A comprehensive admission assessment,

also referred to as an initial database,

nursing history, or nursing assessment is
completed when the client is admitted to
the nursing unit.

These forms can be organized according
to body systems, functional abilities,
health problems and risks, nursing model,
or type of health care setting.
Documentation

Complete the nursing assessment form
which include vital signs, height, weight,
allergies, drug, health history, a list of his
belongings and those sent home, the
result of your physical assessment and a
record of specimens collected for
laboratory tests

Kardexes is concise method of organizing and
recording data about the client, making information
quickly accessible to all health professionals. The
information on kardex may be organized into
sections, for example:

1) Pertinent information about the client, such as name,
room number, age , religion, marital status,
admission date, physicians name, diagnosis

2) List of medications
3. List of intravenous fluids

4. List of daily treatments and procedures

5. List of diagnostic procedures ordered

6. Specific data on how the clients physical need are
to be met, such as type of diet, activity, hygienic
needs

7. A problem list, stated goals, a list of nursing
approaches to meet the goals and relieve the
problems.


Flow Sheet, it enables nurses to record nursing data
quickly and concisely and provides an easy-to-read
record of the clients condition over time.

Graphic Record, this record typically indicates body
temperature, pulse, respiratory rate, blood pressure,
weight.

Fluid Balance Record, all routes of fluid intake and
all routes of fluid loss or output are measured and
recorded on this form.

Medication Administration Record, medication
flow sheets usually include designated areas
for the date of the medication order, the
expiration date, the medication name and dose,
the frequency of administration and route and
the nurses signature.

Skin Assessment Record, a skin or wound
assessment is often recorded on a flow sheet.
These records may include categories related
to stage of skin injury, drainage, color, odor,
and treatment
Progress Notes, it made by nurses provide
information about the progress a client is
making achieving desired outcomes.

- Progress notes include information about
client problems and nursing interventions.

A discharge note and referral summary are completed when
the client is being discharged and transferred to another
institution or to a home setting where a visit by a community
health nurse is required.

Some records combine the discharge plan, including
instructions for care, and the final progress note.

If a client is transferred within the facility or from a long-term
facility to a hospital, a report needs to accompany the client to
ensure continuity of care in the new area. It should include all
components of the discharge instructions.
Regardless of format, discharge and referral summaries
usually include some or all of the following:

Description of clients physical , mental, and emotional status at discharge or
referral

Resolved health problems

Unresolved continuing health problems and continuing care.

Treatment that are to be continued such as wound care

Current medications

Restrictions that relate to (a) activity such as lifting, stair climbing (b) diet,
and (c) bathing

Functional/self-care abilities in terms of vision,
hearing, speech, mobility

Comfort level

Support network including family, significant others

Client education provided in relation to disease
process, activity, and exercise

Discharge destination and mode of discharge such as
walking, wheelchair

Referral services.


Your discharge teaching should aim to ensure
that the patient:
Understands his illness
Complies with his drug therapy
Carefully follows his diet
Manages his activity level
Understands his treatment
Recognize his need for rest
Knows when to seek follow up care

AMA
Occasionally, the pt or his family may demand
discharge against medical advice "AMA". If this
occurs, notify the physician immediately.

If the physician fails to convince the pt to
remain in the facility, he'll ask the pt to sign an
AMA form releasing the facility from leg
responsibility for any medical problems the pt
may experience after discharge

Teach the pt and his family about his illness and its
effect on his lifestyle
Provide instruction for home care
Communicate dietary or activity instructions
Explain the purpose, adverse effects and scheduling
of drug treatment
Can also include arranging for transportation
Follow-up care if necessary
Coordination of outpatient or home health care
services

Review the new orders with the nursing staff
at the receiving unit
Send the pt's chart, laboratory slips, kardex
Use a wheel chair to transport the ambulatory
pts, in which case he may be allowed to walk
Use a stretcher to transport the bed-riiden pts
Introduce the pt to the nursing staff-take him
to his room-place him in bed or seat him in
chair introduce him to his roommate tell him
about call bells
Explain transfer to the pt and family

Assess the physical condition to determine the means
of transfer wheelchair or stretcher

Using the admission inventory of belongings as a
checklist

Collect the pt's property

Don't forget valuables or personal medications

Check the entire room, including the bedside stand,
over-bed table, bathroom

Gather the pts medication from the cart and the
refrigerator

Notify the business office, dietary department, the
pharmacy, the facility telephone operator about the
transfer

Contact the nursing staff on the receiving unit
about the pt's condition and review the nursing care
plan to ensure continuity of care.