Admission
Admission to the nursing unit prepares the patient for his stay in the health care facility. Whether the admission is scheduled or follows emergency treatment, effective admission procedures should include certain steps to accomplish important goals. These steps include verifying the patient’s identity using at least two patient identifiers according to your facility’s policy,1 assessing his clinical status, making him as comfortable as possible, introducing him to roommates and staff members, orienting him to the environment and routines, and providing any supplies and special equipment needed for daily care.
During your assessment, prioritize the patient’s needs, and always be conscious of the patient’s levels of fatigue and comfort. Maintain the patient’s privacy while obtaining his health history; he also has the right to expect that his examinations, consultations, and treatment will be conducted in a manner that protects his privacy.
Effective admission routines that show appropriate concern for the patient can ease his anxiety and promote cooperation and receptivity to treatment. Conversely, admission routines that the patient perceives as careless or excessively impersonal can heighten the patient’s anxiety, reduce cooperation, impair his response to treatment, and possibly aggravate symptoms.
Equipment
Gown ▪ personal property form ▪ valuables envelope ▪ admission form ▪ nursing assessment form ▪ sphygmomanometer ▪ stethoscope ▪ thermometer ▪ Optional: emesis basin, bedpan, urinal, bath basin, urine specimen container, towel, washcloth.
Preparation of Equipment
Obtain a gown. Position the bed as the patient’s condition requires. If the patient is ambulatory, place the bed in the low position; if he’s arriving on a stretcher, place the bed in the high position. Fold down the top linens. Prepare any emergency or special equipment, such as oxygen or suction, as needed.
Implementation
Adjust the lights, temperature, and ventilation in the room.
Quickly review the admission form and the doctor’s orders. Note the reason for admission, any restrictions on activity or diet, and any orders for diagnostic tests requiring specimen collection.
Speaking slowly and clearly, greet the patient by his proper name and introduce yourself and any other staff members present.
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.1 Verify the name and spelling with the patient. Notify the admission office of any corrections.
Escort the patient to his room and, if he isn’t in great distress, introduce him to his roommate.
Help the patient change into a gown or pajamas; if the patient is sharing a room, provide privacy.
Itemize all valuables, clothing, and prostheses on the nursing assessment form (or in your notes if your facility doesn’t use such a form). Encourage the patient to store valuables or money in the safe or, preferably, to send them home along with any medications he may have brought.
Show the ambulatory patient where the bathroom and closets are located.
Take and record the patient’s vital signs, and collect specimens, if ordered. Measure his height and weight if possible. If he can’t stand, use a chair or bed scale and ask him his height. Knowing the patient’s height and weight is important for planning treatment and diet and for calculating medication and anesthetic dosages.
Show the patient how to use the equipment in his room. Include the call system, bed controls, television controls, telephone, and lights.
Explain the routine at your health care facility. Mention when to expect meals, vital sign checks, and medications. Review visiting hours and any restrictions.
Obtain a complete patient history. Include all previous hospitalizations, illnesses, surgeries, and food or drug allergies.
Make sure that a complete list of the medications the patient was taking at home (including doses, routes, and frequency) has been obtained and documented in the patient’s medical record. This list should be compared with the patient’s current medications, and any discrepancies (omissions, duplications, adjustments, deletions or additions) should be reconciled and documented in the patient’s medical record to reduce the risk of transition-related adverse drug events.5
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