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Nursing : Vital Task Of Admission

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Nursing : Vital Task Of Admission

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Nursing : Vital Task Of Admission

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Question:
Describe about the Nursing for Vital Task of Admission.
 
Answer:

Introduction
The admission procedure is a vital task in the nursing care, as proper assessment, documentation is required in this stage, based on which the entire care plan and others medical procedures of the patient are planned (Hung et al., 2012). Therefore, nurses have a great liability regarding the proper admission procedure of each patient, considering all the necessary points. In this report, the admission procedure of a Jewish patient would be discussed, who has a history of breast cancer and has experienced a hip fracture, after falling from the home. The patient has undergone a hip surgery and now admitted for ongoing rehab post hip surgery. Thus, during the patient’s admission, proper documentation regarding the cultural background has to be considered.
Patient’s assessment
The first step of the client’s admission is documentation of the personal details of the patients and then assessing the status of the patient. While assessing the patient, her cultural background should be taken into consideration. A holistic assessment should be done including physical, mental, social and spiritual needs. The patient’s assessment would include the assessment of pain in the surgical area along with the presence of surgical infection. Pain would be assessed through the pain measurement scale. However, as the patient is from Jewish background, she might have problem in uncovering the surgical area in front of opposite sex, thus, during assessment, the patient would be provided with maximum autonomy and similar gender staff would be provided for the assessment (Stenvall et al., 2012). All the vital signs of the patient would be assessed, for instance, BP, BGL, spO2, RR, HR, Urine output and temperature. The vital signs would be followed up regularly. During the assessment, the patient’s diet chart would also be reviewed according to which the specific diet chart would be prepared in the rehabilitation centre. As the patient is from Jewish background, the patient would require a kosher diet to maintain the religious purity. As, pork is restricted in their culture, common foods like ham or bacon should be excluded from the patient’s diet. During assessment, patient would be discussed with the heath issues and why the admission procedure is necessary for starting the rehabilitation program (Auais, Eilayyan & Mayo, 2012).
In addition, the patient’s independence level would be assessed by observing the capability of movement and mobility skills; if the patient is not immobile, relevant physiotherapy would be assigned, on the other hand, if the patient were mobile, proper physical activity would be prescribed, in spite of physiotherapy. All the diagnosing testing and results would be reviewed for gaining a good insight of her post surgical status. Patient’s current medications would also be reviewed thoroughly and the additional concerns, such as drug or food allergy would be assessed properly (Torpilliesi et al., 2012). From the entire process, the patient’s needs would be identified, which would be prioritized during care plan formation.
Documentation
The next step in the admission procedure is documentation. Rather, this procedure is carried out simultaneously with the assessment step. After assessing the patient, the vital signs and necessary information would be documented. The use of electronic health record would be the most appropriate method in this case. The documentation would include all the diagnostic results, diet restrictions, patient’s identity and persona information. The patient is from Jewish background, thus the all the necessary cultural information would be documented, as the care plan would be made, considering the patient’s cultural background. In documentation, the history and family history related data would also be documented. The patient has a history of breast cancer (Hu et al., 2012). Thus, the medication should and care plan should be arranged considering this condition. The social support of the patient, social history and involvement would also be documented, as this information would be required for her social and spiritual well-being. The care providers, who would be accountable for the patient’s well being, would be Finally, patient’s consent would also be documented in proper way.
 
Care plan formation
After all the documentation procedure for patient safety, patient’s care plan would be formed. Initially, after reviewing the assessment information and her post surgical vital signs, the goals would be set for her rehabilitation. For this patient, the goals would be:

To enhance patient’s mobility
To reduce the risk of surgical infection
To reduce pain
To enhance patient’s autonomy in ADLs
To prioritize patient’s dignity and cultural beliefs through the nursing practices

To achieve the above goals, the care plan would include a physical therapy program, planned and reviewed by a physiotherapist. Based on her independence, functional training would be provided along with endurance training, balance or proprioception training which would improve the cardiovascular fitness. Initially, assistive devices would be recommended for the patient, but when the patient would be able to ambulate without assistance, these devices would be disconnected. The patient’s health promotional sessions plan would also be included in the care plan. The health promotion would help the patient to understand the importance and consequences of post surgical rehabilitation (Beaupre et al., 2012). Teamwork is very important in rehabilitation practices, as the goal is the holistic well being of the patient. Thus, in the care team, there would be GP, physiotherapist, surgeon, social worker, oncologist and centre staff along with the registered nurse. During the development of care plan, the cultural background of the patient would also be taken into consideration, especially in the case of diet, autonomy and medication administration. The medication prescribed would be reviewed, for reducing risk related to her past history of breast cancer.
The final step is discharge planning strategy formulation. Based on the follow up care procedures, the discharge planning strategy would be set. An extended care physical therapy might be required. Before discharge, the level of independence would be assessed, based on which further social or community support would be recommended for her. A proper diet and physical activity program would be arranged for her. The wound healing would be assessed.  The patient would be discharged, only when the wound would be healed entirely, as the chance of infection remains until the surgical wound is healed properly (Hung et al., 2012). Finally, patient consent would also be documented regarding discharge. After completion of all the procedures, a nursing handover would be prepared by the registered nurse regarding the patient’s admission.
Conclusion
In conclusion, it can be said that, admission procedure is not very easy process for a registered nurse, while dealing with a patient with contemporary health issues. On the other hand, if the patient is from a culturally diverse background, the nurse’s liability enhances several times and the admission procedure needs the consideration of all the pivotal patient information.
 
Reference List
Auais, M., Eilayyan, O., & Mayo, N. E. (2012). Extended exercise rehabilitation after hip fracture improves patients’ physical function: a systematic review and meta-analysis. Physical therapy.
Beaupre, L. A., Jones, C. A., Johnston, D. W. C., Wilson, D. M., & Majumdar, S. R. (2012). Recovery of function following a hip fracture in geriatric ambulatory persons living in nursing homes: prospective cohort study. Journal of the American Geriatrics Society, 60(7), 1268-1273.
Hu, F., Jiang, C., Shen, J., Tang, P., & Wang, Y. (2012). Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis. Injury, 43(6), 676-685.
Hung, W. W., Egol, K. A., Zuckerman, J. D., & Siu, A. L. (2012). Hip fracture management: tailoring care for the older patient. JAMA, 307(20), 2185-2194.
Stenvall, M., Berggren, M., Lundström, M., Gustafson, Y., & Olofsson, B. (2012). A multidisciplinary intervention program improved the outcome after hip fracture for people with dementia—subgroup analyses of a randomized controlled trial. Archives of gerontology and geriatrics, 54(3), e284-e289.
Torpilliesi, T., Bellelli, G., Morghen, S., Gentile, S., Ricci, E., Turco, R., & Trabucchi, M. (2012). Outcomes of nonagenarian patients after rehabilitation following hip fracture surgery. Journal of the American Medical Directors Association, 13(1), 81-e1.

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