Objectives List the Four Methods of Observations? What is the Rationale for Resident Observation? Discuss when Resident Observation should occur? Discuss the Different Things you can Observe from the Resident? Discuss the Guidelines for Documenting et Reporting Status Changes?

Four Methods of Observation SEEING Look and think about what you are seeing and what it means. Observe for skin rashes, reddened areas, edema (swelling due to accumulation of fluid in the tissue), etc. Observe the resident’s reaction to pain, such as grimacing, guarding the area, etc. Use you intuition; be aware of nonverbal cues.

Figure 6.1 – Observation Form Resident’s Name: Date Time Observation Resident’s Need Nurse assistant may share observations and incorporate into shift care.

Four Methods of Observation HEARING Listen, understand what it means. Listen for cough or wheezing sound with breathing Some changes can be described only by resident pain, nausea, dizziness, a ringing in the ears, or headache. Listen for verbal and nonverbal signs from the resident. Listen to what the resident says. SMELLING Odor of a discharge Odor of resident’s breath. TOUCHING Note the temperature of the skin is ex. hot or cold , wet or dry or changes in pulse rate. It is important to use all of these senses to monitor resident’s vital signs. A change can indicate many things. Anything not within normal range may be significant and should be reported to the charge nurse.

Things to Observe (See HO 1.) Activities of Daily Living (ADLs) (independent/dependent) – The nurse assistant should observe the following: (1) if resident needs assistance , how much (2) what the resident can do (3) if resident can tolerate activity (4) if resident becomes fatigued (5) if resident is short of breath. Dressing untidy, unclean, or neat, clean Grooming 1.) untidy or neat Walking • Gait steady or unsteady; shuffling – describe posture • Difficulty getting up and out of bed • Use of a cane or walker

Things to Observe Eating and drinking • Good appetite or no appetite • Dislikes diet or tries some of each food • Note how much of each type of food was eaten – 100%, 75%, 50%, 25%, none • If less than 75% of the meal was eaten, report to charge nurse asap after the meal. • Thirsty; seldom drinks water, or refuses water if offered • If the resident is a diabetic, chart what was eaten and report to charge nurse. • Dysphagia (difficulty in swallowing)

Breakfast Meal Consumption Guide %

Lunch or Dinner Meal Consumption Guide%

Things to Observe Elimination • Urinary output How often does resident void? Note color, odor, amount, and clarity (clearness) of urine. Is voiding hard to start or is there pain during urination? Is the resident incontinent of urine? Is the catheter in place and draining properly? • Bowel function How often does a resident have a bowel movement? Note color, odor, amount, and consistency (liquid, loose, hard) of stool. Note blood, clumps of mucus, clay color, or if feces looks life black tar.

Things to Observe Sleeping • Able to sleep or restless • Sleeps more than normal; constantly asleep • Lies still or tosses around • Complains about not being able to sleep (compare with your observation)

Mental Condition or Mood Things to Observe Mental Condition or Mood Level of orientation – who, what, where Talkative, not talkative; difficulty speaking Talking sensibly or not making sense Anxious and worried or very calm Speaking rapidly or slowly Cooperative or not cooperating Delirium • Continuous or intermittent; rambling ideas or one persistent idea • Coma or unconscious; failure to respond to verbal commands or stimuli Crying – fretful, sharp, whining, or moaning; give reason if known

Things to Observe • Position Time of position change; what position resident is put in, Turn Schedule Able to move easily or requires assistance of two or three staff members Note if the resident has contractures.

Things to Observe • Skin Color – pallor (pale), flushed (red), cyanotic (blue), jaundiced (yellow) Dry or moist Warm (hot) or cool (cold) Edema – location, general or local, any color changes Reddened areas – location, open, size, drainage Rash, hives, itching, bruises, abrasions, lacerations Chart color, odor, consistency, and amount of any drainage

Things to Observe • Eyes, ears, nose, and mouth Eyelids inflames, watery eyes, bloodshot appearance, or yellowish cast to the whites of the eyes Bothered by bright light; twitching Pupils – constricted or dilated; unequal or equal in size Eyes appear to be fixed; constant involuntary movement Ability to hear you Difficulty breathing through his/her nose Mucus discharge from the nose Mouth – lost or broken dentures, sores, tenderness, bleeding gums Complaint of a bad taste in the mouth; odor of breath – foul (halitosis), sweet or fruity, alcohol

Things to Observe • Breathing Noises when resident breathes, wheezing, moist sounding Dyspnea – difficult or labored breathing usually accompanied by pain Cough – productive (note amount, color, and consistency of sputum) or dry; tight hacking, painful • Abdomen Stomach puffy, distended, hard, rigid, tender Gassiness, belching, hiccups Nausea Emesis (vomit) – self-induced; projectile; note color, consistency, and amount

Things to Observe • Movements Shaking - tremor Jerky - spasm Limp • Pain Location – Ask resident to point to area of pain or to use a doll to indicate where the pain occurs. Duration – How long has he/she had pain? Description of pain – constant, comes and goes, sharp, dull, aching, knifelike If resident has taken pain medication, has the medication relieved the pain? Document exactly what the resident says.

Pain Scale

Things to Observe Vital signs (See Unit I, Lesson Plan 8, Temperature, Pulse, and Respirations (TPR), for further information.) Temperature – febrile or afebrile Pulse – rhythm (regular or irregular); rate (too fast or too slow); force (strong or weak) Respiration • Rhythm – regular or irregular, rate (too fast or too slow), shallow • Cheyne-Stokes – uneven rhythm and rate and periods of no breathing • Noisy breathing – normal breathing cannot be heard

Things to Observe Blood pressure (See Unit I, Lesson Plan 9, Blood Pressure, for further information.) • Strong (easy to hear) • Weak (difficult to hear) • High or low

Things to Observe • Other Seizures – time, duration, intermittent or continuous; mild or violent; generalized or limited to one part of the body Chills – time and duration, severity of chill; temperature at time chill is completed; temperature 30 minutes after chill is completed Accidents or incident – time, witnesses, observations of injury, and cause of suspected injury Discharges – unusual body discharge; location and type (bloody, mucus, pus, or clear)

Guidelines for Reporting Observations of Status Change • Observe unusual , report , document only what you observe. Be objective. Do not make judgments or try to diagnose. • Record the date and time Name of resident Location of any abnormal signs Location of resident in facility Any symptoms the resident mentions Report to the charge nurse as soon as possible Initial your observations.

Conclusion Making observations is one of the most important functions of your job as a nurse assistant. Always be alert for changes and abnormalities of the condition of each of your residents. Become familiar with the terminology that has been included in this lesson.