Question

Module 14: Managing Information Review 1. Why is careful observation important? 5. Why is it important to detect problems in the early stages? 2. What are three requirements for reports? 6. What should the NA do if something seems wrong? 3. List five or more physical changes that should be reported. 7. What are flow sheets? 8. List five or more emotional changes that should be reported. Explain the procedure for charting in a resident's record. 130

Answer 1

Ans) 1) Proper observation and documentation allows physicians and RNs to understand the progress and deterioration in a patient's condition.

- For instance don't simply say that patient has temperature, you need to measure it and give the data for better treatment.

- Key areas for improvement were regular observations, early recognition of deterioration, improved communication and effective response to concerns. Nurses are pivotal to influencing improvements in observations management and ultimately patient safety.

2) Necessary information required by a governmental body, organization, or employer and is often required within a certain period of time and within a specific format.

3) Changes in physical health are often identified by changes in a
particular part of the body. Some are changes you may observe, and others are changes
an individual may tell you.

- For example, you may observe that an individual is pulling his ear or an individual may tell you that his ear hurts.
Ask yourself: Is there any apparent change to the individual’s skin, eyes, ears, nose, or any other part of the body?

Physical changes to pay attention to include:
• Skin: Redness, cut, swelling, rash.
• Eyes: Redness, yellow or green drainage, swelling of the eyelid, excessive tearing, or
the individual reports pain and/or that eyes are burning.
• Ears: Pulling at ear, ringing in the ears, redness, fever, diminished hearing, and
drainage from the ear canal, the individual reports dizziness or pain.
• Nose: Runny discharge (clear, cloudy, colored), rubbing of nose.
• Mouth and throat: Refusing to eat, redness, white patches at the back of the
throat, hoarse voice, fever or skin rash, toothache, facial or gum swelling, gum
bleeding, fever, individual reports pain when swallowing.
• Muscles and bones: Inability to move a leg or an arm that the individual could
previously move, stiffness, limited range of motion, individual reports pain in the
arms, legs, back.
• Breathing (lungs): Chest pain, cough, phlegm (mucous), shortness of breath or
wheezing, fever, rash, stiff neck, headache, chills, nasal congestion, individual
reports pain in nose or teeth, dizziness.
• Heart and blood vessels: Numb or cold hands or feet, swelling of ankles, chest pain,
shortness of breath.
• Abdomen, bowel, and bladder (stomach, intestines, liver, gallbladder, pancreas,
urinary tract): Constant or frequent abdominal pain, bloating, vomiting, loose stools
or diarrhea, constipation, blood in vomit or stools, fever, fruity smelling breath,
difficult, painful and/or burning urination, changes in urine color (clear to cloudy or
light to dark yellow), fruity smelling urine, nausea, pain on one or both sides of the
mid-back, chills.
• Women’s health: Vaginal discharge, itching, unusual odor, burning, changes in
menses, such as change in frequency, length, and flow.
• Men’s health: Discharge from penis, pain, itching, redness, burning.

4) Changes in Mental or Emotional Status
• Behavior: An individual who is usually calm starts hitting and kicking; appears more
or less active than usual.
Ask yourself: Does the individual appear more or less active than usual?
Is the individual acting aggressively to himself or to others?
• Ways of communicating: An individual who usually talks a lot stops talking; speech
becomes garbled or unclear.
Ask yourself: Has the individual’s ability to talk or communicate changed?
• Appearance: An individual who is usually very neat in appearance now has uncombed hair; is wearing a dirty, wrinkled shirt. There are changes in color or appearance (a sudden redness on the hands or an ashy tone and clammy feel to the skin); any changes in weight, up or down.
Ask yourself: Does it seem like the individual has lost interest in things?
Is the individual taking less care in his or her dress?
• General manner or mood: Someone who is usually very talkative and friendly becomes quiet and sullen; an individual who usually spends her free time watching TV with others suddenly withdraws to her room and wants to be alone.
Ask yourself: Has the individual’s mood changed? Does the individual want to
be alone all the time?
• Family/social relationships: The individual may act distant or afraid when family members or visitors are around.
Ask yourself: Is there someone interacting with the person who appears to causing emotional distress? If you notice any signs of drug activity, or verbal or physical abuse, inform your supervisor immediately.