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Admission History Assessment (Nursing)

by Samantha Rhea

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    00:04 So once we get into the admission history assessment, this is typically going to be performed by a registered nurse or an RN.

    00:12 Now, as you can see here on this graphic, we cover a lot of different topics, but this gives us great information for patient care.

    00:21 Now, the first topic we're going to discuss is the exposure and travel screening.

    00:26 Now, this is going to be really important such as, have you had an exposure for possible COVID? For example.

    00:32 Or, if you've traveled anywhere outside of the US, we could be screening for any possible exposure to a contagious infection.

    00:41 Now, next, we also want to make sure that any vaccinations that you may need such as influenza and pneumonia, for example, are up to date.

    00:49 Now, if its flu season for example, we may be able to provide this vaccination while you're in our care.

    00:57 And next, the all-important topic is patient allergies.

    01:02 So as a nurse, I want to remind you that this includes not just medication allergies, but especially food, because of dietary considerations during that hospital stay.

    01:12 Also don't forget about the really important one of latex, for example, or iodine for special procedures.

    01:20 It's really important that we are inclusive here about all patient allergies, because this can affect all kinds of different treatments.

    01:27 The other consideration is the reaction.

    01:30 This is so very important because you can imagine that an anaphylactic reaction such as, "I can't breathe, I'm having trouble breathing, anytime I'm exposed to this allergen," versus mild itching, is much different in regards to treatment and consideration.

    01:48 So be very thorough in regards to getting a collective allergy history from your patient.

    01:54 So one thing to note, if a patient does have allergies, there's a lot of risk bands when we talk about patient treatment, but this one in particular is very important.

    02:04 Now sometimes these are red, they could be different colors, but assure if there's any allergies that your patient has, make sure you identify this with the patient's chart and an allergy bracelet on your patient.

    02:17 Now, let's talk about emergency contact.

    02:19 Now, this is really important that we make sure we have a next of kin, a spouse, a partner, or whoever the patient's preference is for their emergency contact.

    02:30 This is really helpful for providers.

    02:33 Sometimes it could be as simple as we need to call the emergency contact to bring a patient's breathing machine such as a sleeping device, a CPAP up to the hospital.

    02:42 Or it could mean that we've got to call this emergency contact about certain treatment decisions.

    02:48 Now, let's talk about a big one here is the patient's past medical history.

    02:54 Now, many times as a nurse I know we may think, well, this surgery ten years ago or this condition.

    03:01 We're not treating them for this specific issue right now, but indeed, many of those things can impact our overall treatment decision.

    03:10 For example, many times a patient may be coming in for pneumonia, but they have diabetes for example.

    03:17 We still need to maintain that patient's chronic condition, so we don't have those complications in the hospital.

    03:24 Now, let's talk about the really important topic of advance directives and code status.

    03:31 So when we talk about advance directives, this is an actual legal document that if a patient can't carry out decisions for themselves, such as maybe the patient is sedated in the intensive care unit, or if the patient is in a coma, this legal document helps direct any sort of treatment decisions that the patient may want, if they can't make those decisions for themselves.

    03:57 Now this document covers a lot of different things, but some really important points that it typically will cover, is that if I can't make that decision for myself, I can appoint a specific individual to make those care decisions for me, when I'm unable to.

    04:14 Also it may cover the topic of CPR or life saving measures of what I feel is appropriate for me, mechanical ventilation, nutrition, and pain management.

    04:27 Now when we talk about advance directives, we need to provide screening.

    04:31 Meaning, does the patient have one or do they not? Now, if they do have an advance directive, it's important that we take time and review this with the patient on admission or the next of kin or the loved one, to make sure it's still appropriate.

    04:46 Now, if it is, we want to make a copy and place this in the patient's chart.

    04:51 That part is really important because, unfortunately, we may need to refer to this later.

    04:57 Now if the patient does not have this legal document or the advance directive, that is perfectly okay, because in the hospital, if we click no on our screening, this will trigger a consult for them to get assistance.

    05:11 So let's talk about the topic of code status.

    05:14 Now, if you recall this is different than the advance directive.

    05:18 The advance directive was that legal document that covered many aspects of care, especially that appointed person that makes treatment decisions if we are unable to.

    05:29 Now, code status differs because this tells us the type and the extent of the emergency treatment or life-saving measures that a person needs if their heart stops or they stopped breathing.

    05:43 Now, this is a conversation that must come early in patient care, because as you can imagine, determining code status in the middle of an emergency with lots of emotions and a lot of chaos going on, that can be very difficult for families especially.

    05:59 Now, just know when we talk about code status that this has to be a physician's order because the physician will have this conversation as well with the family members and the patient.

    06:11 Now, also note, that the patient is deemed a full code until we know otherwise or changed that particular order.

    06:20 Now, when we talk about code status there's some variation to this but these are biggies.

    06:25 When we talk about full code this means we put out all, there's no stops here, meaning we do medications, CPR, defibrillation, artificial airway, all of these things are life-saving measures, meaning we're going to do everything we can to revive the patient, restart their heart, and help with their breathing.

    06:48 Now, again, there's some variation to this code status, but sometimes the patient may want what we say is a DNI, meaning do not intubate, meaning we can do CPR, we can do medications, but when it comes to the patient not being able to protect their own airway, like you see in this image, and we go to put in a tube, the patient does not want this, so therefore they are the DNI code status.

    07:15 And, lastly, is the do not resuscitate, the DNR, which means we do not want any of these life-saving measures.

    07:23 So no CPR, no meds, no defibrillation, and no airway.

    07:28 So just note as well that during this code situations or an emergency arise, the final decision is from the doctor to stop or call the code.


    About the Lecture

    The lecture Admission History Assessment (Nursing) by Samantha Rhea is from the course Admission History Assessment (Nursing).


    Included Quiz Questions

    1. An advanced directive is a legal document that describes the client's care goals if they become unable to make decisions, whereas a code status indicates what life-saving measures to take if a client's heart stops beating.
    2. Code status indicates what life-saving measures to take if a client's heart stops beating and an advanced directive does not.
    3. An advanced directive and code status are different names for the same term.
    4. A code status is a legal document that describes the client's care goals if they become unable to make decisions and an advanced directive indicates what life-saving measures to take if a client's heart stops beating.
    1. The allergen and the type of reaction
    2. The allergen and the date of the last reaction
    3. The allergen and a family history of allergies
    4. The allergen and the frequency of reactions
    1. All medical conditions and surgeries in a client's lifetime.
    2. All medical conditions and surgeries in the last ten years.
    3. All active medical conditions.
    4. Medical conditions that pertain to the chief complaint.
    1. DNI
    2. DNR
    3. Full code
    4. DNA

    Author of lecture Admission History Assessment (Nursing)

     Samantha Rhea

    Samantha Rhea


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