Monitoring Tool for Admission, Transfer and Discharge I. Admission A. Admitting Department (Emergency Room) 1. 2. 3. 4. 5. 6. 7.

Gather information for billing. Initiate medical record. Prepare patients file. Consent forms are signed. Initial orders obtained. Verbal report given to the ward nurse in-charge. Patient is escorted with hand-over report by the ER nurse.

B. Department Ward 1. Prepare room or bed. a. b. c. d. e. f. Provide personal care items Suction if needed Oxygen IV pole Bed in high position if arriving in stretcher Bed in low position if arriving in wheel chair

2. Meet immediate needs. a. Physical b. Emotional 3. Make introduction and orient patient. a. b. c. d. Greet patient Introduce self Explain admission routine Orient patient Location of nurses station Clothes storage Supplies and belongingness Bathroom Bed control TV controls Meal times Safety measures such as bedrails Visiting hours What tests are scheduled

Diet Scheduled surgery time (if applicable) Time for Drs visit Introduce other staffs and roommates.

3. Perform baseline assessment a. Observation and physical examination TPR BP Weight and height Total Assessment

b. Interview and history Medications Allergies Entering complaints and concern

4. Administer initial medications as ordered and record. 5. Take care of personal property. a. Items to be kept at bedside. b. Items to be put in safe or medicine room. c. Items to be sent home 6. Keep records a. All data recorded. b. Special forms for facility completed. II. Transfer 1. Check for orders. 2. Notify appropriate persons. a. b. c. d. Nursing supervisor Admitting office Unit or facility receiving the patient Family members

3. Visit the patient a. Answer any questions about the transfer.

b. Allay anxiety by spending time with patient.

4. Take care of personal property. a. Items kept at bedside. b. Items in safe or medicine room. 5. Complete or duplicate records. a. Complete basic assessment b. Complete or duplicate care plan. 6. If not already arranged, obtain transportation; within hospital, wheelchair or stretcher. 7. Give report a. If transferring to another unit or department in the hospital, accompany patient and give report. b. If transferring to another facility, call and give report by phone III. Discharge 1. Check for orders. 2. Plan for continuing care. a. b. c. d. Referral as needed. Information for new persons involved in care Contacting family or significant others if needed Transportation

3. Teach patient a. b. c. d. e. f. What to expect Medications Treatments Activity Diet Need for continued health supervision

4. Perform final assessment a. Physical status b. Emotional status c. Ability to continue own care

5. Check and return personal property a. Personal items on unit b. Items from safe or medicine room 6. Perform business functions. a. Financial matters b. Obtaining supplies 7. Keep records. a. Discharge note b. Special forms for facility 8. Terminal cleaning. a. Bed uncovered and disinfectant used on time. b. Bedside cabinet check and cleaned. c. Bathroom cleaned (in private room) and disinfectant used and free from bad odors.

Universal Precaution 1. Wear clean latex gloves when contact with the following: Blood sputum urine feces oral/ nasal secretions vomitus

Semen Vaginal secretions Cerebrospinal fluid Synovial fluid Pleural fluid Peritoneal fluid Pericardial fluid Amniotic fluid

2. Wash hands. a. Immediately after contact with body substances containing blood b. Between patients

c. Immediately after gloves are removed. 3. Wear masks and protective eyewear when appropriate. 4. Staff nurse, assistant nurse, ward boy and aya wear appropriate apron as necessary. 5. Ward boy and aya wear household rubber gloves handling soiled linens and garbages. 6. Wear sterile gloves appropriately. 7. Dispose equipment and secretions properly in the following assigned waste disposal with color coding; a. b. c. d. e. f. g. Syringes disposal Needle disposal Ampoules disposal Vials disposal Infectious disposal Food waste disposal Paper/plastic disposal

8. Handle specimens of blood and body fluids appropriately. 9. Handle soiled linens correctly. a. Aya or ward boy hold soiled linen away from uniform or body contact. b. Nursing staffs including, students nurses Aya and ward boy do not shake or throw linen. c. Transport linen contaminated with blood or body in appropriate bags. 10. Observe proper cleaning and sterilization of contaminated articles. a. Segregate clean, semi-critical, and critical items for disinfection, sterilization and autoclaving accordingly. 11. Staff Nurse supervises cleaning contaminated articles and surfaces observing proper washing and use of an appropriate disinfectant.

Documentation Nurse must follow universal medical abbreviations. Nurse must provide separate sheet for patients need hourly monitoring such as vital signs and intake & output per patients conditions or as ordered by the physician.

I. Medications 1. Record accurately according to the policy of the facility. Include: a. b. c. d. e. f. g. Name of the drug Date ordered Route Dosage Frequency/Timing Actual time the drugs given Nurses signature

II. Intravenous Fluids 1. Record IV insertion accurately in the IV flow sheet; a. b. c. d. Actual time the IV was started Type of IVF Additives Time IV was discontinued, include the time and the amount of fluid consumed or absorbed. e. Nurses signature 2. Record IVF on intake and output monitoring sheet. 3. Provide IVF fluid slip at patients IV pole. III. Blood Transfusion 1. Record the following; a. Type and amount of blood products. b. Blood unit identification number. c. Time started and completed.

d. Vital signs before, at 5 and 15 minutes after initiation of infusion, and on completion of transfusion. e. Flow rate f. Pertinent patient responses and clinical observations. 2. Provide Blood Transfusion slip at patients IV pole. 3. Include blood transfusion on intake and output monitoring sheet. IV. NGT Feeding 1. Recording the following on the Intake and Output Monitoring Sheet: a. b. c. d. e. Date and Time Amount of the feeding Type Amount of water Patients response

V. Vital Signs 1. Record the following; a. Routine (e.g. every 4 hours) vital signs recorded in VS graph sheet. b. Provide separate VS monitoring sheet for patients need frequent monitoring considering patients illness or conditions. c. Indicate the route of temperature, pulse and blood pressure as ordered. VI. Intake and Output Monitoring 1. Record urine output (voided freely) and with normal bowel movements on the VS graph sheet. 2. Record intake and output of post operative patients, those who have indwelling catheters or feeding or suctions tubes on the I & O monitoring sheet. 3. Record intake and output of patients who are diabetes, have burns, draining wounds; or are on steroid therapy and receiving diuretics drugs. 4. Record intake and output of patient has cancer or other debilitating disease. 5. Record intake and output of infants, children and elderly patients.

6. Record urine output (catheter) and include bowel movement (patients with gastrointestinal problems e.g., diarrhea) on the intake and output monitoring sheet.

VII. Hand-Over-Report (Change-of shift report or Endorsement) 1. Provide basic information of each patient (e.g., name, room number, bed designation). 2. Provide reason for admission or medical diagnosis (or diagnosis), surgery (date), diagnostic test, and therapies for 24 hours for new patients. 3. Report each patients needs for special support. 4. Report current nursing orders and physicians orders. 5. Provide a summary of newly admitted patients, including diagnosis, general condition, plan of therapy, and significant information about the clients support. 6. Report patients who have been transferred or discharged from the unit. 7. State priorities of care and care that is due after the shift begins. 8. Perform nursing rounds in the assigned ward after hand-over report. Utilization of Resources 1. 2. 3. 4. 5. Keep the equipments or devices clean or instruments sterile as required. Clean, semi-critical, and critical items are kept appropriately. Utilize all official hospital forms appropriately. Utilize antiseptic or antimicrobial solutions appropriately. Bed linens, pillows and pillow cases are kept clean and dry in the appropriate place. 6. Materials and right equipments needed for patients are available in the ward. 7. Report needed or defective materials/equipments in the ward and make follow-up ward on time. Working Environment 1. 2. 3. 4. 5. 6. 7. 8. 9. Logbooks or daily records are kept in the right place. Cabinets and tables are free from dust. Bedside table or cupboard of the patients are free from rust and cleaned. Windows are free from dust and cobwebs. Hanging curtains are cleaned. Walls are cleaned and free from spitting of phan. Ward is free from bad odors. Patients toilets rooms are cleaned and free from odors. Designated waste disposal are available and used accordingly in the ward.

Professional Attributes 1. 2. 3. 4. 5. 6. Supervise other nursing staff in the ward accordingly. Perform independent nursing responsibilities appropriately. Identify patients needs or health problems. Prioritize patients needs or health problems. Report unusual findings to attending physician on time. Report observation and symptoms to the doctor and attending physician and carry-out doctors order on time. 7. Record observations of the patient and procedures used or independent nursing intervention in giving nursing care. 8. Assist attending physician during patients treatment. 9. Perform after care during assisting the attending physician. 10. Collaborate with other health care professionals. 11. Aware of ones own limitations and accept his/her own mistake. 12. Shows confidence. 13. Carry-out duty with honesty. Personal Attributes 1. Observe good personal hygiene. 2. Communicates with patients and family members appropriately. 3. Shows good interpersonal relationships with other staff and health care professionals.

Quality of Nursing 1. Physical f. Patients are physically comfortable and free from pain or are pain and discomfort controlled as much as possible. g. Patients have bathed and supplied with clean linen. h. Patients are comfortably positioned in bed. i. Patients are encouraged to rest and sleep as much as possible. j. Nursing staff help patients to walk, or encourage and help them other activities. k. Patients are generally pleased with meals and service. 2. Psychological a. Patients have confidence in the physician and nurse. b. Patients knew their condition is observed with concern, knowledge, and intelligence by nurses and doctors. c. Patients are confident that personnel are competent.

d. Patients feel safe from accident and infection. e. Patients medicines, treatment and diagnostic tests explained to them by the nurses and physicians. 3. Emotion a. Patients are emotionally at ease. b. Patients are being helped to understand their natural reactions of fear, apprehension, worry, hostility and apathy. c. Patients feel that healthcare personnel are sympathetic, kind, understanding because they are honestly concerned and compassionate. d. Patients socioeconomic status problems understood by the healthcare personnel. e. Patients are encouraged to have family and friends visit them in the hospital. 4. Spiritual a. Patients spiritual requirements are considered. b. Someone of like faith available to minister the spiritual needs of the patients. c. Books and symbols available for the spiritual comfort of the patients. d. Room or space available for meditation or prayer by the patients and their families. 5. Schedule of nursing care a. Does morning care of patients given? And when it begins? b. Are patients awaked early in the morning or allowed to sleep and rest as long as possible? c. Is morning care begun early enough to have patients ready for breakfast? d. Does the nurse visit each patient early in the day to determine his/her needs (physical, mental, emotional, socio-economic, and spiritual) of the day? e. Is nursing care planned to allow time for doctors visit? f. Are meals served at times which will benefit patient care? g. Are baths and linens changes timed to accommodate patients desires as much as possible? Are arrangement made for some baths in the afternoon and evening? h. Are medications, treatments and diagnostic procedures timed and administered at regular intervals (e.g., every three hours, every four hours)? i. Are rests or quite hours planned for patients? j. Are visiting hours specified, or may visitors come to the wards at any time?

k. Are members of the family allowed to stay with the patient all the time if they wish to do so? l. Are afternoon, evening, and nursing procedures and schedules timed to allow the patient the maximum benefit of rest, relaxation and sleep (e.g., lights out at a specified time)?

IV. Intake and Output monitoring