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ADMISSIO
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1991-07-25
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-1990- REVISED FXS/DSD
SPARR CONV.HOSP.
2367 WEST PICO BLVD.
L.A. CA. 90006
LICENSED NURSE
ADMISSION PROCEDURES
ORDERS TO GET WHEN ADMITTING A NEW PATIENT
1. ADMISSION ORDERS SHOULD INCLUDE THE FOLLOWING ITEMS:
2. DATE -TIME- ADMITTED FROM -MAY ADMIT TO SPARR
3. IDENTIFY THE PATIENT:
A-ADMITTING DIAGNOSIS MUST BE OBTAINED FROM THE D.O.N
B-CHECK PHYSICAL APPEARANCE AND CONDITION
C-BODY CHECK: COMPLETE ASSESSMENT
1-CHECKING FOR BRUISES,SKIN RASHES,DECUBITUS,WOUNDS
2-CONTRACTURES,BLIND,DEAF,GLASSES,HEARING AIDE,PACEMAKER
3-DENTURES,FOLEY CATHETER,G-TUBES
4-PROSTHESIS
5-WITH OR WITHOUT OXYGEN
4. ASSESS THE PATIENT:
A. IF THE PATIENT IS AMBULATORY OR NON-AMBULATORY
B. WHEEL CHAIR OR BEDRIDDEN
C. CONFUSE, ALERT, ORIENTED
D. IF THE PATIENT REQUIRES FEEDING ASSISTANCE
E. IF THE PATIENT REQUIRES ADL ASSISTANCE
F. DETERMINE IF DIABETIC PATIENT AND LIST ALLERGY
5.PHYSICIAN'S ORDERS:
A-ADMIT ORDER
B-DIET ORDER & NOURISHMENT RX
C-MEDICATION & TREATMENT ORDER-
1. NAME OF THE MEDICATION/ TREATMENT
2. STRENGTH OF MEDICATION AND FREQUENCY AND HOW MEDS
OUR TO BE GIVEN OTHER THAN P.O
3. PSYCHOTROPIC DRUGS MUST STATE THE BEHAVIOR TO BE
MONITOR AND CONTROLLED.
4. NOTE P.R.N MEDICATION MUST INDICATE THE REASON
5. IRRIGATION ORDER FOR FOLEY SHOULD INCLUDE THE SOLUTION,
AMOUNT AND HOW OFTEN OTHER THAN MONTHLY.
6. CHANGE FOLEY P.R.N SHOULD INDICATE THE SIZE, AND THE
REASON , e.g. FOR PLUGGING, LEAKING,BLOCKAGE, ETC.
7. PSYCH CONSULT
8. NURSING ROUTINE ORDERS:
A. TYLENOL TABS: FOR SEVERE PAIN, ELEVATED TEMP Q 4 HRS.P.R.N
B. M.O.M. RX FOR C/O CONSTIPATION AS PER DOCTORS ORDER.
C. POSTURAL SUPPORT P.R.N (SPECIFY TYPE OF SUPPORT)
e.g. VEST,PELVIC,WAIST,FOR SAFETY & PROTECTION
D. PATIENT MAY ATTEND IN ACTIVITIES AS NOT IN CONFLICT
WITH THE TREATMENT PLAN. FOR PHYSICAL AND MENTAL STIMULUS
AS TOLERATED.
E. PODIATRY CARE Q 3 MONTHS P.R.N FOR HYPERTROPHIC/MYCOTIC
NAILS AND KERATOTIC LESSIONS. Q ONE MONTH DIABETIC PATIENT
F. ACTIVITY AMBULATORY OR WHEELCHAIR
G. TWE Q 3RD DAY P.R.N IF MOM NOT EFFECTIVE
9. RESTORATIVE ORDERS:
ROM TO ALL 4 EXTREMITIES BY RNA 5XWEEK
PAGE 2
5. LICENSED NURSE CHARTING ON ADMISSION:
* NURSING ASSESSMENT MUST BE DONE ON ADMISSION
* PROCEDURES NO #1-2-3 MUST BE DOCUMENTED TO REFLECT THE
PATIENT LEVEL OF CARE.
* VITAL SIGNS MUST BE TAKEN ON ADMISSION RIGHT AWAY
* HEIGHT & WEIGHT MUST BE TAKEN BY RNA & DOCUMENTED BY
LICENSED NURSE IN THE FLOW SHEETS ON ADMISSION.
* PATIENT INVENTORY OF PERSONAL BELONGS--INCLUDE DENTURES,GLASSES
A. SIGNED BY THE PATIENT/RELATIVES/ANY
REPRESENTATIVE.
B. SIGNED BY THE ATTENDING NURSING AIDE ON
DUTY/LICENSED NURSE & DATE
* PATIENT UNABLE TO SIGN: NEEDS TWO WITNESS SIGNATURE TO JUSTIFY
ADMITTING NOTES ARE TO BE DONE UPON ADMISSION:
LICENSED NOTES MUST BE DONE Q SHIFT FOR THE FIRST 3 DAYS ON ALL NEW ADMISSIONS
LICENSED NOTES MUST BE DONE Q SHIFT Q DAY ON ALL MEDICARE PATIENTS FOR
THE DURATION OF MEDICARE COVERAGE.
ADDITIONAL INFORMATION ON DIETS:
DIETS: INCLUDING H.S. SNACK 7:00 - 12:00PM - 5:00PM - 8:00PM
REGULAR: PUREE- CHOPPED - SOFT
LOW RESIDUE: BLAND IV
LOW FAT: LOW CHOLESTEROL
SODIUM RESTRICTED IGM-2GM- NAS- NO ADDED SALT
BLAND DIET
DIABETIC 1200-1500-1800 CAL
TUBE FEEDING - TOTAL CALORIES PER 24 HOURS.
HOW DIVIDED - AMOUNT PER SERVING- TIME OF FEEDINGS
LIQUID OR CLEAR LIQUID
REGULAR -NO ADDED SUGAR OR SALT
H.S. SNACK INCLUDED IN ALL DIETS,
BETWEEN MEAL FEEDING SHOULD BE ORDERED SEPARATELY