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What are the four senses to observe objective abnormal/normal changes?
Sight
Smell
Touch
Hear
What are some objective sight observations?
Redness, rash, fall, seizure, blood, vomiting, eyes change colors, dark urine
What are some objective smell observations?
Infection, wound, peri area, urine, breath, foul odors, CDIFF
What are some objective touch observations?
Skin that's hot/cold, clammy, fast/slow pulse and a LUMP
What are some objective hearing observations?
wheezing, rales, difficulty speaking, difficulty breathing
What do you do if you notice abnormal observations?
Immediately do an assessment and have the nurse call the doctor and family.
What are some subjective signs to be reported?
Complaint of pain, sight, hearing, dizziness
body language reflects pain and discomfort
What should you do with any information, whether it is normal or abnormal?
Document: document FACTS, according to the policy and procedures, using approved abbreviations only.
never have cowork document for you
Pain in the __ can indicate:
Head: aneurysm
Chest: heart attack
If a resident can’t see:
clean glasses
Glaucoma
pressure behind eyes. can only fix with surgery