Learning Objectives
By the end of this section, you will be able to:
- Identify different types of patient admissions
- Describe nursing preparation in the admission process
- Recognize how to establish an effective nurse–patient relationship during the admission process
There are many situations that require admission to a healthcare facility. These situations can range from a calm and planned procedure to a traumatic and life-threatening emergency. Nurses play a vital role as the initial point of entry into the healthcare system because they are responsible for the initial assessment, evaluation, and documentation of a patient’s healthcare status, needs, and concerns. The information gained through the admission process sets the stage for the patient’s course of care. It is the role of the admitting nurse to use clinical judgment skills and strong communication techniques to obtain necessary information about the patient and their condition (Figure 8.2). Therefore, it is crucial that the nurse conducting the admission is organized and thorough.
Unfolding Case Study
Unfolding Case Study #2: Part 1
A 65-year-old patient presents to the emergency room with reports of severe chest pain radiating to the left arm and new onset shortness of breath. Patient appears pale, diaphoretic, and visibly anxious.
| Past Medical History | Medical history: Hypertension, type 2 diabetes, coronary artery disease Family history: Mother deceased, father alive with severe dementia; two healthy sons in their early 40s. Social history: Previous divorce, married to current husband, George, for twenty years. Allergies: Latex Current medications:
|
| Flow Chart | 0815: Assessment Blood pressure: 160/100 mm Hg Heart rate: 110 beats/minute Respiratory rate: 24 breaths/minute Temperature: 98.6°F (37°C) Oxygen saturation: 92 percent on room air Pain: 7/10 (chest pain that is “tight”) |
| Provider’s Orders | 0817: New orders Page cardiology team for urgent consult. Administer 325 mg aspirin orally. Conduct 12-lead ECG stat. Administer supplemental oxygen to maintain saturation > 94 percent. Establish IV access and administer IV nitroglycerin per protocol. Conduct cardiology lab panel and HbA1c. Admit patient. |
Types of Admissions
There are different types of admissions to ensure that patients are routed to the proper level of care. It is important that patients go to the right point of entry to the healthcare system—for example, a doctor’s appointment, an urgent care clinic, or an emergency room visit—to receive the best and most efficient medical treatment required. Admission placements can change quickly; for example, an admission to an ambulatory clinic for monitoring during administration of a medication can become emergent if the patient’s vitals become unstable. Situations such as this are not uncommon. With the ongoing evolution of medical care and the growing complexity of patient illnesses and comorbidities, the role of nursing in the admission process is vital to detecting these changes quickly. Nurses must understand the different types of admissions, assess their patients’ situations accurately, and advocate for escalation to a higher level of care when necessary.
Acute Care Admissions
Acute care admissions begin in hospital settings, most often in the emergency department. The acute care is for patients who require inpatient monitoring and medical care under professionally trained healthcare providers. Their medical situation has been assessed as one that could potentially endanger their life if the problem is left unaddressed (Table 8.1). Some examples include difficulty breathing, chest pain, a fever over 103°F (39.4°C) that is unrelieved by over-the-counter medications, uncontrolled bleeding, or an injury that resulted in a loss of consciousness. Symptoms that are less likely to require an acute care admission include chronic headaches, a laceration requiring stitches, a severe cough, or abdominal pain with vomiting. In many cases, however, symptoms such as these may also warrant an acute care admission; many other elements such as the patient’s medical history, current medications, and vital signs all factor into an acute care evaluation.
| Mild Symptoms (Nonacute) | Severe Symptoms (Acute) |
|---|---|
| Hives (red, swollen, itchy areas on the skin) Skin rash (persistent, dry, itchy skin) Redness of the skin or around the eyes Itchy mouth or ears Diarrhea Stomach pain Nasal congestion or sneezing Slight, dry cough Odd taste in mouth |
Loss of consciousness Shortness of breath or wheezing Swelling of the lips, tongue, and/or throat Trouble swallowing Bluish discoloration of the skin Drop in blood pressure Chest pain Weak pulse |
Emergency department nurses that assess patients for acute care admission employ a prioritization system called triage. When a nurse evaluates patients according to the severity of their symptoms and ensures that those with the most serious and potentially life-threatening symptoms are seen first it is called triage. If a nurse has an asthmatic patient with mild wheezing but stable vitals and a patient with mild chest pain and very unstable vitals, the nurse will see the patient with the chest pain first. The admission process also involves additional nursing responsibilities including completing an admission history, performing a physical assessment, completing a medication reconciliation, developing the care plan, and documenting a belonging inventory.
Patient Conversations
Triage in the Emergency Department: Who Is the Priority?
Scenario: It is a busy night in the Emergency Department (ED) and Jacqui is the triage nurse. Two patients come in, one after the other, and are directed to the waiting area near security. One patient is wheezing and holding an inhaler. The other is pale and sweaty and looks distressed. Jacqui approaches the wheezing patient.
Nurse: Hi there. My name is Jacqui and I’m the nurse that is here to assess you. What is your name? What brings you in tonight?
Patient 1: My name is Leah, and I can’t breathe. I have asthma and my inhaler isn’t working. I need help now.
Nurse: It’s okay, Leah, you are in the right place, try to remain calm. I’m going to put this monitoring equipment on you, and it is going to measure your heart rate, blood pressure, and level of oxygen. While the machine is doing this, I’m going to talk to this other patient, and I’ll be right back.
[Then nurse brings a second set of monitoring equipment over and approaches the second patient.]
Nurse: Hi, my name is Jacqui and I’m your nurse right now. Are you feeling okay? You look pale; are you in pain?
[While introducing herself, the nurse places the monitoring equipment on the patient.]
Patient 2: I don’t know how I feel, my chest aches and I’m sweaty. I feel like something is very wrong and I’m scared so I came here.
Nurse: What is your name? On a scale of 1 to 10, how badly does your chest hurt? 1 is no pain at all, and 10 is the worst pain you’ve ever been in.
Patient 2: My name is Paul, and my pain is like a 7 or an 8. My chest aches a lot and my heart feels funny and I . . . I just don’t feel good at all.
[The nurse looks at Paul’s vitals and sees he is severely hypertensive (186/108), tachycardic (143), and his oxygen saturation is 86 percent on room air. She glances at Leah’s vitals and sees her blood pressure (132/90) and heart rate (118) are slightly elevated, and her oxygen saturation is 93 percent on room air. Jacqui knows Paul’s symptoms are more serious, and immediately calls for assistance on the hospital phone. Two nurses come into the ED; one is pushing a wheelchair.]
Nurse: Paul, I’m glad you came in. We need to take you into the ED immediately for testing and further monitoring. We will take you in this wheelchair to your room, and the doctor will be in shortly.
[The nurse looks over at Leah.]
Nurse: Hey Leah, I will be right back. This nurse will be keeping an eye on you, and someone will come talk to you soon, okay?
[The nurse helps Paul into the wheelchair and escorts him back.]
Scenario follow-up: Paul is exhibiting the classic signs of a potential myocardial infarction, or heart attack. His vitals are not normal and are unstable enough to quickly decline into a life-threatening emergency. Leah’s symptoms are also not normal and need to be addressed, but at this time Paul’s symptoms have the greater potential to decline into an emergency. Jacqui triages her patients and prioritizes Paul to be seen before Leah.
Observational versus Inpatient Admissions
Observational admissions are typically one- or two-night stays where the patient needs to be closely monitored by a professional for a limited amount of time. Situations for observational admission could include vital signs monitoring during administration of a medication that can have severe side effects (such as chemotherapy) or potential for an allergic reaction (such as intravenous immunoglobulins), monitoring after setting a broken bone, monitoring bleeding from a severe laceration that has been sutured, or monitoring after a procedure where the patient was sedated. Sometimes patients will be kept in observation awaiting diagnostic test results, such as computed tomography (CT) or magnetic resonance imaging (MRI) scans.
Inpatient admissions are for problems that require more than just observation. Examples may include abdominal pain of unknown origin with concurrent changes in vital signs, or intravenous antibiotic administration for a serious bacterial infection. These patients have the potential to decline to a life-threatening level if not monitored by a healthcare professional.
Unplanned Admissions
Many admissions to the hospital are unplanned and are usually an emergency, such as a motor vehicle accident, trauma, or a collapse in the field due to a myocardial infarction (heart attack). Strokes are unplanned admissions that require rapid assessment and intervention; many hospitals have a stroke protocol that streamlines their admission into the system and often dictates what treatments must begin immediately (Figure 8.3).
Exacerbation of chronic conditions such as asthma or heart failure can also result in an unplanned admission. A patient may be at a clinic for a routine appointment but on assessment their vitals are found to be unstable, at which time the clinic staff will call an ambulance or 911. Generally, unplanned admissions are routed through the ED of a hospital. Sometimes unplanned admissions may be transferred from other healthcare facilities, such as a rehab facility or nursing home, directly to an inpatient unit. Admitting an unplanned patient requires rapid assessment and action on the part of the entire healthcare team.
Planned Admissions
Of course, not all entries into the hospital system are emergent. One example of a planned admission is childbirth, which includes a mother in labor, a scheduled cesarean section, or an induction. Many planned admissions are prearranged surgeries, such as hip and knee replacements (arthroplasties). A patient may work with their cardiologist and cardiac surgeon to receive a planned coronary artery bypass graft (CABG) or to have a stent placed to relieve vessel blockage. These surgeries are planned because they are nonurgent at the time but can become life-threatening in the future. Sometimes patients can even be sent as an admission direct from a doctor’s appointment because their provider deemed their admission necessary, such as a patient with heart failure who is fluid overloaded and needs IV diuretic therapy. Because these admissions are planned, the patient’s entry into the system is generally organized and structured.
Thirty-Day Readmissions
Admissions to the hospital that happen within thirty days of a prior admission are monitored by the Centers for Medicare and Medicaid Services (CMS). Only certain conditions are monitored under this thirty-day rule and include heart failure, recent CABG surgery, knee/hip surgery, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease (COPD). This thirty-day measure was started to ensure that patients with these conditions were not being readmitted due to careless or poorly administered care.
Hospital Readmissions Reduction Program (HRRP)
By monitoring readmissions through the Hospital Readmissions Reduction Program (HRRP) and giving hospitals financial incentives to prevent readmissions for these conditions, only patients who genuinely require further hospitalization are readmitted, thus improving the overall quality of care (Centers for Medicare and Medicaid [CMS], 2023a). HRRP, a program run by CMS, manages hospital reimbursements based on the number of readmissions reported. Hospitals are reviewed according to their performance on these metrics and reimbursement is determined accordingly. If a facility has high readmission rates for patients with conditions monitored under this program, then CMS may not reimburse the hospital for care provided. Linking reimbursements to readmission rates encourages healthcare facilities to be thorough and efficient when admitting and treating their patients and planning their discharge care.
Hospital Value-Based Purchasing (VBP) Programs
Similar to HRRP, hospital value-based purchasing (VBP) programs seek to reduce readmissions and improve patient care through financial incentives at the hospital. VBP functions by basing Medicare payments on the quality of the care provided instead of the quantity (CMS, 2023b).
VBP in hospitals begins with their Inpatient Quality Reporting (IQR) measures. To qualify for VBP, hospitals must submit data to CMS that show they are adhering to the measures required to keep patients safe. Each measure is scored, weighted, and then generated as a Total Performance Score (TPS). These scores are then used by CMS to determine payment adjustments for that hospital. The hospital receives the payment amount, and the cycle of incentivized VBP begins again (Figure 8.4).
Ambulatory Care Admissions
The ambulatory care is care given in outpatient settings, which includes doctor’s offices, clinics, and outpatient surgery centers. Nurses admitting patients in the ambulatory setting generally obtain a set of vitals and conduct a short assessment. If there are no complications, the patient goes home after the visit or procedure is completed. Examples of outpatient surgery include a tumor biopsy, laser eye surgery, or cataract surgery. Sometimes patients need to be admitted from these settings to the acute care setting, perhaps for a complication related to the surgical procedure or for an exacerbation of a chronic problem during the procedure, such as asthma, diabetes, heart failure, or hypertension. Admissions from these settings are often serious or emergent, and it is important to ensure that information to the admitting nurse is conveyed clearly and all details are given. Reports that are organized and structured help ensure the patient’s safe transition to a higher level of care.
Link to Learning
The Agency for Healthcare Research and Quality (AHRQ) has a toolkit for ambulatory settings to ensure there are no gaps in patient care during this transition. The toolkit includes a rationale, a short step-by-step guide to implement these tools, an assessment template, a PowerPoint presentation for healthcare team member training, and a checklist for patients to empower themselves when receiving care in an ambulatory setting (Agency for Healthcare Research and Quality, 2017b). These tools are comprehensive enough to offer a more consistent and standardized flow for patient safety in ambulatory care while still being customizable for a facility’s individual needs.
National Patient Safety Goals for Ambulatory Care
The Agency for Healthcare Research and Quality (AHRQ) has noted that efforts to maintain patient safety have mainly been focused on acute care and inpatient settings, and that ambulatory settings provide “unique” challenges to patient safety (Agency for Healthcare Research and Quality, 2019). The Joint Commission (TJC), a United States healthcare regulatory nonprofit, ensures continuous quality improvement and excellence in patient care. TJC partnered with AHRQ to create national patient safety goals for ambulatory care (Table 8.2). These standards ensure patient safety when transitioning from ambulatory to acute care (TJC, 2023).
| Goal | Guidelines to Goal |
|---|---|
| Identify patients correctly. | Use at least two ways to identify patients, ideally name and date of birth. |
| Use medicines safely. | Label all medications without a label before a procedure. Be cautious with patients on blood thinners (such as heparin or warfarin). Reconcile medications as best as possible with the patient and communicate information clearly and completely. Ensure the patient is educated on their medications |
| Prevent infection. | Use guidelines from the Centers for Disease Control and Prevention (CDC) for handwashing. |
| Prevent mistakes in surgery. | Ensure correct surgery is being done on the correct patient and at the correct place on the patient’s body. Mark the correct place where the surgery is to be done. Pause before the surgery and do a final check to ensure no mistakes are being made. |
These goals are very similar to those that have been and are still used in inpatient and acute care settings. The application of these goals to an ambulatory care setting raises the standards of patient care throughout healthcare facilities nationwide, ensuring that patient safety is at the forefront of all patient care at all points of admission into the system.
Link to Learning
The National Patient Safety Goals for hospital admissions are described on The Joint Commission’s website.
Long-Term Care Admissions
Patients with chronic health problems who no longer require inpatient acute care but cannot be managed at home are often admitted to facilities for continuing care. A long-term acute care (LTAC) facility is very similar to acute care facilities in that it will take on acute patient tasks such as ventilator weaning, wound care, and/or intravenous (IV) antibiotics. The difference between LTAC and acute care facilities is that an LTAC facility is approved for longer periods of stay. LTAC facilities care for patients with acute care problems that require long-term care; examples of these admissions may include tracheostomy care, ventilator weaning, feeding tube maintenance, or patients with long-term wound care needs. A long-term care (LTC) facility and a nursing home, on the other hand, are not acute care facilities. Rather, they are permanent residences that provide medical assistance and care to their residents, just not at the acute care level. The main difference between an LTC and an LTAC facility is the length of stay. An LTC facility is approved for a longer admission time; LTC facilities are licensed for patients to stay for approximately thirty to ninety days compared to an LTAC facility that has a maximum reimbursable stay of twelve days or less. As with any other medical admission, it is important that patients are routed to the appropriate facility for their level of care. Other types of long-term admissions include home health care and assisted living, each with individual state-mandated guidelines.
Federal Guidelines for Nursing Home Admissions
CMS and the U.S. Department of Health and Human Services (HHS) offer guidelines for admission to nursing homes and other types of LTC facilities. These guidelines help prevent unnecessary admissions to nursing homes and ensure that people who can be cared for safely in their own home can remain there. To this end, Medicare has federal guidelines that Medicare-certified nursing facilities must use when assessing patients for admission. A form (generally state-specific) outlines a Level 1 and Level 2 Preadmission Screening and Resident Review (PASRR) assessment. The overall goal of these guidelines is to ensure patient safety while still meeting patients’ personal goals and needs.
Link to Learning
The CMS website provides guidelines and documents about nursing home admissions and operations. There are also links to guidelines governing various other types of LTC facilities.
Nursing Preparation in the Admission Process
What an admitting nurse assesses and learns upon admission is important to all members of the healthcare team in planning the patient’s course of treatment. It is also an opportunity to develop a rapport with the patient and their family. There is a lot to learn about a patient in the first stages of caring for them, so it is important to be organized in the admission process.
Many hospitals have an admission template in the electronic health record (EHR), which guides the questions and assessments needed when admitting a patient. During the initial stages of admission, the nurse may get a report from an emergency medical technician (EMT) or a nurse from the ambulatory facility. It is important to be prepared and have an organized set of questions that cover all the necessary information. Using a report sheet can be helpful; some hospitals have them predesigned (Figure 8.5).
Regulatory Guidelines for Patient Admission
Guidelines from CMS exist regarding hospital inpatient admissions. CMS guidelines tie back into reimbursement for service. TJC and other regulatory agencies, such as HHS and the American Hospital Association (AHA), establish strict standards and guidelines for healthcare facilities and institutions. These organizations, along with CMS, are in place for patient safety, and hospitals found in violation can be severely fined. The TJC standard is that each patient’s need for admission must be assessed by a registered nurse (RN). These guidelines ensure that patients are admitted to inpatient care under a commonly held standard of necessity. To understand the clinical decisions nurses make on important assessments, refer to a learning framework such as the Clinical Judgment Measurement Model (CJMM).
Link to Learning
The National Council of State Boards of Nursing (NCSBN) website discusses the Clinical Judgment Measurement Model (CJMM) framework for nursing students to learn clinical decision-making. Utilizing this framework provides measurable decision points for making reasoned clinical judgments. It takes what often seems like a subjective, experiential, and instinctive process and turns it into a defined learning format.
Preparing the Room
A key part of a successful admission is ensuring the room is stocked with all the necessary equipment. Ensure basic supplies are available—linens, pillows, a hospital bed. Check that vital sign and monitoring equipment are functioning and that all connecting cords and sensors are present. Ensure the call light is working. Have basic toiletries available for the patient. Depending on the patient’s level of mobility, the nurse may want to have a walker, urinal, or bedside commode present.
Preparing a room for an admission also depends on the condition of the patient being received, such as critical versus stable. Consider a patient in heart failure being admitted from their doctor’s office for shortness of breath. Because they are having difficulty breathing, ensure an oxygen hookup and tubing are available. If it seems likely that IV medications are going to be required, have IV pumps and tubing available, as well supplies to place additional IVs if necessary.
Also, consider the patient’s mental status. If they are confused or at risk of a fall, place them in a room close to the nurse’s station, apply bed alarms, and/or place nonskid pads on the floor. Preparing for an admission may also involve delegating, or assigning specific jobs or tasks to coworkers, especially if the patient is an acute admission.
Specialty Equipment
Sometimes special equipment is required for an admission; when receiving a report on a patient, it is important to ask if the patient has any specific needs. In a critical care unit, the nurse may need a ventilator or specialized oxygen equipment such as a high-flow nasal cannula (Figure 8.6). If the patient has specialized lines, such as arterial lines, a Swan-Ganz catheter, or an intra-aortic balloon pump (IABP), ensure the equipment they are coming with is compatible with the admitting hospital’s equipment.
It is good nursing practice to have the proper supplies and tools to convert the patient to the hospital’s approved equipment available or have a backup on hand in case the equipment malfunctions. Does the patient need a bariatric bed? Even if one is not available until after the patient arrives, ordering one before the patient arrives reduces the time the patient has to be in the wrong-sized bed and minimizes the risk of skin injuries and breakdown.
Personal Preparation for Increased Workload
Admitting a patient on top of caring for current patients can be a difficult process for new nurses. Experience is the best teacher, and being well organized is essential. Think ahead:
- When is the patient arriving?
- Is the room set up with the necessary equipment?
- Is any special equipment necessary?
- Will you need additional help to move the patient?
- Am I caught up on tasks for my other patients?
- Will the family be accompanying the patient?
Review the tasks that must be done for current patients to ensure they are comfortable and that their needs are met before the admission arrives. Administer scheduled medications, if possible. Check that IV drips are sufficiently full. Obtain help from colleagues to monitor current patients while handling a new admission. Review what admission tasks can be delegated (such as weighing or bathing an admission) and notify the appropriate unit staff (such as the nurse’s aide or patient care technician).
Preparing for Admissions Report
The nurse should have an organized and standardized report sheet prepared ahead of receiving report that can be clearly and quickly referenced for information about the patient. This also helps to ensure all relevant information is obtained from the nurse giving the report. Missing information can have negative repercussions on the unit and/or hospital, such as an unreported skin wound or decubitus ulcer. Skin issues such as these that are present on admission are treated differently with CMS from ones that develop while the patient is on the unit, and they can result in increased costs, decreased reimbursement, and/or the healthcare facility assuming liability for the injury.
It is also important to think through what the relevant questions and concerns are for the admission: Why is the patient being admitted? What medical conditions does the patient have, and what information does the nurse need about them? Asking the right questions during the report ensures the patient is safe for transport and that the nurse is well prepared for the admission. Standardized reports, such as an SBAR, are discussed in Chapter 2 Communication.
Informed and Voluntary Consent
Patients, their chosen decision-maker, or power of attorney (POA), must consent to any procedures done while admitted to the hospital. A POA is a legally binding agreement that documents that the patient is giving the authority to manage personal matters (such as medical care, financial business, or property) to another person. When giving consent, the patient acknowledges what procedure they are going to have, what the benefit is, and what the potential risks and side effects are. This is informed consent, meaning that the patient is aware of the risks and benefits of the procedure and has accepted those risks and benefits. This includes major procedures such as surgery and minor ones such as invasive line placement or blood product administration. The voluntary consent, on the other hand, is simply agreeing to treatment. The distinction between the two is a fine one, but very important.
Generally, it is the role of the doctor, resident, or midlevel advanced practice provider (APP) to obtain consent, though nurses are often asked to witness consent being given. It is not the nurse’s role to obtain consent, but the nurse can alert the doctor and ensure consent is obtained while the patient is still conscious, or while the patient’s decision-maker or POA is present at bedside. Nurses must ensure that the patient and family understand what was discussed during the consent process. They can also ensure a qualified translator is present if the patient and the doctor do not speak the same language.
Preparing Interprofessional Team Members of Patient Admission
It is good practice, especially if the admission is emergent, to alert all members of the interprofessional team of a patient’s arrival. Departments such as the cardiac catheterization lab, radiology, and/or perfusion may need to be notified. If the admission is an emergency, such as a stroke, the facility will have protocols in place to alert the necessary staff—hematology, neurosurgery, and radiology, to name a few. Depending on the patient’s situation, other members of the interprofessional team may include nutritionists, physical therapists (PTs), occupational therapists (OTs), social workers, and discharge planners. Sometimes spiritual counselors, chaplains, or other therapists are involved as well. Ensure the unit clerk knows an admission is coming so they can enter the patient into the system, and make sure the charge nurse is updated. Pharmacy may also be alerted to an incoming admission, often if the patient has had a stroke and/or is critical enough to require rapid availability and administration of certain medications. It often falls to the nurse to alert all necessary team members to an admission, so be aware of the facility’s resources and how to find them before the admission arrives.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Teamwork and Collaboration
Definition: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.
Skill: The nurse will:
- Demonstrate awareness of your own strengths and limitations as a team member, and communicate effectively within your own scope of practice.
- Clarify roles and accountabilities to ensure patient safety and an effective, efficient admission.
Knowledge: The nurse will:
- Demonstrate your own strengths, limitations, value, and knowledge when functioning as a team member.
- Describe scope, practice, and role of team members.
Attitude: The nurse will:
- Acknowledge your own potential to contribute as a functioning member of the team.
- Appreciate the importance of collaboration among team members.
Preparing for Optimal Patient Safety
Knowing a patient’s level of mobility and function at home helps the nurse keep a patient safe while in the hospital. This is a key part of report and the admission process. If the patient is older, has a history of falling, and/or has impaired mobility and requires a walker or cane, ensure the patient understands they must call for assistance every time they need to get up, and reinforce this often if necessary. If the patient is confused due to dementia, Alzheimer disease, or sundowning (a phenomenon where adults [often older] become confused when the sun goes down [Canevelli et al., 2016]), consider utilizing a bed or chair alarm. These devices monitor the pressure of the patient’s weight on its surface, and if that weight lessens or disappears, an alarm goes off. If the patient becomes increasingly confused, reorient them kindly and frequently.
Another good practice for patient safety is to review all orders placed by the provider for the patient’s care. Is the patient to go for a procedure early in the morning and therefore has orders to not eat or drink anything? Have parameters for their vital signs been placed, indicating when to alert the provider if the patient’s vitals cross them? Knowing these orders guides the care the nurse provides for the patient. For instance, the nurse may have to teach the patient about the importance of not eating or drinking before a procedure.
Once the patient is settled and aware of the current plan, ensure everything the patient needs is within reach before leaving the room: set up their bedside table with water and/or snacks if allowed, any personal equipment such as glasses, hearing aids, or a cup for dentures if necessary. Ask if they have a cell phone and want it near them, or if they would like it charged. Ensure the call light is within reach and that the patient knows how to use it. If available, place mats or padding on the floor. Ensure the room is clean and organized, and no excessive cords or wires are on the floor as potential hazards.
If the patient cannot speak or cannot communicate in words or sentences, some hospitals have communication boards with pictures and phrases to help patients who cannot articulate their needs (Figure 8.7). These boards generally are flat, plastic, or laminated sheets with pictures on them. Some have words, others can simply be facial expressions or pictures of things (a phone, chair, or toilet, for example). The patient can point to the picture or word-and-picture that expresses what they want, and the nurse will be able to respond accordingly.
Preparing to Establish an Effective Nurse–Patient Relationship
Admitting a patient to the hospital is the nurse’s best opportunity to begin a positive and effective nurse–patient relationship. Verbal and nonverbal communication is key to this process. The verbal communication involves using words and language to convey meaning, whereas nonverbal communication involves reading the meaning behind gestures and movement. This often sets the tone for the patient’s interactions going forward at the hospital. Research shows the nurse–patient relationship can reduce the length of hospital stays, improve patient satisfaction, and increase the quality of nursing and medical care (Molina-Mula, 2020). Be professional, friendly, and culturally respectful when introducing yourself. Establishing trust and respect between the patient and nurse encourages communication between all parties. Engage active listening: make eye contact, be present in the conversation, and let the patient speak without interrupting them. Show the patient that staff are available to help and that the patient is an important part of the care team. Often, nurses are the main communicator between the patient and the physicians and specialty teams. The nurse’s ability to communicate effectively and compassionately with their patient is a key to facilitating clear and open communication between the patient and all members of the healthcare team.
Cultural Context
Cultural Considerations When Admitting New Patients
Living in a diverse society, nurses need to be considerate of patients’ backgrounds and cultural norms. Not every culture greets people with a handshake, while other cultures find it rude if you don’t offer your hand. Some cultures find direct eye contact rude. In some Asian cultures, there is a strong sense of age- and gender-centered hierarchy. “Elders” are not to be contradicted, and while a patient may agree to a medication, they may have to ask their spouse or eldest male family member for approval.
Some cultures and religions are very uncomfortable with casual physical touch; it is good to talk through an assessment with patients and ask if something is okay to do. For example: “Mrs. X, I need to listen to your heart. To do so I need to place this stethoscope under your shirt. Is that okay?”
Some religions and religious sects will refuse to have nurses or doctors of the opposite sex. When that happens, do not be offended; let the patient know you understand and will try to see if their requests can be accommodated.
In general, when dealing with diverse populations, be professional and empathetic. Do not make assumptions. Be observant. Mistakes are likely to be made, but the important thing is to be humble, apologize if necessary, and try again. Approach interactions with people that are different from you with intentionality, respect, and kindness, and you will continue to learn and do your best to bridge these divides.
Reduce Patient Anxiety
Being admitted to the hospital can be a very frightening experience for the patient as well as their family members. This may be the first time the patient has ever been admitted, or they may be sicker than they have ever been. This understandably can make patients anxious, and this anxiety can manifest in many ways. Anxiety, panic, feelings of helplessness, and loss of control can result in the patient showing maladaptive health behaviors (Otto, 2018). It is important to identify these behaviors and reactions for what they are and to provide the reassurance the patient needs. Give the patient choices as much as possible, staying within the limits of proper patient care and maintaining their safety. Regaining a small sense of control by being able to make a choice as simple as when they want to take their nighttime sleeping pill can help ease patient anxiety and increase their comfort. Ultimately, clear communication is a key factor in relieving patient anxiety; assessing a patient’s anxiety level upon admission enables the nurse and healthcare team to develop a plan to address it sooner rather than later (Baldwin, 2019).
Patient Conversations
Addressing Patient Anxiety with Intuition and Therapeutic Communication
Scenario: Jamal Brown is a 58-year-old male who has been admitted to acute care from his doctor’s office; he has heart failure, shortness of breath, and oxygen saturations in the mid-80s, and he is on 2 L of oxygen via nasal cannula. Until his diagnosis of heart failure, Jamal was very active and independent. He does not like feeling vulnerable or helpless. He has just been wheeled in by emergency medical services (EMS) and transferred to the bed. Anh is his admitting nurse.
Nurse: Hi, Mr. Brown. My name is Anh, and I will be your nurse tonight. I’ve got a few questions to ask you. Do you prefer to be called Mr. Brown or Jamal?
Patient: Jamal is fine. I really need help though. Is the doctor coming in soon? Where is my daughter? Is she coming?
Nurse: Yes, the doctor will be in shortly. Your daughter called and she is on her way. Are you in any pain right now?
Patient: [frustrated] Didn’t my doctor tell you when they called to say I was coming? I’m not in pain, I can’t breathe. How old are you? Do you even know what you are doing?
Nurse: Yes, they told me. I just wanted to know if anything else was bothering you.
Patient: [frustrated] That’s stupid, you already know why I’m here. I thought this was a good hospital. I want a nurse who knows what side is up. Go away.
Nurse: [patiently] I understand all of this is really scary, Jamal. I want to reassure you that you’re in a safe place and we are all here to help you. Please just give me a moment to ask a couple of questions until the doctor comes in.
Patient: [angrily] No! I feel awful and you’re making me feel worse. I want a new nurse when he comes in. Get out.
Nurse: I can step out if you want a minute to yourself. I can see from our monitors though that your blood pressure is a bit high, your heart rate is fast, and your oxygen is just a little over 90 percent, which is a bit low and could be why you feel short of breath. I’m going to increase the oxygen flow in your nasal cannula to 4 L. Does that feel any better?
Patient: [breathing a bit more slowly] Yes, that does feel a bit better. I don’t know why my breathing is so bad when it’s my heart that is sick. Why is this happening?
Nurse: When you have heart failure, you can accumulate a lot of fluid in your body because your heart can’t pump as well as it should, and that can make it harder for you to breathe. Plus, coming to the hospital is scary, and that doesn’t help. We will help you through this. Do you want to hold off on the rest of the admission questions until your daughter gets here?
Patient: Yes, please, if that’s okay. She always knows the right things to say.
Nurse: That’s not a problem. Here are your belongings along with your cell phone. I’ll step out and take care of a couple things; just know that you’re on our hospital monitors now [points at screen] and we will be watching and making sure you’re okay. Call me if you need anything, otherwise I’ll be back to check on you in ten minutes.
Patient: [grateful] Thank you, Anh. I’m sorry I yelled at you; I’m really scared. I appreciate you being so understanding.
Nurse: It’s all right, Jamal. Here’s your call light, I will be back soon.
Scenario follow-up: Anh could sense Jamal’s anxiety both in his verbal and nonverbal communication (tone of voice). Anh understands that while the admission process is important, it is okay to give the patient some space to cope with what is happening. The patient is still safe because he is hooked up to the telemetry monitoring so Anh can watch his vitals while giving him some time. Also, Anh knows that waiting for his daughter to arrive is another way to ease his anxiety; once she is at the hospital, Anh can try the admission assessment again.
Orientation of Routines in Care
Even if the patient has been in the hospital before, it is always good practice to explain the care routines that happen on the unit. These routines may differ greatly between units in the same facility—acute care units may take vitals every four to eight hours, whereas in the ICU vitals are measured every hour. Assessment times can vary as well, from every hour to as long as every eight hours. Some assessments must happen hourly, such as those for patients who have had a stroke or have neurological disorders, or every two hours, such as peripheral vascular pulse checks. Assessments can also vary in the degree of involvement: Is there an automatic blood pressure cuff or does the nurse have to manually take the blood pressure? Is the patient asked questions they must answer, or can they be asleep? Routine tests and procedures also can vary in their necessity or frequency. When are labs drawn? Are x-rays daily or as needed? Daily hygiene and cleanliness should also be discussed; patients must be bathed or can receive assistance with bathing daily.
Another step in orienting the patient and their loved ones to the healthcare facility is informing them about visiting hours and policies regarding who can come and how many at a time. Policies can differ from one unit to another in the same facility; visiting hours on an acute care unit are very different from those on a critical care unit where the patients are sicker and require closer monitoring. Ensuring everyone is clear on the policies of the unit helps prevent potential misunderstandings that can increase patient and family anxiety. Other details that are helpful to share with the family of patients in the hospital are when meals are delivered, what dining and amenity options are available, or how to get information about the patient’s status.
Encouraging Involvement in Decision-Making
Health care is a team-oriented process, and the patient is perhaps the most important part of that team. Nothing is done without the approval of the patient or their designated decision-maker; thus, it is important that patients and their family be engaged with healthcare providers. Decisions regarding the care plan should be clearly discussed with the patient, and the patient should feel empowered to ask questions and express their concerns. It is the role and responsibility of the entire healthcare team (doctors, nurses, therapists, technicians) to ensure the patient can make the most educated decision they can.
Initiation of Discharge Goals
One of the most important parts of the admission process is discharge planning, which begins when the patient is admitted. Consider all details, such as the examples listed here, that can be observed upon admission and can be discussed among the healthcare team as the patient’s hospital stay progresses.
- Does the patient seem like they understand what their disease process is and what is happening to them? Will this be a problem when they are discharged?
- Do they need more education and what kind?
- What resources are available for follow-up?
- Can they access their medications? Do they understand what their medications are for? Can they afford their medications?
- Does social work or case management need to get involved?
- Will the patient need a home health nurse to check their blood pressure or blood sugar, or do a dressing change?
- Will they need rehabilitation, or physical or occupational therapy?
- Are they safe at home, or are they at risk?
- Are there any noticeable red flags that are concerning, perhaps in what the patient says or one of their family members or caregivers says?
Keep the patient’s whole picture in mind and remember that discharge planning begins upon admission.