Question

You got information from the admitting office that Mr John 45 years old client with complaints of fever and headache wants to get admitted to your unit for observation and treatment. Answer the following questions.

1.Describe your role as an enrolled nurse in admitting Mr John to your unit (in 30-40 words).

2.Enlist twelve(12) pieces of information that you would document in his admission database.

3. What is the role of doctors in care of above client?

4. What is the role of the pharmacist in care of client from admission to discharge?

5.Discharge planning should commence once the client has admitted. Describe the discharge planning process of Mr John (in 30-40 words).

6. Briefly describe the discharge details to be recorded in the client's discharge summary. (in 30-40 words).

Answer 1

1)The role of a nurse in admitting Mr. John are

• Initial patient assessment
• History collection (Past medical and surgical history)
• They should identify treatment palns, safety measures, and foundation to the discharge process
• After initial assessment documentation has to be done for effective quality care
• Informing the duty doctor or the physician assistant has to be informed
• Orientation of the room to be done to get familiar to the environment
• Tying the name bracelet on his hands

2)The 12 pieces necessary to document are

• His personal details (Name ,age ,sex and ID card)
• Diet to be provided
• Follow ISBAR ( Idebtify,Situation,Background,Assessment ,Recommendation)
• Admission assessment
• Shift assessment
• Real time progress note
• End of shift progress notes
• Identifying the plan of care
• His vital signs
• Medication administered
• Plan of care
• Any diagnostic procedure done
• Any allergies

3)The role of the doctor is to assess and prescribe the necessary requirements of dignosing the type of fever as per the dignostic tests and treat the patients. Initially the doctor's aim is is to bring down the fever and headache.

Medication like analgesic, antipyretic helps in doing this

4)The role of the pharmacist is to arrange and deliver the necessary items for this patients till his discharge

5)Mr.John has to be given a brief knowledge about the discharge formality. Information about his ediclaim (Medicare or Medicaid) details as to be furnished for smooth process

• First the doctor has to mention it on the documentation
• The nurse should call the family doctor or primary doctor to get appointment for follow up visits
• Patient should be informed about transportation
• The nurse will review all the discharge details with yopu detailly and make sure you understood it clearly

5)The discharge card should clearly specify the patients diagnosis ,date of admission and discharge,condition of patient during admission and at discharge, Tests performed on him,Medication history, Treatment given during hospital stay and follow up details.