2/20/14

Discharging Patient Questions

1. Mention concepts related to caring for clients belongings on admission.
2. State some of the nursing consideration related to admission of a client.
3. Exercise how to transfer a client from one unit to another safely and effectively.
4. Identify nursing considerations related to discharge of a client from health care facility
5. Explain teaching that should occur at time of a client discharge.
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Discharging a Patient

Indications for discharge
• Progress in the patient's condition
• No change in the patient's condition (Referral)
• Against medical advice
• Death

Nurse's Responsibility during Discharging a Patient
1. Check for orders that a patient need to be discharged
2. Plan for continuing care of the patient
   • Referral as necessary
   • Give information for a person involved in the patient care.
   • Contact family or significant others, if needed.
   • Facilitate transportation with responsible unit
3. Teaching the patient about
   • What to expect about disease outcome
   • Medications (Treatments)
   • Activity
   • Diet
   • Need for continued health supervision, and others as needed

4. Do final assessment of physical and emotional status of the patient and the ability to continue own care.

5. Check and return all patients’ personal property (bath items in patient unit and those kept in safe area).

6. Help the patient or family to deal with business office for customary financial matters and in obtaining supplies.

7. Keep records
   o Write discharge note
   o Keep special forms for facility

Discharge summaries usually include:
• Description of client’s condition at discharge
• Treatment (e.g. Wound care, Current medication)
• Diet
• Activity level
• Restrictions

Referral is a condition in which a client/patient is sent to a higher health care system for better diagnostic and therapeutic actions.
• Any active health problems
• Current medication
• Current treatments that are to be continued
• Eating and sleeping habits
• Self-care abilities
• Support networks
• Life-style patterns
• Religious preferences

Discharging a patient against medical advice (AMA)
1. When the patient wants to leave an agency without the permission of the physician/nurse in charge – an authorized.
2. Ascertain why the person wants to leave the agency
3. Notify the physician/ nurse in charge of the client’s decision
4. Offer the patient the appropriate form to complete
5. If the client refuses to sign the form, document the fact on the form and have another health professional witness this
6. Provide the patient with the original of the signed form and place a copy in the record
7. When the patient leaves the agency, notify the physician, nurse in charge, and agency administration as appropriate
8. Assist the patient to leave as if this were a usual discharge from the agency (the agency is still responsible while the patient is on premises)
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Transfer of the patient to another unit

Transfer of the patient to another unit is done for several reasons.

Procedure
• Explain the transfer to the client and the family
• Assemble all the client’s personal belongings, charts, x-films and lab reports. Double check for all other cloths and materials.
• Determine how the client is moved
• Provide for client safety. Take measures to accommodate IV bottles, drains and catheters. Protect the client from draft, and cover the client with a blanket for warmth and privacy.
• Collect all the client medications; IV bags tube feedings, and so forth. Check the cardex or medication administration record for accuracy.
• Review the client’s health records and check for completeness.
• Record the transfer in a transfer note. Give the time, the unit to which the transfer occurs, types of transportation (wheelchair, stretcher), and the cleint’s physical and psychological condition
• Make sure that the receiving unit is ready. Usually a short verbal report is given to the reciving department nurse.
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Admission

Admission is a process of receiving a new patient to an individual unit (ward) of the hospital. (Hospitalized individuals have many needs and concerns that must be identified then prioritized and for which action must be taken).

Purpose
• To help a new patient to adjust to hospital environment and routines.
• To alleviate the patient's fear and worry about the hospitalization.
• To facilitate recovery of patient from his/her problems

Nurse's Responsibilities during Admission of a Patient to Hospital
1. Check for orders of admission.
2. Check about financial issue, payment scheme (free or paying)
3. Assess the patient's immediate need and take action to meet them. These needs can be physical (e.g. acute pain) or emotional distress, (upset)
4. Make introduction and orient the patient
• Greet the patient
• Introduce self to the patient and the family
• Explain what will occur during the admission process (admission routines) such as admission bath, put on hospital gowns etc.
• Orient patient to individual unit: Bed, bathroom, call light, supplies and belonging; and how these items work for patient use.
• Orient patient to the entire unit: location of nurses office, lounge etc.
• Explain anything you expect a patient to do in detail. (This helps the patients participate in their care).
• Introduce other staff and roommates.

4. Perform baseline assessment
General assessment
a. Observation and physical examination such as:
• Vital signs; temperature pulse, respiration and blood pressure.
• Intake and output
• Measure the weight of the patient
• Height is measured (if required)
b. Interview patient and take nursing history to determine the patient conditions.

5. Take care of the patient's personal property
• Items that are not needed can be sent home with family members
• Other important items can be kept at bedside or should be put in safe place by cabling with patient's name.

6. Documentation
• Record all parts of the admission process
• Other recording include
⇐ Notification to dietary departments
⇐ Starting kardex card and medication records
⇐ If there is specific form to the facility, complete it.

N.B. Additional measures can be carried out according to the patient problems (diagnoses).
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Admission, Transfer and Discharge of Patients

Learning Objectives:
At the end of this chapter students will be able to:
• Demonstrate how to orient a new client to the health care facility.
• Discuss concepts related to caring for the client’s clothing and valuable items on admission.
• State some of the nursing consideration related to admission of a client.
• Demonstrate the ability to transfer a client from one unit to another safely and effectively.
• Identify nursing considerations related to a client’s discharge from the health care facility.
• Explain teaching that should occur at the time of a client discharge.


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Rubber Bags

Example: hot water bottles, ice bags should be drained and dried

They should be inflated with air and closed to prevent the sides from sticking together

Rubber Tubing
• Should be washed with warm, soapy water
• The inside should be flushed and rinsed well

Study questions:
1. State some of the important general instructions for nursing procedures.
2. List items commonly found in patient unit.
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Care of Pick Up Forceps and Jars

Pickup forceps: is an instrument that allows one to pick up sterile equipment.
Sterile equipment: material, which is free of all forms of microorganism.

Pick up forceps should be kept inside the jar in which 2/3 of the jar should be filled with antiseptic solution
• Wash pick up forceps and jars and sterilize daily
• Fill jar with disinfectant solution daily such as detol or preferably carbolic solution
• Care should be taken not to contaminate tip of the forceps
• Always hold tip downward
• If tip of forceps is contaminated accidentally, it should be sterilized before placing it back in the jar to avoid contamination.
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Care of Linen and Removal of Stains

• Clean linen should be folded properly and be kept neatly in the linen cupboard.
• Dirty linen should be put in the dirty linen bag (hamper) and never be placed on the floor.
• Torn linen should be mended or sent to the sewing room.
• Linen with blood should be soaked in cold water to which a small amount of hydrogen peroxide is added if available.
• Linen stained with urine and feces is first rinsed in cold water and then washed with soap.
• Iodine stained linen- apply ammonia, rinse and then wash with cold water.
• Ink stained linen – first soak in cold water or milk for at least for 24 hrs then rub a paste of salt and lemon juice on the stain and allow the article to lie in the sun.
• Tea or coffee stains – wash in cold water and then pour boiling water on the stain.
• To remove vitamin B complex stains dissolve in water or sprit.
• Mucus stains – soak in salty water.
• Rust - soak in salt and lemon juice and then bleach in sun.
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Care of Equipment in General

• Rinse used equipment in cold water. Sock materials in recommended antiseptic solutions. Remove any sticky material. Hot water coagulates the protein of organic material and tends to make it adhere.
• Wash well in hot soapy water. Use an abrasive, such as a stiff-bristled brush, to clean equipment.
• Rinse well under running water.
• Dry the article.
• Clean the gloves, brush and clean the sink.
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General Instructions for Care of Hospital Equipment

• Use articles only for the purpose for which they are intended.
• Keep articles clean and in good condition. Use the proper cleaning method.
• Protect mattresses with rubber sheets.
• Use protective pillowcases on pillows.
• Do not boil articles, especially rubber articles and instruments longer than the correct time.
• Do not sterilize rubber goods and glass articles together wrap glass in gauze when sterilizing it by boiling.
• Protect table tops when using hot utensils or any solution that may leave stain or destroy the table top.
• Report promptly any damaged or missing equipment.
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General Rules for Cleaning

• Dry dusting of the room is not advisable.
• Dusting should be done by sweeping only.
• Use a damp duster for collecting dust.
• Dust with clear duster.
• Collect dust at one place to avoid flying from place to place.
• Dusting should be done without disturbing or removing the patients from bed.
• Dusting should be done from top to bottom i.e. from upward to downward direction.
• While dusting, take care not to spoil the beds or walls or other fixtures in the room or hospital ward.
• While dusting, wounds or dressing should not be opened by other staff.
• There should be a different time for dusting daily.
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The patient unit in the hospital is of three types

1. Private room – is a room in which only one patient be admitted

2. Semi private room – is a patient unit which can accommodate two patients

3. Ward- is a room, which can receive three or more patients. Consists of a hospital bed, bed side stand, over bed table, chair, overhead light, suction and oxygen, electrical outlets, sphygmomanometer, a nurse’s call light, waste container and bed side table and others as needed and available. In the home, the client unit is the primary area where the client receives care. It may be bedroom, or the main living area.

A. Hospital Bed
• Gatch bed: a manual bed which requires the use of hand racks or foot pedals to manipulate the bed into
desired positions i.e. to elevate the head or the foot of the bed
• Most commonly found in Ethiopia hospitals
• Are less expensive and free of safety hazard
• Handles should be positioned under the bed when not in use

C. Side rails
• It should be attached to both sides of the bed
_ Full rails – run the length of the bed
– Half rails _ run only half the length of the bed and commonly attached to the pediatrics bed.

D. Bed Side Table/Cabinet
• Is a small cabinet that generally consists of a drawer and a cupboard area with shelves
• Used to store the utensils needed for clients care. Includes the washbasin (bath basin, emesis (kidney) basin, bed pan and urinal
• Has a towel rack on either sides or along the back
• Is best for storing personal items that are desired near by or that will be used frequently
E.g. soap, shampoo, lotion etc

E. Over Bed Table
• The height is adjustable
• Can be positioned and consists of a rectangular, flat surface supported by a side bar attached to a wide base on wheels
• Along side or over the bed or over a chair
• Used for holding the tray during meals, or care items when completing personal hygiene

F. The Chair
• Most basic care units have at least one chair located near the bedside
• For the use of the client, a visitor, or a care provider

G. Overhead Light (examination light)
• Is usually placed at the head of the bed, attached to either the wall or the ceiling
• A movable lamp may also be used
• Useful for the client for reading or doing close work
• Important for the nurse during assessment

H. Suction and Oxygen Outlets
• Suction is a vacuum created in a tube that is used to pull (evacuate) fluids from the body E.g. to clear respiratory mucus or fluids
• Oxygen is one of the gases frequently used for health care today. Oxygen is derived through a tube.

I. Electrical Outlets
• Almost always available in the wall at the head of the bed

J. Sphygmomanometer
• The blood pressure assessment tool, has two types:
1. An aneroid
2. Mercury, which is frequently used during nursing assessment.

K. Call Light
• Used for client’s to maintain constant contact with care providers
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Care of Patient Unit

Learning Objective
At completion of this unit the learner will be able to:
• State the general instruction for nursing procedures.
• Define patient and patient unit.
• Take care of patient unit and equipment in health care facilities

General Instructions for all Nursing Procedures
1. Wash your hands before and after any procedure.
2. Explain procedure to patient before you start.
3. Close doors and windows before you start some procedures like bed bath and back care.
4. Do not expose the patient unnecessarily.
5. Whenever possible give privacy to all patients according to the procedure.
6. Assemble necessary equipment before starting the procedure.
7. After completion of a procedure, observe the patient reaction to the procedure, take care of all used equipment and return to their proper place.
8. Record the procedure at the end.

PATIENT UNIT
Definition:
Patient: A Latin word meaning to suffer or to bear.
- Is a person who is waiting for or undergoing medical/nursing treatment and care.

Patient Care Unit: is the space where the patient is accommodated in hospital or patient home whereto receive care. There may also be closet space or drawer.

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Guide lines for Disposing of Contaminated Equipment

• Disposable gloves: place in isolation bag separate from burnable trash and direct to appropriate hospital area for disposal

• Glass equipment: Bag separately from metal equipment and return to CSR (Central Sterilization Room).

• Metal equipment: Bag all equipment together, label and return to CSR

• Rubber and plastic items: Bag items separately and return to CSR for gas sterilization.

• Dishes: Requires no special precautions unless contaminated with infected material; then bag, label and return to Kitchen.

• Plastic or paper dishes: Dispose of these items in burnable trash.

• Soiled linens: place in laundry bag, and send to separate area of laundry room from special care. If possible place linens hot-water-soluble bag. This method is safes for handling as bag may be placed directly into washing machine. (Double-bagging is usually required because these bags are easily punctured or torn. They also dissolve when wet.)

• Food and liquids: Dispose of these items by putting them in toilet – flush thoroughly.

• Needles and syringes: Do not recap needles; place inpuncture proof (resistant) container.

• Sphygmomanometer and stethoscope: Require no special precaution unless they are contaminated. If contaminated, disinfect using the appropriate cleaning protocol based on the infective agent.

Thermometers:
Dispose of electronic probes cover with burnable trash. If probe or machine is contaminated, clean with appropriate disinfectant or infective agent. If reasonable thermometers are used, disinfect with appropriate solution.

Study questions
• Describe infection prevention in health care setups
• List chain of infection
• Identify between medical asepsis and surgical asepsis
• Discuss the purpose, use and components of standard precautions.
• Maintain both medical and surgical asepsis
• Describe how to setup a client’s room for isolation, including appropriate barrier techniques.
• Identify hoe to follow specific airborne, droplet and contact precautions.
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Protocol for Leaving Isolation Room

Untie gown at wrist
- Take off gloves
- Untie gown at neck
- Pull gown off and place in laundry hamper
- Take off goggles or face shield
- Take off mask
- Wash hands

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Transporting Isolated Client outside the Room

Equipment
- Transport Vehicle
- Bath blanket
- Mask for client if needed

Procedure
1. Explain procedure to patient

2. If client is being transported from a respiratory isolation room, instruct him or her to wear a mask for the entire time out of isolation. This prevents the spread of airborne microbes.

3. Cover the transport vehicle with a bath blanket if there is a chance of soiling when transporting a client who has a draining wound or diarrhea.

4. Help client to transport vehicle. Cover client with a bath blanket.

5. Tell receiving department what type of isolation client needs and what type of precaution hospital personnel should follow.

6. Remove bath blanket, and handle as contaminated linen when client returns to room.

7. Instruct all hospital personnel to wash their hands before they leave the area.

8. Wipe down transportation vehicle with antimicrobial solution if soiled.
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Using Double Bagging for Isolation

Equipment
2 isolation bags
Items to be removed from room
Gloves

Procedure
1. Follow dress protocol for entering isolation room, or, if you are already in the isolation room, continue with step 2.

2. Close isolation bag when it is one-half to three-fourths full. Close bag inside the isolation room.

3. Double-bag for safety if outside of bag is contaminated, if the bag could be easily penetrated, or if contaminated material in the bag is heavy and could break bag.

4. Set-up a new bag for continued use inside room. Bag is usually red with the word “Biohazard” written on outside of bag.

5. Place bag from inside room in to a bag held open by a second health care worker outside room if double bagging is required. Second health care worker makes a cuff with the top of the bag and places hands under cuff. This prevents hands from becoming contaminated.

6. Place bag in to second bag with out contaminating outside of bag. Secure top of bag by typing a knot in top of bag.

7. Take bag to designated area where biohazard material is collected; usually “dirty” utility room.

8. Remove gloves and wash hands

N.B. Out side of base is contaminated
Base could easily be penetrated
Contaminated material is heavy and could break bas.
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Removing Items from Isolation Room

Equipment
- Large red isolation bags
- Specimen container
- Plastic bag with biohazard level
- Laundry bag
- Red plastic container in room
- Cleaning articles

Procedure
1. Place laboratory specimen in plastic bag. Afix biohazard label to plastic bag.

2. Dispose of all sharps in appropriate red plastic container in room.

3. Place all linen in linen bag

4. Place reusable equipment such as procedure trays in plastic bags.

5. Dispose of all garbage in plastic bags

6. Double bag all material from isolation room. Follow procedure for utilizing double-bagging for isolation. All materials removed from an isolation room is potentially contaminate. This will prevent spread of micro organisms.

7. Replace all bags, such as linen bag and garbage, in appropriate container in room.

8. Make client’s room clean as necessary, using germicidal solution.

9. Leave the client’s room today
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Using a Mask

Equipment
Clean mask

Procedure
1. Obtain mask from box

2. Position mask to cover your nose and mouth

3. Bend nose bar so that it conforms over bridges of your nose

4. If you are using a mask with string ties, tie top strings on top of your head to prevent slipping. If you are using a con-shaped mask, tie top strings over your ears.

5. Tie bottom strings around your neck to secure mask over your mouth. There should be no gaps between the mask and your face.

6. Important; change mask every 30 minutes or sooner if it becomes damp as effectiveness is greatly reduced after 30 minutes or if mask is moist.

7. Wash your hands before removing mask.

8. To remove mask, untie lower strings first, or slip elastic band off without touching mask.

9. Discard mask in a trash container

10. Wash your hands
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Donning and Removing Isolation Attire

Equipment
- Gown
- Clean gloves

Procedure
For donning attire
1. Wash and dry hands

2. Take gown from isolation cart or cupboard. Put on a new gown each time you enter an isolation room.

3. Hold gown so that opening is in back when you are wearing the gown.

4. Put gown on by placing one arm at a time through sleeves, put gown-up and over your shoulder

5. Wrap gown around your back, tying strings at your neck.

6. Wrap gown around your waist, making sure your back is completely covered. Tie string around your waist.

7. Done eye shield and/or mask, if indicated. Mask is required if there is a risk of splashing fluids.

8. Don clean gloves and pull gloves over gown wristlets.

For Removing Attire
1. Unite gown waist strings

2. Remove gloves and dispose of then in garbage bag.

3. Next, untie neck strings, bringing them around your shoulders, so that gown is partially off your shoulders.

4. Using your dominant hand and grasping clean part of wristlet, put sleeve wristlet over your non-dominant hand. Use your non-dominant hand to up pull sleeve wristlet over your dominant hand.

5. Grasp outside of gown through sleeves at shoulders. Pull gown down over your arms.

6. Hold both gown shoulders in one hand, carefully draw your other hand out of gown, turning arm of gown inside out. Repeat this procedure with your other arm.

7. Hold gown away from your body. Fold gown up inside out.

8. Discard gown in appropriate place

9. Remove eye shield and/or mask and place in receptacle.

10. Wash your hands.

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Preparing for Isolation

Purpose
To prevent spread of microorganisms
To control infectious diseases

Equipment
Specific equipment depends on isolation precaution system used.
- Soap and running water.
- Isolation cart containing masks, gowns, gloves, plastic bags isolation tape.
- Linen hamper and trash can, when needed.
- Paper towel
- Door card indicating precautions

Procedure
1. Check orders for isolation

2. Obtain isolation cart from central supply, if needed.

3. Check that all necessary equipment to carry out the isolation order is available.

4. Place isolation card on the client’s door.

5. Ensure that linen hamper and trash cans are available, if needed.

6. Explain purpose of isolation to client and family.

7. Instruct family in procedures required.

8. Wash hands with antimicrobial soap* before and after entering isolation room.

* Types of antimicrobial soap or agent depend on infectious agent and client condition.
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Types of isolation

Historically, two primary types of isolation systems were used in health care:
1. Category -specific isolation
2. Disease- specific isolation

Currently these isolation classifications are mostly replaced by standard precaution and transmission based precaution. How ever, still some facilities follow such system.

Category specific isolation, specific categories of isolation (eg. Respiratory, contact, enteric, strict or wound) are identified, using color-coded cards. This form of isolation is based on the client’s diagnosis. The cards are posted outside the client’s room and state that visitors must check with nurses before entering.

Disease:
specific isolation, uses a single all-purpose sign. Nurse selects the items on the card that are appropriate for the specific disease that is causing isolation.
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Isolation

Is defined as separation from others, separation of people with infectious disease or susceptible to acquire disease from others. Isolation technique is a practice that designed to prevent the transmission of communicable diseases.

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Procedures for putting on sterile gloves

Steps:
1. Wash the hands to limit the spread of microorganisms

2. Open the outer glove package, on a clean, dry, flat surface at waist level or higher

3. If there is an inner package, open it in the same way, keeping the sterile gloves on the inside surface with cuffs towards you.

4. Use one hand to grasp the inside upper surface of the glove’s cuff for the opposite hand. Lift the glove up and clear it of the wrapper.

5. Insert the opposite hand in to the glove, placing the thumb and finger in to the proper openings. Pull the gloves in to place, touching only the inside of the glove at cuff. Leave the cuff in place.

6. Slip the fingers of the sterile gloved hand under (inside) the cuff of the remaining glove while keeping the thumb pointed outward.

7. a. Insert the ungloved hand in to the glove
   b. Pull the second glove on; touching only then outside of the sterile glove with the other sterile gloved hand        and keeping the fingers inside the cuff.
   c. Adjust gloves and snap cuffs in to place. Avoid touching the inside glove and wrist area

8. Keep the sterile gloved hands above waist level. Make sure not to touch the cloths. Keep hands folded when not performing a procedure. Both actions help to prevent accidental contamination.
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Items to be use to maintain sterility technique

Hair covering:
In sterile environments a cap or hood is worn to cover the hair. Remember that no hair can show. If the hair is long, a special type of hood will be worn.

 Surgical Mask
In strict sterile situations such as in operation room (OR) or with protective isolation, the mask covers the mouth and nose. The purpose of mask is to form a barrier to stop the transmission of pathogens. In the OR or during other sterile procedure, the mask prevents harmful microorganisms in your respiratory tract from
spreading to the client. When the client has an infection, the mask protects you from his/ her pathogens.

 Sterile gown
Sterile gown is commonly worn in the OR, with protective isolation and some times in the delivery room. The hands touch only the part of sterile gown that will touch the body after the gown is in place. Thus, touch only the inside of the gown. Some one else ties the strings. The back of the gown is considered contaminated, even though it was sterile when put on. Any part of the gown below waist level and above nipple level is also considered contaminated. Be careful when wearing a sterile gown not to touch any thing that is unsterile.

Sterile Gloves
For some procedures sterile gloves are worn. Remember that once gloves are put on, touching any thing unsterile contaminates them. Therefore, make all preparations before putting on gloves.


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