1. 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?

2. 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.

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

4. 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.

5. 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

6. 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)

7. Breakfast Meal Consumption Guide %

8. Lunch or Dinner Meal Consumption Guide%

9. 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.

10. 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)

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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.

17. Pain Scale

18. 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

19. 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

20. 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)

21. 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.

22. 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.