5 Nursing practice

admission and beyond

• To understand the admission process and rationale for information required on admission

• To understand how admission influences the care planning process

• To be able to explore the role of the nurse and other professionals within the admission process

• To be able to identify learning opportunities from the admission process

• To understand the importance of infection control within the admission process and throughout the care of a medical patient

Introduction

This chapter aims to prepare you for what may be your first contact with a patient on your medical placement – their admission. It will describe the admission process and help you to identify how you can be involved in the admission process and meet your learning outcomes, whether you are in your first year or your final placement prior to joining the register. It will also cover some important aspects of infection control which need to be addressed on admission and throughout your patient’s journey.

Admitting a patient is an opportunity to be involved at the start of the care planning process and the preparations you made in Chapter 1 will enable you to now put this knowledge into practice. This chapter will also form the basis for the following chapters on risk assessment and the assessment of patients’ vital signs and changing health status, which are often an integral part of a patient’s admission as well as their ongoing care.

Depending on where your placement learning experience is, your patients could be admitted from a number of different areas.

If you are placed on a medical admission unit, the majority of your patients will come from the accident and emergency (A&E). There may also be an arrangement with local GPs that patients can be referred to the on-call medical team and admitted directly to the admissions unit rather than go through A&E.

On a medical ward, your patients may be admitted from a number of different areas. Most will come from the admissions unit or directly from A&E if there isn’t an admissions unit in your hospital. Some patients may be admitted directly from the out-patient department if the doctor feels they are unwell and need to stay in hospital for treatment or investigations.

Other patients may have been day patients in a medical investigations unit, for example for an endoscopy, and are too unwell to be discharged home the same day. They may also be transferred from another ward if their needs will be better met in your placement area. This might be because the nature of their medical problem is the specialty of your ward or they have specialist needs, for example a need for barrier nursing for infection control reasons and your ward has a single room available.

In an intermediate care or virtual ward setting, your patient could be transferred to you from a medical ward or they may be admitted from home following an assessment from their GP or community matron.

Admitting a patient requires a specific set of skills including communication, patient assessment, documentation, prioritising and delegating. You are likely to have competencies and/or learning outcomes associated with all of these skills. The competencies from the Nursing and Midwifery Council (NMC; 2010a) Domains – Professional Values, Communication and Interpersonal Skills, Nursing Practice and Decision Making – will all be particularly relevant to patient admission.

Activity

Speak to your mentor and find out all the different places your patients are likely to be admitted from. Maybe you could visit some of these areas or arrange to spend some time in them if they are not already a part of your placement learning experience (see Ch. 4 for examples of a patient’s journey).

Depending on where you are placed, a patient being admitted to your area may have been in another area of the hospital for a few days already, but other patients may have only been in hospital for a few hours before they get to you.

Reflection point

Imagine how it may feel for a patient when they are admitted to hospital in an emergency. What sort of emotions and anxieties might they have? If you have a friend or family member who has been a patient in hospital, ask if they would be happy to tell you about how it felt.

Now think how it might feel to be moving from one area, such as the admissions unit, to another area, such as a hospital ward. What could you do to make the process easier for the patient?

Think of all the different areas of a hospital a patient may move between – A&E, out-patient clinic, ward, X-ray department – and how a patient may feel moving from one area to another often within a short space of time.

The admission process

A certain amount of information will have been collected about your patient in the department they started their journey in. Usually this will consist of at least their:

– name

– date of birth

– address details

– contact details for next of kin

– GP details.

A member of staff from the area your patient is being admitted from will accompany the patient and ‘handover’ their care to you. The handover in this case is when the nurse from the area transferring the patient to you hands over or communicates verbally all the information they have about the patient, their plan of care and treatment required so that you can continue to provide care to the patient.

The handover process is vital in ensuring that all the necessary information about the patient is communicated to the receiving nurse, so that the transfer of care happens as smoothly as possible. (For more information about handover and skills required to hand over successfully, see Ch. 8.)

Activity

Discuss with your mentor how you can be involved in the handover of a patient being admitted to your area. Think about the information you are likely to need to know in order to provide care for your patient and then, when you have the opportunity to be involved in receiving a handover, listen to how this information is communicated and subsequently recorded.

When taking handover from the nurse transferring the patient, you will need to know the following:

• Why the patient was admitted and when.

• The medical team caring for the patient and contact number.

• A provisional diagnosis.

• What the patient has been told about their provisional diagnosis.

• Infection control status.

• Vital signs on transfer and frequency of monitoring.

• Nursing interventions required, e.g. wound care, fluid balance monitoring, blood sugar monitoring.

• Treatment given prior to transfer.

• Planned treatment and/or investigations.

• Results of any investigations so far.

• Problems identified so far, e.g. pain, incontinence, pressure ulcers, and interventions required.

• Estimated date of discharge.

• Social circumstances of the patient.

• Any referrals that have been made, e.g. specialist team/nurse, social worker, physiotherapist.

• Patient’s next of kin and whether they have been informed of admission.

Chapter 8 includes more information about the different types of nursing handover and their importance.

Orientating your patient to the ward is extremely important. Informing them of the ward name and their whereabouts in the hospital can help to reassure them and help them to inform any relatives or friends that may call them wishing to visit. Knowing the ward routine, the location of toilets, bathrooms, where they can store their personal belongings and how to call for the nurse are all essential for the patient to know to help them feel in control of their situation.

Once your patient is settled into their bed and orientated to the ward, you will need to prioritise their needs accordingly. If the patient has been transferred from another setting within the same hospital or organisation, some of their assessments and care planning may already have been completed. If this is the case it is essential that you check all of this and make yourself familiar with the patient’s care plans and ensure that they are still relevant.

For many patients you will need to begin with a full assessment to inform your care planning.

You may find that the documentation used when admitting a patient will be arranged to fit with a particular nursing model, for example Roper, Logan and Tierney’s (2000) ‘activities of daily living’. It is vital that completing such documentation is not seen as merely a paper exercise but as an essential opportunity to learn about your patient, their actual and perceived needs and an opportunity to start to plan their care.

Activity

Refresh your memory about the nursing process discussed in Chapter 1 and reflect on how this happens within your placement area. Which members of staff assess patients, when and how is care planned and implemented and how often is it evaluated? Find out where all of the patients’ assessments are documented and familiarise yourself with the paperwork used in your placement area.

Patient assessment

Your initial assessment of your patient needs to inform yourself and your colleagues of the patient’s actual and potential problems and the plan of care to address these problems. The assessment will also help to determine your priorities in caring for your patient. Your assessment will often include all or some of the following, depending on your placement area:

• Confirming patient details, e.g. date of birth, GP, next of kin.

• Vital signs.

• Assessment of needs based on a nursing model, e.g. activities of daily living.

• Physical assessment of skin condition, mobility, wound condition.

• Risk assessments, e.g. falls risk, pressure ulcer risk, malnutrition risk.

• Collection and testing of specimens, e.g. urine sample, stool sample, MRSA swabs, wound swabs.

• Measurement of the patient’s weight, height and calculation of body mass index.

Assessment of vital signs and risk assessment will be covered in detail in Chapters 6 and 7. This section will focus on the assessment of your patients’ needs and care planning.

The initial assessment of your patient can be quite lengthy so it is important that you plan for this to take place when there is sufficient time. For example, if meals are about to be served it may be appropriate to complete some of the assessments, such as measuring vital signs and taking any details about dietary needs and assistance required with eating and drinking, before the meal is served and then complete the remaining assessments afterwards. Also, if your patient is in pain or requires urgent treatment or intervention, this should take priority along with checking of vital signs and confirming their personal details.

In some circumstances your patient will not be able to take part in the assessment. They may be confused and unable to understand or answer your questions or they may be unconscious or too drowsy. They may also be very unstable and too unwell to hold a full conversation. When this is the case, it is important that you complete all the physical assessments, checking of vital signs, collection of swabs and specimens, etc., with your patient and then use other sources to complete the nursing needs part of your assessment.

Your placement area is likely to have a standardised set of questions to ask which

Activity

Speak to your mentor and identify an opportunity to observe or take part in a patient assessment. Find out which aspects of assessment above are carried out in your placement area and which nursing model is used to structure the assessment. Read up on this model to refresh your memory.

form the basis of the patient’s nursing needs assessment. Appendix 4 in Holland et al (2008) has questions to consider during the assessment stage of care planning based on the activities of daily living model.

Activity

Consider how you may find out information about your patient’s abilities and needs if they are not able to tell you themselves.

Some of the possible sources of information to help complete your assessment will be:

Talking to family, friends, carers of your patient.

Transfer documents or a phone call to the care home your patient lives in.

Information already recorded in the medical/nursing notes from the patient or family.

Previous admissions and assessments made which are filed in the patient’s notes.

Contacting social services or care agencies if the patient is in receipt of a care package at home.

Contacting the patient’s GP – this will be particularly useful if you have any queries about previous medical conditions, medications, etc.

Care planning

In Chapter 1, the nursing process was introduced as a systematic way of assessing, planning, implementing and evaluating nursing care (see Habermann & Uys 2005). This same process is reflected in care planning.

Nursing care plans are paper or electronic documents used to help direct the care we give to patients, detailing what the patient’s actual or potential problems are, the goals we are aiming for and the care required to achieve these goals. Every organisation will have a slightly different system with regards to how they produce their care plans, where they store them and how they record their evaluation of them.

When you arrive in your placement area, speak to your mentor about the system used and take some time to familiarise yourself with the paperwork used. Some examples of nursing care plan documents can be found in Holland et al (2008). Most care planning documents will have space to document the patient’s actual or potential problems and then the nursing actions required to care for the patient. The date of review and evaluation will also be recorded on the care plan.

Standardised care plans which are preprinted for a specific condition are used in some areas. They have the advantage of reducing the time required to write the care plan and also ensure that the standard of care received by all patients with a similar condition is the same. But they don’t allow for individual variation and not all patients will have the same needs, even if they have the same medical problem. Consequently, if you are using standardised care plans, it is important that you take the time to individualise them as appropriate to meet your patient’s needs.

The alternative to standardised care plans are hand-written ones that are developed specifically for an individual patient. They can be tailored to meet the specific needs of the patient and address all of the needs your patient may have. It is essential, though, that such care plans are evidence-based and written by a nurse who understands not only the condition of patients but also the patients themselves.

Ideally care plans should be written in conjunction with the patient, but this will not always be possible depending on the condition of the patient. Some patients will be too unwell to take part and others may not wish too. It is important that, even if the patient is not involved in planning their care, you try to establish how involved they want to be in their overall treatment plan: for example, do they want to know what investigations are planned and why? For some patients, knowing all the details will help to relieve their anxieties, but for others it may cause more distress and they would rather only know when there are definite results to be given or decisions to be made.

Reflection point

Think about why patients may or may not want to be involved in their care. What might influence their decisions to be involved or not? Consider the influence of a patient’s cultural or spiritual beliefs, age, family or home circumstances.

Infection prevention and control in your medical placement

The infection control status of your patient is an important aspect of the handover you receive when the patient is admitted as it may affect the physical environment your

Case history 5.1 A patient with a chest infection

Ian is a 68-year-old man with chronic obstructive pulmonary disease (COPD). He lives alone and has a carer once a day to help him wash and dress. His daughter visits daily to help him prepare meals. He has long-term oxygen therapy at home and rarely leaves the house – when he does he requires a wheelchair. He has developed an infective exacerbation of his COPD and his GP sent him to A&E yesterday as he was not responding to oral antibiotics. He has been admitted to hospital and transferred to your ward.

Ian is breathless, his respiratory rate is 28 breaths/min and he is unable to speak in full sentences. His oxygen saturations are 92% on 2 litres of oxygen. Ian speaks English and understands why he is in hospital. He is currently receiving intravenous antibiotics to treat his chest infection and intravenous fluids as his breathlessness is reducing his ability to drink adequately and his increased respiratory rate means his insensible fluid loss is increased.

Activity

Imagine you are assessing Ian using the Roper, Logan and Tierney model.

1. Which activities of daily living do you think he will require assistance to maintain at the moment?

2. What do you think his actual and potential problems may be?

3. Try to write a care plan for each of these problems and consider how you would evaluate whether Ian has met the goals set in his care plans.

(See page 82 for answers.)

patient is placed in. For example, if you are placed on a ward and your patient has an infection that could be passed on to other patients, they may need to be nursed in a single room. You also need to know what precautions you may need to take to protect yourself and your patient.

Infection control will be an essential aspect of any placement area you are working in. It also forms a large part of the Essential Skills Clusters (NMC 2010b) which contain competencies you must achieve at all levels throughout your training in infection prevention and control. At entry level to the register it will be expected that:

• You can identify and take effective measures to prevent and control infection in accordance with local and national policy.

• You can maintain effective standard infection control precautions and apply and adapt these to the needs and limitations in all environments.

• You can provide effective nursing interventions when someone has an infectious disease including the use of standard isolation techniques.

• You can fully comply with hygiene, uniform and dress codes in order to limit, prevent and control infection.

• You can safely apply the principles of asepsis when performing invasive procedures and be competent in aseptic technique in a variety of settings.

• You can act, in a variety of environments including the home care setting, to reduce risk when handling waste, including sharps, contaminated linen and when dealing with spillages of blood and other body fluids.

Most organisations will have a policy or procedure regarding how information about infection control is communicated, to ensure that those who need to know the infection control status of a patient are able to obtain the information easily, but at the same time ensuring the confidentiality of such sensitive information. Consequently, you need to be careful about where you are physically in the placement area when discussing infection control issues as you may not want other patients or relatives to overhear such sensitive information.

Activity