Observation, Reporting, and DocumentationUnit 8

Nursing Process• Steps of Nursing Process:

• Assessment • Planning• Implementation• Evaluation

Nursing Process• Assessment: learning about the patient

• Nursing assistant actions include:• Observing carefully during admission

process• Listening carefully to what the patient and

family say• Measuring vital signs• Reporting findings to the nurse

Nursing Process• Assessment: learning about the patient

• Nursing assistant actions include:• Reporting changes in the patient’s

condition, response, and behavior promptly

• If permitted, charting or documenting• Charting: vital signs, intake/output

(objective)• Documenting: observations

(subjective/objective)

Nursing Process• Planning: preparing the nursing plan

• Nursing assistant actions include:• Being informed of, and following the

nursing care plan• Participating in the planning conference• Contributing information and

observations that will help the team develop a plan

Nursing Process• Implementation: seeing that the care plan is

followed• Nursing assistant actions include:

• Carrying out assignments correctly• Being willing to cooperate and help other

team members

Nursing Process• Evaluation: determine how well care plan

goals have been met• Nursing assistant actions include:

• Reporting your observations• Inform the nurse if an approach cannot

be implemented• Informing the nurse if the patient has

problems with a listed approach

Making Observations• Observing is an important part of the nursing

assistant's job, which includes:• Using all of your senses when making

observations• Noting anything unusual or extraordinary• Reporting your observations to your team

leader in an accurate, timely manner

Making Observations• Observations of normal values:

• The nursing assistant must have basic knowledge of the range of normal observations

• Anything outside the range of normal should be reported to the nurse

Making Observations• Observations of specific body systems:

• Integumentary system:• Color, temperature, flexibility (turgor),

dryness, moisture, redness, open areas, bruises, swelling, scars, rashes

• Musculoskeletal system:• Deformities, ability to walk, sit, or move,

pain, posture, or abnormal movements• Circulatory system:

• Skin color, heart rate, pulse, blood pressure, nails, lower extremities

Making Observations• Observations of specific body systems:

• Respiratory system:• Difficulty breathing, blueness of skin,

shortness of breath, rate of respirations, noisy respiration, cough

• Nervous system:• Level of consciousness, response to

questions, paralysis, orientation to time & place, condition of eyes & ears

Making Observations• Observations of specific body systems:

• Urinary system:• Frequency, amount and character of

urine, inability to hold urine, drainage, color of urine, blood in urine, pain during urination

• Digestive system:• Appetite, tolerance to certain foods,

diarrhea, constipation, gas, difficulty chewing or swallowing, unusual color or consistency of stool, nausea, vomiting

Making Observations• Observations of specific body systems:

• Endocrine system:• Signs and symptoms of

hypo/hyperglycemia• Reproductive system:

• Abnormalities of the breasts, menstrual cycle, and vaginal discharge, lumps in testes, abnormal drainage from the penis

• Other observations:• Pain, behavior, ability to function

Making Observations• Observations of pain:

• Pain is never normal• Body language and facial expressions may

provide clues to the presence of pain, particularly in children and cognitively impaired adults

• The patient’s self-report of pain is always the most accurate; avoid making assumptions about pain (subjective)

• Pain scales are used to help patients communicate level/intensity of pain

Reporting• A “report” is given by staff going off duty to the

oncoming shift • Oral Reporting:

• Most accurate because it is “up to the minute”

• Face to face• Allows for questions• Allows for review of medical records, lab

results, etc.

Reporting• A “report” is given by staff going off duty to the

oncoming shift • Written report:

• Less accurate• Writing can be illegible• Details can be omitted for sake of brevity• Events that occur after report is written may

not be updated on report for oncoming shift• Can be “misplaced”• Can be HIPPA violation if not secured

Documentation• General guidelines for charting:

• PRINT entries as neatly as possible, unless cursive entries are allowed – must also be neat and legible

• Use BLACK ink for all entries• Use short, concise, factual phrases – no

opinions• Always chart after the event – NEVER

before• Always enter time of event in entry

Documentation• General guidelines for charting:

• Leave no blank spaces when documenting• Sign EACH entry with first initial, last name

and your title• NEVER, ever (next slide please…..)

Documentation• General guidelines for charting:

•NEVER

Documentation• General guidelines for charting:

• Leave no blank spaces when documenting• Sign EACH entry with first initial, last name

and your title• NEVER, ever erase, use “white-out,” or

repeatedly cross through an error.• Draw single line through error, print word

“error,” and initial. Single line• Use medical terms appropriately and spell

them correctly

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Documentation• General guidelines for charting:

• Use international (military) time when you document, or follow your facility’s policy• 1:00 PM = 1300 Hours• 12:00 AM (midnight) = 0000 Hours