ADMISSION OF A PATIENT

REQUIREMENTS #

1. Admission bed and its accessories (Per patient condition)
2. Manual or electronic folder
3. Vital signs tray
4. Oxygen apparatus
5. Treatment or emergency tray
6. Suction apparatus
7. Admission and Discharge documents (Manual or Electronic)

STEPS #

1. Welcome patient and relatives to the nurses’ station
2. Introduce self (nurse) and any staff present
3. Collect necessary documents, admission notes and any other information from the accompanying nurse
4. Assess the patients’ conditions and note any supportive gadgets/devices
5. Identify and confirm patient’s name, particulars and reassures him/her and relatives
6. Send patient to bedside and position him/her as per the conditions permits
7. Make relative comfortable in the waiting area
8. Take comprehensive history from the patient or relatives
9. Perform general head to toe assessment
10. Check vital signs and records
11. Secure intravenous access and extracts sample for requested laboratory investigations
12. Send patient to do other requested investigations e.g. X-rays, C.T. Scan etc. (if any)
13. Inform charge nurse of any urgent prescribed medication and ensure they are available
14. Administer prescribed medications
15. Assist patient to change into appropriate clothing
16. Ask patient to declare valuables if any according to the institution’s protocol
17. Keep patient valuables according to the institution’s protocol
18. Explain National Health/Mutual Insurance Schemes to patient and relative(s)
    1. If client is a scheme holder, go ahead and process
    2. If client is a cash-in client, request for deposit per the institutional protocol
19. Introduce him/her to other patients near him/her in the ward
20. Orientate patient/relative(s) to ward if condition permits
21. Inform patients/relatives about the routine ward activities
22. Enter patient’s name into admission, discharges book and daily ward state (manually or electronically)
23. Instruct patient/relatives to read and sign consent form if necessary
24. Allow relative(s) to see patient and bid goodbye
25. Document all assessments, findings and treatments in appropriate notes charts (manually or electronically)
26. Plan care for the patient using the nursing process approach