1. Observation, Reporting, and Documentation
Unit 8

2. Nursing Process Steps of Nursing Process: Assessment Planning
Implementation
Evaluation

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

18. 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.

19. 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

20. 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

21. 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…..)

22. Documentation
General guidelines for charting:
NEVER

23. 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
error
CER

24. 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