Observing,Reporting, Charting

See it and Say it

The Nursing Process

v 1. Assessment- (Observations)
v Collect data (info) strengths/problems
v Listen and observe carefully
v Measure carefully
v Report findings/changes
v Document
v 2. Planning- developing care plan
v Participate in care conference
v Identify solutions to problems
v Develop approaches/interventions
v Establish goals- must be measurable- for
example (within 10 days the resident will
have no S/S of UTI)

The Nursing Process (con’t)

v 3. Implementation- carry out approach
v Who is going to do it.
v When the approach is done
v How will it be done.
v 4. Evaluation- have goals been met?
v If not, why?
v What still needs to be done.
v Review the new plans of care
v Aids need to report if approaches
can’t be carried out or if patient is
having problems with the approach.

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 C.N.A.’s as medical scouts
v As the primary caregiver, your observations can be the
difference between a resident who receives early and
effective treatment, and a resident who becomes gravely ill.
v A recent study by Kenneth Boockvar MD, Assistant
Professor in the Department of Geriatrics at Mount Sinai
School of Medicine found:
v That C.N.A.’s almost always saw that a resident was
becoming ill earlier than anything noted in chart.
v Illnesses that were detected early were:
UTI’s, pneumonia, CHF, gastroenteritis, arrhythmias, and
dehydration.

The 5 early warning signs of illness

v 1. Weakness- sudden onset
TIA, pneumonia, dehydration, CHF,
infection, liver failure.
v 2. A change in greeting
severe hearing loss, depression,
confusion.
v 3. Nervousness or agitation
being emotionally off can signal
physical illness.
v 4. Loss of appetite
v 5. A resident complains

Observations by Body Systems

use sight, touch, hearing and smell to gather info.

v Integumentary System
v color - flushed, pale, ashen, icteric,
v cyanotic, don’t forget nails.
v temperature - warm, hot, cool,
v moisture - dry, moist, perspiring
v abnormalities- rashes, bruises, wounds
v Musculoskeletal System
v posture- stooped, fetal position, straight
v mobility- in bed, balance, ambulation
v range of motion- performance of ADL’s

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More about you being the eyes and ears
v Circulatory System
v pulse- strength, regularity, rate
v blood pressure
v skin- color
v extremities- edema

v Respiratory System
v respirations- rate, regularity, depth,
v dyspnea, SOB (exertion, at rest)
v stertorous.
v cough- frequency, dry, productive,
v sputum- color, consistency

More about Observations

v Nervous System
v mental status- orientation
v ability to communicate
v Senses
v eyes- pupils equal, reddened,
drainage.
v Ears- drainage, hearing
v nose- drainage, bleeding
v Urinary System
v frequency, amt., color, dysuria
v clarity, blood or sediment, incon.

v Digestive System

v appetite- amt. of solids/liquids consumed,

belching,burping, intolerance to foods.
v eating- difficulty chewing or swallowing.
v nausea/vomiting
bowel elimination- frequency, amt.
consistency, color, diarrhea, constipation,
incontinence, flatus.

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vReproductive System female
breasts- any drainage from nipples, discoloration,
lumps.
vvaginal- any discharge, amt. odor, character
.

vReproductive System male

vtestes- lumps
vpenis- amount and character of drainage

Don’t Forget the ABC’s of

Observation

v Appearance- has been covered by

observations of body systems.

v Behavior- actions, conduct, pain

v Communication- has been covered

Two types of Observations

v Objective- signs that you can

see, hear, feel, smell
v factual, measurable
v Can you think of examples?

v Subjective- what the resident

tells you.
v Can you think of examples?

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 Now that you saw it, Say it!
v Reporting Your Observations.
v Be objective, don’t interpret
observations.
v write it down
v report only the facts
v do not make assumptions
v consider the patient’s culture
v never compare residents
v oral reports are given by the nurse or aide
going off duty to the oncoming shift, the
aide to the nurse during the shift, and at
the end. Did you notice anything unusual?
v Don’t be shy- “I’m worried that….”

Documentation/Charting
in medical record/legal document
v Must be legible, print, no ditto marks.
v Use black or blue ink
v do not use the term patient
v use short, concise phrases
v always chart after the event
v always indicate the time
v leave no blank lines
v proper signature
v never erase, single line through, initials
v use appropriate medical terms/abbreviations
v use international time, or follow policy.