Admitting the adult patient
- Speak slowly and clearly, greet the patient by his proper name, and introduce yourself and any staff present.
- Compare the name and number on the patient's identification bracelet with that listed on the admission form. Verify the name and its spelling with the patient. Notify the admission office of any corrections.
- Quickly review the admission form and the physician's orders. Note the reason for admission, any restrictions on activity or diet, and any orders for diagnostic tests requiring specimen collection.
- Escort the patient to his room and, if he isn't in great distress, introduce him to his roommate. Then wash your hands, and help him change into a gown or pajamas; if the patient is sharing a room, provide privacy. Itemize all valuables, clothing, and prostheses on the nursing assessment form or in your notes if your facility doesn't use such a form. Encourage the patient to store valuables or money in the safe or, preferably, to send them home along with any medications he may have brought with him. Show the ambulatory patient where the bathroom and closets are located.
- Take and record the patient's vital signs, and collect specimens if ordered. Measure his height and weight if possible. If he can't stand, use a chair or bed scale and ask him his height. Knowing the patient's height and weight is important for planning treatment and diet and for calculating medication and anesthetic dosages.
- Show the patient how to use the equipment in his room. Be sure to include the call system, bed controls, TV controls, telephone, and lights.
- Explain the routine at your health care facility. Mention when to expect meals, vital sign checks, and medications. Review visiting hours and any restrictions.
- Take a complete patient history. Include all previous hospitalizations, illnesses, and surgeries; current drug therapy; and food or drug allergies. Ask the patient to tell you why he came to the facility. Record the answers (in the patient's own words) as the chief complaint. Follow up with a physical assessment, emphasizing complaints. Record any wounds, marks, bruises, or discoloration on the nursing assessment form.
- After assessing the patient, inform him of any tests that have been ordered and when they're scheduled. Describe what he should expect.
