First, make sure you understand the nursing process and how CNA’s fit in with it.
When we think about it, CNA’s are the eyes, ears, hands and nose of the nurses. We use these senses when providing care and with the right skill, we can assist the nurse with valuable patient information that may avert a serious problem. Things get confusing though when we make judgments about the things we’re seeing, feeling, smelling and hearing.
There are two types of observations.
Subjective and objective.
Objective observations are fact. They are measurable.
• Vital Signs
• Open Areas and other skin conditions
• Blood in urine
• Urine output from a cath
Objective observations are reported in the same manner by many people. They are not biased and they do not rely on statements and guesswork.
Subjective observations are made by the patient:
• “I have a headache”
• “I feel sick to my stomach”
• “My sugar levels are off”
Subjective observations are reported by the patient and are just as important as objective observations, except they are not measurable. The nurses need to know when patients have complaints such as those listed above; the nurse can assess the patient and determine what course of treatment or intervention is needed. CNA’s cannot pass judgment on these statements.
It’s not in our role to do so. Our job is to REPORT the statements, accurately and without added
flair. I often see CNA’s report observations- with their own opinion added in. This isn’t necessary and it’s not good to do. Just the basics is all that is needed. If you’re asked for more information, like, “What do you think is going on?” then by all means give your opinion. But don’t offer it up front as part of the observation.
Examples of CNA statements that are not correct:
“Mrs. Smith says she has a headache. She does this whenever it’s her bath time!”
“When I went to assist Mrs. Smith with her bath she stated that she had a headache.”
“Mr. Jones ambulated ten feet today; he said his foot hurt…yesterday he was fine and walked a hundred feet and his foot didn’t hurt! He’s being lazy.”
“Mr. Jones ambulated ten feet today.”
“Ms. Hawthorne had a really loose BM and it smells like C Diff.”
“Ms. Hawthorne had a loose BM that was very foul smelling.”
I think we get the picture here. Many of the things we know from experience with our work turn out to be true. Ms. Hawthorne probably does have C Diff…we can tell by the odor. BUT it’s not up to us to report that as fact. Are we absolutely sure Mr. Jones is being lazy? What makes us assume that? IS it possible that his foot really does hurt? As CNA’s, our job is NOT to make assumptions and diagnose conditions. We observe, we report. It’s pretty simple. No need to embellish our reports with our own opinions. We’re not always right.
How we observe
Using our eyes we see things:
• Broken skin, open areas, cuts, bruises
• Blood- in urine, in and around the mouth
• Changes in the patient’s ability to walk, speak, eat
Using our hands we feel things:
• Skin temperature (warm, cool)
• Lumps and bumps under the skin
Using our ears we hear things:
• B/P readings
• Respiration problems (wheezing, coughing)
• Patient’s statements
Using our noses we smell things:
• Body odors
• Foreign odors not normal to what we are doing (gas and oil, chemicals and the like)
Observations must be accurate.
Observations must be made in a timely manner and the nurse must be notified of unusual findings.
Observations must be free of our opinions and bias.
Report patient statements word for word…directly quoted. Don’t add your own thoughts.