Responsibilities and tasks when receiving a new patient to the unit

[Jyj5050jyj]

I'm starting my first direct patient care position soon so I'm trying to get a sense of what a routine day is like. I can't find any information on exactly what an RN does when a new patient is admitted to one of her beds. All I can really find is the admission in the ER or point of contact, but not how to receive a patient on the floor. I assume they take report before the patient is transferred unless the previous RN is transporting the patient, takes vitals, does a baseline assessment, checks lines and bandages, checks orders and sets parameters. Is there anything I'm missing? What is the general order of events for all of this?

Edit: This is assuming there is no "admitting nurse" on the floor who takes every admission. Is that really even a thing?

[smf0903]

Congrats on the new gig! You should be oriented to the tasks at your facility, including admissions. That being said, for our facility we take report before getting the patient, unless the patient comes up with the RN from ED/surgery/PACU/wherever. We get the room ready which includes zeroing the bed (we weight pts in bed), welcome packet ready, check to make sure supplies are ready. When pt comes to floor we do a basic admission which documents items brought to the hospital/what got sent home, ht/wt, initial set of vitals, etc. we do a complete pt history, including previous surgeries, pertinent family hx, med reconciliation, allergies, depression assessment, social hx, pertinent information such as current or hx of abuse, etc, etc. a complete assessment is performed. Check lines and place any new or extra lines as needed, check orders (I check dosing and such against their med rec too as this has been an issue in the past), label lines and bags. I always chart a note about how the patient presented upon arrival, including vent/BiPap settings, generally how they looked, LOC...just a quick snapshot of how they came to me.

We also always go over room policies (yeah, no smoking etc), when the docs will be around, what their diet order is and when they can order, if they are NPO I explain why and make sure family understand this as well if they are present, things like that.

Hope that helps! I was VERY slow with admissions as the start, but after you do a few you get quicker at them (like anything else!). Good luck to you in your new job!! :)

[snowflower2016]

I would think that your institution has a policy for admissions. Check your policy and procedures information. Mine does all the things you mentioned, plus a health history, medication reconciliation, skin assessment, IPOC goals, flu shot assessment, personal belongings documentation, and learning style/patient education assessment.

[brownbook]

Everywhere I've worked has a standard admit form on paper or on computer the admitting nurse completes. It pretty much covers everything you need to do. A nurse new to the unit would receive training on patient admissions.

Did you receive orientation training to the unit?

[Jyj5050jyj]

Thanks for taking the time. This was so thorough! I'll add this to my cheats list =)

[Jyj5050jyj]

No. I haven't started orientation. I'm a couple of weeks out from even getting my start date. I'm just trying to get ahead a little bit so I have a grasp on the areas I may need to focus a little extra on.

[maxthecat]

While I like your initiative, it probably makes more sense to wait for orientation. You could read up on the policies and procedures, but you may find that a typical admission to your unit doesn't necessarily follow those exactly. I think you'll find it less confusing if you just wait and let your preceptor show you how it's done for your unit.

[jodispamodi]

My hospital does not have the sending nurse call report anymore, just the patient is coming and check the sbar (another of the 200 million reasons I hate epic, but I digress), which gives you virtually none of the info you really want to know. SO... don't be afraid to call the sending nurse if you see the sbar and want more tangible info. A couple of ICU nurses used to still call me with report and I felt I knew the patients picture so much better. Best of luck with your new job.