Charlotte Eliopoulos RN, MPH, PhD Executive Director American Association for Long Term Care Nursing

Observation refers to the use of all your senses in collecting information about a resident.

Alertness and Orientation

 New or different: ◦ Dullness, drowsiness ◦ Confusion ◦ Slow responses ◦ Not recognizing you

General Function

 Changes in ability to: ◦ move, transfer ◦ ambulate ◦ eat ◦ bathe ◦ dress ◦ toilet ◦ use any body part

Skin

 New or worsened: ◦ Break in skin ◦ Rash ◦ Sore ◦ Discoloration  Unusually warm or cold areas

Joint Movement

 New or worsened: ◦ Stiffness of a joint ◦ Inability to move any body part ◦ Pain when using/moving any body part

Intake and Output

◦ Excess thirst ◦ Reduced fluid intake ◦ Excess voiding ◦ Lack of voiding ◦ Urine that has a strong odor, is of a dark color, or contains pus or particles

Eating

 Reduced or increased appetite  Difficulty chewing  Difficulty swallowing  Choking  Nausea, vomiting  Reduced intake

Weight

 More than 5 pounds increase or decrease in past month

Breathing

 Difficulty breathing at rest  Difficulty breathing with activity  Wheezes or other sounds when breathing  Coughing  Complaints of not being able to breathe or get enough air

Eyes and Vision

 New or worsened: ◦ Redness of eye ◦ Discharge from eye ◦ Itching of eye ◦ Inability to see ◦ Eye pain

Ears and Hearing

 New or worsening ◦ Inability to hear ◦ Ear wax ◦ Discharge from ear ◦ Ear pain

Mental Status and Mood

 New or worsened: ◦ Confusion ◦ Inability to recognize familiar people or objects ◦ Inability to perform routine tasks, activities ◦ Depression ◦ Fearfulness ◦ Anxiety ◦ Anger

 Gather as much information as you can  Report all details to the nurse

Thank you for all you do!