Language of Care Observing, Reporting and Recording

Observing Observing is using the senses of sight, hearing, touch, and smell to collect information.

Data is Information You will observe and report two types of data to your charge nurse: Objective – signs Subjective – symptoms

Objective Data - Signs Objective data are seen, heard, measured or smelled.

Subjective Data - Symptoms This kind of data are things a person tells you about that you can not observe through your senses.

Reporting Reporting is the oral account of care and observations. Be prompt Be accurate Be thorough Give time of observation Report your observations and what you did Report changes ASAP

Recording – Done on the Medical Chart Recording is the written account of care and observations. Report: What you observed What you did The person’s response

Military or 24 Hour Clock Time The 24-hour clock has four digits; the first two digits are for the hour and the last two digits are for the minutes.

Time 2:00 PM MILITARY TIME :00 AM 1100

Medical Chart A written account of a person’s condition and response to treatment.

Forms in Medical Chart – related to your work Admission Sheet Progress Notes Flow Sheets

Admission Sheet This is completed when the person first enters the nursing home for care. It has information that identifies the new resident.

Progress Notes These are written notes about observations, the care given, and the resident’s response to the care.

Flow Sheet These are used to record frequent measurements or observations. Baseline measurements are taken when the resident enters the nursing home.

Admitting a New Resident Knock and greet the new resident Welcome the resident to the nursing home and introduce yourself Explain what happens in the admitting process: You will label the clothing Fill out personal belonging list Show the pt how to use the call light Ask her how she would like to be addressed (Mrs. Smith, or Rebecca, or Becky) Provide a pitcher of water for the pt Take baseline measurements Give pt and their family a tour of the facility

Baseline Measurements Baseline measurements are taken when the pt is first admitted into the nursing facility. It is important to take accurate measurements of a person’s vital signs and weight. Example: Weight is taken on admission to a facility. Weight gain or loss could be related to a person’s medical condition. The baseline weight is used as a reference for the health care team. They are Used to comepare with future measurements.

Discharging a Resident Explain how you are going to help: Gather belongings, pack Re-check closet, drawers, nightstand for missed items Assist pt into a w/c Assist resident to the exit Tell pt how much you’ve enjoyed helping her Return w/c to the unit, cleaned. Back in the residents room: Strip the bed Pick up discarded items Report any important observations to charge nurse

Transferring a Resident to a Different Unit Explain that you are going to help pt get read for her transfer by: Packing suitcase and equipment (bedpan, washbasin, etc) Re-check closet, drawers, nightstand for missed items Assist pt into w/c and Transfer pt and belongings to new room Tell her how much you enjoyed helping her Return the w/c to correct unit, cleaned Return to residents room: Strip bed Remove equipment that was not taken to new unit Remove discarded items

Reflect on Maslow’s Hierarchy of Needs: What needs should you focus on when admitting a resident into a facility? What needs should you focus on when transferring or discharging a resident? Ideas: Physical needs (food, water, elimination) Safety and Security (safety of belongings- environment) Love and Belonging (feel at home and welcome) Esteem (tell them you will miss them and you were happy to work with them)

Sources Google Images Basic Skills for Nursing Assistants in Long-Term Care (Sorrentiono-Gorek) Most information was taken directly from this book.