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CNA-NIC F25 CH 3.11
Describe how to observe and report accurately
| Question | Answer |
|---|---|
| Describe the time a nursing assistant spends with residents in comparison to other members of the care team | Nursing assistants spend more time with residents than other members of the care team |
| because nursing assistants spend more time with residents than other members of the care team what happens | they may observe changes in residents that other team members have not noticed |
| what is very important and vital to the residents health | reporting observations accurately |
| what is the residents care managed with | a CARE PLAN |
| who develops a care plan | developed by a registered nurse RN |
| what information is used in the development of a care plan | uses data collected from resident, their family and care team members |
| what does person centered care emphasize | the importance of the resident's input |
| what does the plan outline | the steps and tasks that the care team must perform to help the residents achieve their goals |
| what must be followed carefully | the care plan |
| how do nurses plan care | collect information from staff |
| what do nursing assistants do to help the nurses plan care | report signs and symptoms that they observe |
| what sort of information do nursing assistants provide to nurses about the signs and symptoms they observe | this information will be either objective or subjective |
| OBJECTIVE INFORMATION | information based on what a person sees, hears, touches or smells |
| how is objective information collected | it is collected using four of the five senses: sight, hearing, smell and touch |
| what is objective information also called | signs |
| SUBJECTIVE INFORMATION | is information collected from something that residents or their families reported, and it may or may not be true |
| what is subjective information also called | symptoms |
| describe how subjective information is observed | subjective information is something a person cannot or did not observe |
| what is subjective information considered to be | it is an opinion |
| who relays subjective information | subjective information is the information the subject is relaying |
| objective information may confirm | subjective information |
| what is an example of objective information | Mr. Hart is rubbing his temples and holding his head |
| what is an example of a subjective report (information) | Mr. Hart says he has a headache |
| describe the value of objective and subjective reports | both are valuable |
| what needs to happen in order to report accurately | NAs must observe residents accurately |
| when should NAs use medical terminology | when making and recording observations |
| what do NAs need to use to observe accurately | they need to use as many senses as possible to gather information |
| how can you use smell to make observations | residents' body or breath odor |
| how can you use sight to make observations | changes in resident's appearance |
| how can you use hearing to make observations | resident's words, tone and breathing |
| how can you use touch to make observations | resident's skin and pulse |
| what should the NA look for in regard to sight observations | should look for changes in the resident's appearance, such as skin discoloration, swelling, rashes, discharge, changes in the eyes or ears, and changes in mobility |
| what should the NA look for in regard to hearing observations | the NA should listen to what the resident says. is the resident making sense? is he breathing normal? does he cough, groan or cry? does he appear to be angry or sad? |
| what should the NA look for in regard to smell observations | are there any odors coming from the resident's body? Odors can indicate infection, a need for bathing, incontinence, or poor mouth care |
| what should the NA look for in regard to touch observations | does the resident's skin feel hot or cool, moist or dry? |
| observing and reporting the resident #1 | note any changes in orientation (does the resident know who he is, who you are, where he is, and what year it is?) |
| ORIENTATION | is a person's awareness of person, place, and time |
| observing and reporting the resident #2 | Check to see if the residents' vital signs are normal or abnormal |
| VITAL SIGNS | are measurements that monitor the functioning of vital organs of the body |
| vital sign measurements | temperature, pulse rate, respiratory rate, blood pressure |
| observing and reporting the resident #3 | report any changes in ability |
| what are changes in ability to look out for | has there been a change in the residents ability to move any part of her body? Can the resident perform all of the activities today that she could yesterday? Are the residents' senses of sight, hearing, smell, touch, and taste the same today? |
| observing and reporting the resident #4 | report other important changes (changes in weight or overall appetite, changes in ability to have bowel movement or changes in mood |
| what is important to residents well being | accurate documentation and prompt reporting |
| what involves critical thinking | determining what to report immediately to the nurse and what can wait until later |
| what do nursing assistants not do | NAs do not try to solve problems or make decisions about a residents health |
| what is the nurses or doctors role | solving problems or making decisions about a residents health |
| while working what must an NA determine | whether any information they collect regarding residents could mean a problem is developing or has already occured |
| for nursing assistants CRITICAL THINKING means | making careful observations, evaluating resident information, and immediately reporting all potential problems |
| what can reporting these types of changes in a residents condition do | may lead to the quick diagnosis and treatment of a potentially serious problem |
| anything that endangers residents should be reported when | reported immediately |
| what are things that endanger residents and should be immediately reported #1 | falls, wheezing, difficulty breathing, chest pain or pressure, pain in calf or leg, blurred vision, slurred speech, abdominal pain, vomiting, sudden limp or change in ability to walk, numbness or loss of feeling in one side of the body or in arms/legs |
| what are things that endanger residents and should be immediately reported #2 | changes in vital signs, sudden or severe headache, change in mental status (confusion or disorientation) |
| sometimes a nurse will ask a NA to do what | to report every change in a resident, no matter what that change is - the NA should report each change as it happens |
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