Patient Arrival and Initial Assessment (Nursing)

00:04 Welcome to the topic of patient admission.

00:07 Now this is a really important process and a great method to help us collect medication history, past medical history, to give us more information for better treatment decisions.

00:20 So, before we get started, let's talk about what we do on patient arrival.

00:25 First of all, we want to note that time and this could be in the emergency room for example, this could be on the medical-surgical unit.

00:33 Now, once we note the time we need to start assessing the patient when we first see them.

00:38 We need to make sure they're stable and make sure we lay eyes on them.

00:43 And then of course, we've got to introduce ourselves.

00:46 This may seem silly, but you can imagine all of the different healthcare providers that come in and out of the patient's room. Make sure you state who you are and your purpose.

00:56 And the other thing to note, make sure we check their hemodynamic status, meaning we want to get a baseline set of vital signs, assess the patient's pain, and also don't forget about the height and weight.

01:10 Now, you may be wondering about this, but the height and weight is really important because sometimes we dose medication based on these numbers.

01:19 Now, before we get too much further, let's talk about some important keys to success when you're talking about the patient mission.

01:27 So a great key point is to gather all the necessary equipment that you may need before entering back into that patient's room.

01:35 This is going to be a huge time saver and be much more efficient in meeting your patient's needs.

01:40 And remember to always be assessing.

01:43 Now, as you can imagine, they're coming into our ER or maybe your medical facility, they're there because of an illness or an exacerbation of a disease, so always be assessing your patient, because, of course, condition can change.

01:57 And, of course, always gather information.

02:00 All of that information and being in that detective mode is really helpful because sometimes, the patient may make a statement or we may see and assess an abnormality.

02:10 By asking clarifying questions and being in detective mode that can give us great information for treatment.

02:17 And, of course, make sure you verify your patient's identify.

02:22 I know we talk about this a lot, but when we're talking about a patient admission, we've got to make sure the orders are appropriate for that right patient, were in the right patient's medical record as well.

02:34 You can imagine there's a lot of patients out there with the same name, so make sure you confirm identity with the two patient identifiers, the name and the date of birth.

02:45 Now, once we've verified the identity of our patient, this is a great time to complete the initial physical assessment.

02:52 Now when we're talking about admission history or initial physical assessment, this is typically going to be done by a registered nurse or an RN.

03:02 Now, this is the time we're going to check all of those really important body systems.

03:08 Don't forget about your ABCs otherwise known as your airway, breathing, and circulation.

03:14 This is also a great time just to ask what brings you to the hospital today.

03:20 We typically call this the chief complaint and you'd be surprised how much information you get from your patient just by this simple question.

03:28 And don't forget about the all important cognitive or neurological status.

03:33 Many times if there's a decline or a change in a patient, we may see it here first.

03:39 And we want to make sure we move through the head to toe, and check their gastrointestinal and their genitourinary system.

03:47 Along with their skin and their musculoskeletal system.

03:51 This is going to help us to know if the patient need any assistive devices for example.

03:56 Once we've completed the head to toe initial physical assessment, we want to be prompt to check our orders, because many times there may be something, a priority that we need to address.

04:08 So when you check your orders make sure you've got those identifiers and the right orders for the right patient.

04:15 Now, this is kind of come with time, but make sure the orders you receive as nurse make sense for your patient.

04:23 Now, as you can imagine with the electronic medical record and tons of patients in the hospital, sometimes there's orders that come in that we always need to evaluate and say, does this make sense for our patient? If not, make sure you have that communication with the provider.

04:40 Now are there any priorities or any stat or even timed orders for example.

04:45 This could be anything like a stat CT of the head.

04:48 This could be a stat antibiotic for the patient.

04:52 Make sure you review these orders thoroughly, and again, make sure they make sense to your patient.

04:58 Next, when you're talking about collecting information and the history, sometimes, depending on the patient's mental status or maybe their disease process, the patient sometimes can indeed be a poor historian, meaning they can't always remember or give accurate information.

05:15 So do your best to assess this.

05:18 This could mean that we need to wait for a different time, when maybe the patient is feeling a little bit better that we collect information, or sometimes, maybe a patient's partner or spouse or next of kin arrives, and we need to get that information for accuracy from that individual.