This form is used by all home health agencies for
exercises) Medicare clients.
c. Social worker. b. Form must include:
Interventions must contribute significantly to the Identifying data
improvement of the client’s medical condition. Diagnosis (ICD-9CM)
Indication that social, environmental, or family Start of care
conditions inhibit progress of recovery from medical Types of services required and frequency
condition. Functional limitations
d. Occupational therapy. Activities permitted
Design maintenance program. Safety measures
Teach compensatory techniques and ADLs. Treatments
Design self-help devices to assist with ADLs. Medications
Provide restorative therapy. Mental status
6. Provide care that is part-time and intermittent. Nutritional status and diet orders
a. Care must be episodic or acute and not chronic. Medical supplies and DME
b. Medically predictable recurring need for care must be Goals and discharge plans
present. Significant clinical findings
c. Knowledge that condition will improve in a limited Prognosis
time frame. Physician’s name, address, signature
d. Frequency of service ranges from daily to every 90 Certification of homebound status
days, depending on individual client’s need. 8. Assess that care is medically reasonable and necessary.
7. Check that plan of treatment is authorized by physician a. Entire plan of care must correlate with client’s med-
and recertified every 60 days. ical problems and client’s clinical status.
a. Centers for Medicare and Medicaid Services form b. Each service’s goals (client outcomes) must be clearly
(CMS-485) is standardized for plan of treatment. stated and realistic for the client.
Completing Admission Documentation

Procedure
1. Complete all sections of the OASIS C document. m. Lack of Knowledge section.
a. Demographic data: address, referring physician, pay- n. Treatment/Procedures Performed.
ment source, etc. o. Response to Teaching/Training Performed.
b. Present history. p. Patient Rights and Responsibilities.
c. Present illness. q. Coordination of Patient Services.
d. Living arrangements. r. Discharge Planning.
e. Supportive assistance. 2. Signed consent forms.
f. Physical assessment/review of systems. a. IV therapy.
g. ADLs. b. Consent for treatment.
h. Medications. c. Consent for service
i. Equipment management. 3. Signed HIPAA form.
j. Homebound status.
4. Signed Advance Directive document.
k. Therapy modalities required.
l. Unmet needs. 5. Signed Patient’s Bill of Rights document.
113
6. Billing Data Base. 11. Physician Plan of Care.

7. Discipline Specific Evaluation, if therapy was instituted. 12. Home Health Plan of Care.
8. Plan of Care. 13. Nurses’ Notes as necessary.
9. CMS-485 Worksheet. 14. Identify if prehospital “Do Not Resuscitate” form has
10. Aide Assignment and Duties, if appropriate. been signed.
Maintaining Nurse’s Safety

Procedure
1. Evaluate safety of nurse before the visit. 5. Maintain personal safety while walking on the street.
a. Call the client before the visit to determine conven- a. Keep one arm and hand free when walking from car
ient time. to house.
b. Confirm directions to home. b. Walk directly to client’s residence.
c. Determine whether household pets are present; if so, c. When approaching a group of strangers, cross the
ask that they be secured during visit. street or walkway, if appropriate.
d. Check neighborhood to determine need for assis- d. When leaving a residence, keep keys in your hand with
tance from police to make home visit. the pointed end of the key facing outward. Rationale:
2. Wear identifying name badge. Most agencies request The keys can be used as a weapon if necessary.
that the nurse wear a lab coat. e. Carry a chemical spray and whistle within easy reach.
3. Wear flat shoes to allow you to walk quickly or to run if
necessary. Clinical Alert
If your safety is in jeopardy, use one of the following
4. Maintain personal safety while traveling in the car. defensive strategies: Scream or yell FIRE or STRANGER.
a. Keep car in good working order and stocked with Kick the person in the shin or groin. Bite or scratch the
necessary equipment. person. Use chemical spray or blow a whistle. If you
b. Keep gas tank at least half full at all times. feel your personal safety is in question, do not make a
c. Obtain automobile club membership for emergency use. visit or stay in the residence.
Rationale: To call for assistance with car problems.
NOTE: Attendance at a class is necessary before it is legal to
d. Keep a windshield cover with CALL POLICE sign
carry a chemical spray such as Mace.
available. Rationale: To alert neighbors you need
immediate assistance. 6. Maintain personal safety when making home visit.
e. Have car phone available and charged at all times. a. Use common walkways or hallways. Do not park be-
f. Keep blanket in car. Rationale: To keep warm in hind a building or in a dark area.
the winter if you need to wait for assistance. b. Knock on the door and wait for permission to enter.
g. Keep thermos of water in car at all times. Rationale: c. Keep a clear pathway to the door if the situation is
In case you need to wait for assistance in hot weather. potentially unsafe.
h. Keep doors locked and windows up at all times. d. Observe home environment for safety hazards (i.e.,
i. Park in full view of neighbors, preferably directly in weapons).
front of home. e. Make a joint visit with another agency staff member or
j. Lock all personal items in the car trunk before leav- ask for an escort if there is a potentially unsafe situation.
ing home or office. f. Call for police support if the visit is essential and the
k. Keep all equipment in the car trunk. situation is unsafe. Rationale: There may be times
l. Restock the nurses’ bag before the visits for the day. when a visit is essential, but it is unsafe for one indi-
Keep nurses’ bag on front seat. vidual to make a visit.
m. Keep change in car for phone calls if necessary. g. Make a visit in the morning when good visual
n. Place all valuable objects out of direct sight in car support exists if neighborhood is unsafe.
(i.e., laptop computers, phone). Place these under h. Close the case if the nurse feels the situation is un-
the seat if possible. Rationale: To prevent car safe and there are no alternative actions that can
break-in and theft. guarantee nurse’s safety.
114
Assessing for Elder Abuse

Procedure
1. Assess client for indications of neglect: failure to pro- 7. Ask about visits to the hospital ER. Ask why client
vide adequate food, clothing, medical assistance, or as- sought medical care, how much time elapsed between
sistance with ADLs. Check body for signs of cleanliness. injury and visit to ER.
Determine whether emotional abuse is present. Ask 8. Assess for signs of emotional abuse. Observe if client is
about threats, intimidation, or isolation. fearful of strangers, becomes quiet when caregiver enters
2. Identify whether financial abuse has occurred, such as room, craves attention and socialization.
misuse of finances or property.
3. Assess for signs of physical abuse: signs of restraining;
hitting, biting, burning; black and blue marks on trunk, Questions to Ask If Suspicion of Abuse
abdomen, buttocks, upper thighs; scars; and abrasions. • Who cares for you at home?
Bilateral bruises or parallel injuries may indicate forceful • Did someone hurt you?
restraining; shaking may cause parallel injuries of upper • Are you happy with where you live?
arms. Accidental injuries affect knees, back of hands, • Tell me about your daily routine.
forehead, and elbows. • Who assists you with ADLs?
4. Assess for signs of malnourishment or dehydration. • Do you feel safe living here?
5. Check skin for pressure ulcers. • Who manages your money?
6. Assess for signs of sprains or dislocations from pulling or • How did the injury (or bruises) occur?
pushing the client. • Did you receive medical attention?
• Has this type of injury happened before?
DOCUMENTATION for Admission to Home Care

• Complete all required forms, i.e., OASIS C, CMS-485, • Nursing care plan update
agency-specific forms • Medication side effects and referral to physician
• Safety issues occurring within house • Changes in client status
• Mental status of client and ability to care for self • Notification of physician
• Teaching activities for client or caregiver
CRITICAL THINKING Applications

Expected Outcomes • Safe environment provides for client safety in home.
• Client is acclimated to home environment and is able to • Nurse’s safety is maintained during home visit.
provide care after a period of support from agency staff.
• Client is provided appropriate home care modalities.
Client is noncompliant with treatments, safety procedures, and • Explain rationale for following home care plan.
taking medications at home. • Discuss reason with client, caregiver, and family members
to determine whether change in plan would increase
compliance.
• Remind client that if he or she refuses to follow plan, he or
she will be taken off services.
• Document appropriately on all forms indicating
noncompliance issues.
• Notify physician.
115
GERONTOLOGIC Considerations
U.S. Demographics Affect Hospital Admissions • Repeated orientation may be indicated due to short-term
• The average life expectancy has increased. memory deficit, confusion, sensory impairment.
• The number of elderly will double by 2020. • Special problems associated with age must be anticipated
• Healthcare services are used by the elderly more than any and nursing care planned appropriately (e.g., risk for falls).
other age group. Elderly Clients Admitted to Home Care Require
• Three of four elderly people die of heart disease, cancer, or Special Consideration
stroke.
Elderly Clients Admitted to the Hospital Require
Special Consideration
• Fatigue and pain may be pronounced; admission procedures
may need to be altered.
MANAGEMENT Guidelines
Each state legislates a Nurse Practice Act for RNs and Communication Matrix
LVN/LPNs. Healthcare facilities are responsible for establish- • Clients being admitted to the hospital are usually fright-
ing and implementing policies and procedures that conform ened and unsure of the events that will take place. It is im-
to their state’s regulations. Verify the regulations and role pa- portant to communicate their needs to and collaborate
rameters for each healthcare worker in your facility. with all staff members involved in the client’s care. This
will provide a team approach for comprehensive care.
Delegation
• A complete report on the newly admitted client must
• Delegation for the admission of a new client may be di- be given to all team members. If an LVN/LPN or CNA
vided into three task areas: assisted in the admission process, he or she must provide
1. A CNA may assist the client into bed, place client’s immediate feedback to the RN manager regarding their
personal items in a designated area, describe the room findings.
environment including the use of telephone, television, • The client Kardex and Medication Reconciliation List
and nurse summon controls, visiting hours, mealtimes, must be completed in a timely manner to facilitate safe and
and other hospital routines. The CNA may also take effective care. It is often the responsibility of the unit sec-
vital signs and obtain height and weight measurements. retary to process orders and initiate the documentation;
2. The LVN/LPN may complete a health history form, ob- however, it is the responsibility of the RN to check the
tain admission data required by the hospital, witness con- processing and documents for accuracy and completeness.
sent forms, and complete the same tasks identified above. • A client care plan must be established within a designated
3. The RN is responsible for the complete health history time frame. The time is determined by the facility in accor-
and reviewing the data obtained by other health care dance with The Joint Commission guidelines.
workers, initiating the client care plan (nursing diagno- • “Hand-Off” shift report must contain a brief history: reason
sis, goals, and interventions), and beginning the dis- for admission, overview of the client’s assessment, current
charge plan in collaboration with the healthcare team. status, and any special needs. Diet, specific treatments, pro-
• An LVN/LPN may complete discharge teaching following cedures, test results or those pending, and any alerts (e.g.,
the established discharge teaching plan. DNAR, isolation) should be included. The hand-off
• Escorting a client out of the hospital can be delegated to a process (including audio-taped reports) must allow
volunteer, CNA, or LVN/LPN. Many facilities have escort opportunity for asking and receiving answers to questions
services that utilize volunteers. relevant to safe client care.
CRITICAL THINKING Strategies

Scenario 1
Mr. Moore has been told by his cardiologist that his coronary preadmission testing unit 1 week before admission for prelimi-
arteriogram indicates he has three-vessel disease and he is a nary blood work and preoperative instructions. At this time
candidate for coronary artery bypass surgery. The surgery is he receives information about his expected clinical course,
scheduled and Mr. Moore is welcomed at the facility’s which includes a multidisciplinary Plan of Care.
116
1. What is the advantage of providing the client with infor- After the first day of antibiotic therapy, she says she’s going to
mation this far in advance of surgery? leave the hospital AMA without completing the recommended
2. What is included in the Plan of Care? course of treatment. She “wasn’t prepared for prolonged hospi-
3. Who participates in the development of the Plan of Care? talization” and has to go home to care for her 3-year-old grand-
daughter and elderly mother who live with her.
4. How does the Plan of Care facilitate the client’s admission,
transfer, and discharge processes? Are there drawbacks? 1. What right does a client have to leave the agency prema-
Scenario 2 turely, AMA?
2. What should the nurse’s initial response to this client be?
Marilyn James, age 45, has been admitted to the hospital for
incision and drainage of a wound infection following knee 3. How can the nurse advocate for this client?
surgery she had 3 weeks ago. Her therapy now requires 2 more 4. What are the usual procedures involved in discharging a
weeks of hospitalization for twice-daily intravenous antibiotic client AMA?
therapy. 5. How is this process documented in the client’s record?
NCLEX® Review Questions

Unless otherwise specified, choose only one (1) answer. 6. This information should be included in the client’s orien-
tation to the hospital environment
1. DNR decisions are made by the
Select all that apply.
1. Client’s family.
1. Meal times.
2. Advance Directive counselor.
2. Use of emergency call system.
3. Client.
3. Roommate’s name.
4. Client’s physician.
4. Use of nurse call system.
2. Who is responsible for inquiring if the client has an 5. Physician visit times.
Advance Directive?
7. Mr. Jones has been admitted to your unit with a diagnosis
1. The hospital chaplain.
of “Rule Out MI” (myocardial infarction). The Joint
2. The admitting nurse. Commission requires that this client be assessed for and
3. The hospital attorney. counseled about
4. The client’s physician. 1. Smoking.
3. During the admission process, the client receives an iden- 2. Diet.
tification bracelet (Ident-A-Band) 3. Exercise.
1. Before arriving on the nursing unit. 4. Stress.
2. Upon arrival to the nursing unit. 8. The client’s body mass index (BMI) is calculated using
3. After the initial assessment has been the client’s
completed. 1. Age and waist measurement.
4. Upon receipt of admitting physician’s orders. 2. Age and weight.
4. The Ident-A-Band contains the client’s name as well as 3. Height and weight.
this information 4. Sex and waist measurement.
Select all that apply. 9. Serious injuries can occur when clients are transferred
1. Client’s room number. from one hospital unit or one bed to another because of
2. Admitting physician’s name. 1. Client misidentification.
3. Client’s date of birth. 2. Loss of personal items.
4. Client’s hospital number. 3. Delays in medication administration.
5. During the admission process, the client is oriented to the 4. Falls during transport.
hospital unit, including use of various control systems. 10. When a client intends to leave the hospital prematurely,
The purpose of this orientation is to against medical advice, the nurse should first
1. Save time for the nursing staff. 1. Have the client sign the hospital AMA form.
2. Provide client control over the environment. 2. Try to identify the reasons why the client wants to
3. Release the hospital from liability in case the client leave AMA.
falls. 3. Notify the client’s physician.
4. Prevent the client’s abuse of expensive equipment. 4. Inform the client about risks of leaving AMA.
117
NCLEX-RN® Answers with Rationale
1. (3) Only the client has the right to make decisions about resuscitation 7. (1) Smoking is the most preventable cause of morbidity. Hospitalization
efforts. This is in compliance with the Client Self-Determination Act. offers an opportunity to identify clients at risk for smoking-related dis-
2. (2) Admitting personnel inquire about Advance Directives so that doc- eases and to offer smoking cessation counseling.
uments can be added to the client’s record, updated, or executed on ad- 8. (3) These are the two factors used for calculating BMI.
mission. 9. (1) Mistakes in client identification are a major cause of client injury
3. (1) The individual receives an ID bracelet during the admission process, due to errors in administration of medications or procedures to the
at which time he/she becomes a client. wrong client, as well as the omission of care intended for another client.
4. (2 4) These correlate with the client’s medical record. Birth date is not 10. (2) The nurse should advocate by determining why the client wishes to
an identifier, and room number may change during hospitalization. leave AMA, since the client’s concerns may be alleviated once identi-
5. (2) A strange environment causes anxiety. Familiarity with the room fied (e.g., further explanation, social service consult, individualized ac-
and equipment promotes independence and control. commodations).
6. (1 4) This information is useful and predictable. The client would not
use the emergency call system, physician visits are unpredictable, and
HIPAA protects against revealing client identity.
118
Client Education and
Discharge Planning
From Chapter 6 of Clinical Nursing Skills: Basic to Advanced Skills, 8/e. Sandra F. Smith. Donna J. Duelle. Barbara C. Martin. Copyright © 2012 by
Pearson Education. All rights reserved. 119

Admission, Transfer, and Discharge

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Admission, Transfer, and Discharge

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Admission, Transfer,

UNIT • Admission and Transfer

UNIT • Height and Weight

Identifying Eligibility for Medicare Reimbursement . . . . . . . Maintaining Nurse’s Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ADMISSION, TRANSFER, AND Admission Protocol

Documentation Medicare requires the nurse to make a home visit at least

NURSING DIAGNOSIS RELATED FACTORS

Anxiety Actual or perceived threat to self-concept, threat to biologic integrity, unfamiliar

Admission and Transfer

Nursing Process Data

Procedure 9. Obtain client’s health history and complete the

Obtaining a Health History • History of food, drug, device, or device materials

INFORMATION PROVIDED BY DISBURSEMENT VALUABLES KEPT BY PATIENT

ROUTE OF ADMISSION Home

See Progress Note for additional comments. Date & Time:

Pacemaker Artificial Joint Diabetes Are you an Organ Donor? Yes No

Latex Rubber Yes No Unknown

EDUCATIONAL NEEDS ASSESSMENT

WHAT DO YOU KNOW ABOUT YOUR PRESENT ILLNESS?

DISCHARGE PLANNING NEEDS COMMUNITY

Home Health Meals on Wheels Assistance Program

Sight Yes No Glasses Any one indicator checked indicates HRFF

Central Line Yes No Type Dialysis Access

Have you experienced any discomfort / pain Yes No

ROLE / RELATIONSHIP-SEXUALITY / REPRODUCTIVE PATTERN

Special Diet at Home Yes No Specify

Food Allergies Yes No Specify

RN SIGNATURE DATE TIME

Sample nursing history assessment form (b).

DOCUMENTATION for Admitting and Transferring

Source: Scribner v. Hillcrest Medical Center (1992).

CRITICAL THINKING Application

Unexpected Outcomes Alternative Actions

Height and Weight

Nursing Process Data

Measuring Height and Weight

9. Place L-shaped sliding height bar on top of client’s head.

DOCUMENTATION for Height and Weight

CRITICAL THINKING Application

Unexpected Outcomes Alternative Actions

Nursing Process Data

PLANNING Objectives Pearson Nursing Student Resources

Discharging a Client Against Medical Advice (AMA)

DOCUMENTATION for Discharging a Client

CRITICAL THINKING Application

Unexpected Outcomes Alternative Actions

Unexpected Outcomes Alternative Actions

Admission to Home Care

Nursing Process Data

Nurse’s Role in Home Care

Identifying Eligibility for Medicare Reimbursement

Completing Admission Documentation

6. Billing Data Base. 11. Physician Plan of Care.

Maintaining Nurse’s Safety

Assessing for Elder Abuse

DOCUMENTATION for Admission to Home Care

CRITICAL THINKING Applications

CRITICAL THINKING Strategies

NCLEX® Review Questions

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