OBSERVATION AND RECORDING

1. OBSERVATION AND RECORDING

2. OBSERVATION AND RECORDING • The most important practical lesson that can be given to nurses is to teach them what to observe-how to observe-what symptoms indicate improvement –what the reverse- which are of importance –which are of none-which are the evidence of neglect – and of what kind of neglect. All these are what ought to make part, and an essential part , of the training of every nurse. (Florence Nightingale 1860/1969)

3. OBSERVATION AND RECORDING • One of the most valuable qualities of a nurse is that he/she must be observant. Observations is one of the many tools used in gathering data for planning nursing care for patients. • Observation is gathering data by using one or more of the five senses (sight, hearing, touch, smell and taste ) with an understanding of what has been detected. Without an understanding/ interpretation of what has been observed, the act of observation is useless.

4. OBSERVATION AND RECORDING • What are some of the observations you make about a friend that gives you some information about him/her? • It is a highly developed skill that uses knowledge from the physical and social science as its basis. Thus when a nurse must have a sound understanding of normal behaviour , she will then be able to recognize an abnormal one. • nurses work with other health team members and also run shifts. (list some members of the team)

5. OBSERVATION AND RECORDING • For this reason, it is paramount that observations made on patients are accurately communicated from the nurse who made the observation to other members of staff. On account of this, observations made are written for keeping as records. • records are written documents of events or proceedings. Health records are formal, legal and confidential documents that should be accessible only to the members of the health team involved in the patient’s care to use and deliver effective health care to the patient.

6. OBSERVATION AND RECORDING • Records from observations should be • Factual – state exactly what has been observed and devoid of words like “ it appears , it seems, as if …” ; record exactly what was observed. • Complete – contain the important facts that should be known for effective planning. E.g. the correct unit of measurement (mg, g, ml, Fahrenheit (oF), oC ) medication orders-dose, frequency and duration of administration, review dates, types of surgery, etc.

7. OBSERVATION AND RECORDING • Accurate – use the right instrument, gadgets, procedures and observe the precautions necessary to get correct results. Records should be free from mistakes and other errors as much as possible. • Relevant/ Appropriate – record only information that has a bearing on the issue at stake. The nurse should use his/her knowledge and discretions to sieve relevant information from the irrelevant ones

8. OBSERVATION AND RECORDING • Current – observations should be recorded immediately with date and time as delay in recording can lead to omissions resulting in denial of the needed care to the client or commissions that may be detrimental. Recording observations instantly keeps it current and up to date. • Organized–chronological recording of observations make the records meaningful and also makes interpretation easier.

9. OBSERVATION AND RECORDING • Confidential – the records of the patient should be made accessible only to health care team members who need it to care for him/her. • Standard – records from observations should contain only standard and acceptable format and terminologies to avoid misinterpretation. Why should we keep record of observations? • For effective communication among members of the health team for continuity of care.

10. OBSERVATION AND RECORDING • To avoid duplication of effort. • For research purposes • To serve as a legal document • For auditing and peer review of health institutions • For education purposes. • What do we observe in our patients/clients?

11. OBSERVATION AND RECORDING • Vital signs • Level of consciousness • Amount of fluids input and output • Blood sugar level • Appearance of the client • Activity level of the client • Mental state of the patient • Nutritional status of the client • Facial expression • Gestures • Effects of medications Etc.

12. OBSERVATION AND RECORDING • Though the senses are used in observation, there are pieces of instruments that aid in the procedure E.g. • The thermometer • The sphygmomanometer • Stethoscope • The glucometer find the rest for our next meeting

13. observation and recording of vital signs • Vital signs are physiological data that enables health care workers to monitor the functioning of the body. The vital signs –temperature, pulse, respiration and blood pressure – reflect changes in body function that otherwise might not be observed. • since vital signs also known as cardinal signs reflect changes in body functions, they should not be monitored as a matter of routine but a thoughtful reflective scientific assessment.

14. observation and recording of vital signs When Should Vitals Signs be Checked? • During admission to establish a baseline for comparison with later readings • When there is a sudden change in a client/ patient’s condition or patient reports symptoms e.g. fainting, palpitation, dizziness etc. • As a routine matter of routine in a health facility • Before and after surgery/invasive procedures e.g. blood transfusion, delivery, etc.

15. observation and recording of vital signs • Before and after administration of medications that can affect the cardiovascular and or the respiratory system • According to nursing or medical order for provision of individualized care. • before and after nursing interventions that could affect the vital signs e.g. ambulating a patient who had been on bed rest for long. • When client reports some symptoms

16. observation and recording of vital signs • Factors influencing vital signs • Age • Sex • Race • Geographical location/environment • Lifestyle • Disease conditions (thyrotoxicosis) • Medication e.g. Paracetamol

17. VITAL SIGNS • Vital signs consist of : • Temperature • Pulse • Respiration • Blood pressure In some institutions assessment of the level of ; • Oxygen saturation • Pain level • Consciousness level, are added.

18. VITAL SIGNS • Vital signs are checked to monitor the functions of the body. They reflect changes in function that otherwise might not be observed. • Vital signs must be looked at in total not individually/singly or as different entities to achieve the above

19. VITAL SIGNS • Temperature: It is the degree of hotness or coldness measured against a standard scale. It reflects the balance between heat production and heat loss. • The standard scales commonly used are: • the centigrade/degrees Celsius (OC) • the Fahrenheit scale (OF) • Temperature checked in one scale can be converted into the other

20. VITAL SIGNS • To convert temperature checked in centigrade (OC) to Fahrenheit (OF), OF = ( OC x 9/5) + 32 OC = (OF - 32) x 5/9 • Two (2) kinds of body temperature are: • The core body temperature and • The surface body temperature.

21. VITAL SIGNS • Core temperature refers to the temperature of the deep tissues of the body as in the abdominal cavity, thoracic cavity, the cranium etc. It is relatively constant • Surface temperature is the temperature of the skin, the subcutaneous tissue and fat; it rises and fall in response to the environment.

22. VITAL SIGNS • Factors influencing vital signs • Age • Sex • Race • Geographical location/environment • activity • Disease conditions (thyrotoxicosis) • Medication

23. VITAL SIGNS • ALTERATIONS IN BODY TEMPERATURE • The normal body temperature is a range between 36.2 OC – 37.2 OC. • There are basically two main alterations in body in body temperatures: • Hyperthermia; Temperatures above the normal range (pyrexia/fever) • Hypothermia; Temperatures below the normal range • Temperatures below or above the normal range needs interventions to restore it.

24. VITAL SIGNS • Readings may be: • 1. Subnormal <36.2°C • 2. Normal 36.2°C - 37.2°C • 3. Pyrexia > 37.6°C • - Mild (low) pyrexia 37.6 °C- 38.3ºC • - Moderate pyrexia 38.4°C - 39.4°C • - High pyrexia 39.5°C - 40.0°C • - Hyperpyrexia > 40°C

25. VITAL SIGNS Checking and recording of Temperature • This refers to the use of instruments to estimate the degree of hotness or coldness of the body. • Thermometers are used to check temperature. • There are many types of thermometers; the one used for checking body temperature is the clinical thermometer

26. OBSERVATION AND RECORDING OF VITAL SIGNS Electronic Chemical • Electronic thermometers • Mercury in glass thermometers • Chemical dot disposable thermometers

27. VITAL SIGNS Infrared thermometer (electronic) Mercury in glass thermometer (chemical)

28. VITAL SIGNS Skin thermometer (chemical) Digital thermometer

29. VITAL SIGNS Sites for Checking Surface Temperature • Mouth • Axilla • groin • Rectum • Ear • Skin (forehead) NB: rectal temperature is 0.5°C higher than oral; axillary and tympanic temperatures are 0.5°C lower than oral temperatures

30. VITAL SIGNS Checking and Recording of Temperature Requirements; • A clinical thermometer • A gallipot containing clean cotton wool swabs • A receiver for used swabs • A gallipot containing clean water for rinsing the thermometer (mercury in glass) • Lubricant (for rectal thermometer) • Temperature chart and pens (usually red and blue) • A watch with second hand

31. VITAL SIGNS The Procedure of Taking Temperature in the Axilla (steps using mercury in glass thermometer) • Explain procedure to the patient • Provide privacy • Take temperature tray to the patient’s side • Make patient comfortable in a position that can enable you work (either sitting or lying) • Take the thermometer, dry with cotton wool swab from the bulb towards the stem

32. VITAL SIGNS • Shake mercury thermometer till mercury falls below 35 OC. • Raise arm of client away from torso, inspect for lesion and if none, dry axilla by cleaning with dry cotton and discard swab. • Insert the thermometer in the axilla and lower the arm making sure the bulb is in between the skin folds (of the axilla) and place arm across patient’s chest. • leave the thermometer in situ for three (3) minutes or as indicated on it.

33. VITAL SIGNS • Remove the thermometer and wipe from the stem towards the bulb and check reading, holding the thermometer at an eye level • Record reading on the temperature chart, document in nurses’ note and report any abnormality to the in - charge • Thank patient and make him/her comfortable. • Discard the tray • Wash and dry hands • Report any abnormality in the reading appropriately.

34. VITAL SIGNS NB: • Patient must be still to prevent dislodging and breaking of the thermometer. • Site must be dry before the insertion of the thermometer • The skin surfaces must completely surround the bulb of the thermometer. Some Contraindications for Taking Temperature in the Axilla • Boil in the axilla • Fracture of the bones of the arm • Wound (burns, ulcers etc.) in the axilla

35. VITAL SIGNS The Procedure for Taking Oral Temperature (Steps using electronic thermometer) • Explain procedure to the patient • Provide privacy • Take temperature tray to the patient’s side • Make patient comfortable in a position that can enable you work (either sitting or lying) • Take the thermometer, dry with cotton wool swab from the bulb towards the stem (mercury in glass thermometer) OR

36. VITAL SIGNS • Remove the thermometer from the container/charging unit and assemble if necessary(electronic) • Ask client to open his/her mouth; insert the thermometer gently with the probe placed in the posterior sublingual pocket lateral to the centre of the lower jaw • Ask client to hold the thermometer in place with closed lips

37. VITAL SIGNS • Leave the thermometer in situ for 3 minutes or until a signal (beep) indicates completion and reading appears on the digital display • Remove thermometer and wipe from stem towards the bulb with a swab/discard the probe used is disposable or *** • Check the reading • Record the reading on the temperature chart, indicate site e.g. ‘OT’ • Return the thermometer into it’s container/charging system • Leave patient comfortable. • Discard tray. • Wash and dry hands • Report any deviations

38. VITAL SIGNS Some Contraindications for Taking Temperature in the mouth • Difficulty in breathing • Patient who fits/convulse frequently • Patients with nose packs • When there is disease or surgery done in the mouth • Unconscious patient • Psychiatric patients. • NB: unless electronic thermometers with disposable probe are used, patients must have individual thermometers.

39. VITAL SIGNS The Procedure for Taking Rectal Temperature (Steps using electronic thermometer) • Explain procedure to the patient • Provide privacy • Take temperature tray to the patient’s side • Make patient comfortable in the Sim’s position with upper leg flexed and expose the anal region/area. • Donn disposable gloves

40. VITAL SIGNS • Lubricate the probe of the electronic thermometer from bulb upwards covering about 2.5cm. • With non-dominant hand part patient’s buttocks to expose the anus; let him breath slowly and relax. • Insert the bulb of the rectal thermometer gently in the direction of the umbilicus (to 3.5cm from bulb) if no resistance is met; otherwise stop the procedure. • Hold the thermometer in situ until a signal (beep) indicates completion and reading appears on the digital display • dispose off the probe used

41. VITAL SIGNS • Record the reading on the temperature chart, indicate site e.g. ‘RT’ • Return the thermometer into it’s container/charging system • Wipe the client’s anal region and discard the tissue • Leave patient comfortable. • Discard tray. • Wash and dry hands • Report any deviations

42. VITAL SIGNS Some Contraindications for Taking Temperature in the rectum • Diarrhoea • Disease condition of the rectum e.ghaemorrhoides • Rectal surgery • Rectal prolapse • NB: please read and make note on taking temperature at the rest of the sites not discussed.

43. VITAL SIGNS PYREXIA/FEVER/HYPERTHERMIA • Body temperature above the normal range is termed pyrexia/hyperthermia/fever. A person who has fever is said to be febrile; otherwise, he is afebrile. • A very high fever of above 40OC is termed hyperpyrexia. A person is said to be spiking temperature or fever when his temperature rises rapidly from normal range to above normal then to normal within few hours.

44. TYPES OF PYREXIA Constant-continuous elevation of temperature which does not vary more than 1.1 °C in a day. Remittent – there are variations of more than 1.1 °C in a day but the lowest temperature does not reach normal temperature Intermittent / hectic/ swinging- it varies from normal to subnormal to moderate or hyper pyrexia with 1-3days, there is a variation of more than 1.1 ° C between the highest and the lowest temperature and the lowest being normal or below normal . E.g. In malaria and T.B

45. Irregular- does not fall into any clear group, it shows some characteristics of all the groups. Inverse- highest temperature is recorded in the morning and lowest in the evening

46. VITAL SIGNS • When nursing a client with fever, interventions should be designed to support the body’s physiologic processes, provide comfort and prevent complications. • To achieve this the patient’s vital signs should be monitored closely.

47. VITAL SIGNS Fever may run through the 3 stages: • Onset/Cold/Chill Phase that is characterized by • Shivering • Increased pulse rate • Increased respiratory rate • Cold skin with “goose-flesh” • Complaints of feeling cold

48. VITAL SIGNS Management-nursing measure during this phase is to aimed at helping the client to reduce heat loss: • Check and record vital signs • Provide extra warmth (with extra clothing, give warm drinks; • switch off fan/ac etc and close nearby louvers, windows, doors etc

49. VITAL SIGNS 2. Course/Hot/Plateau Phase is marked with • Complaint of feeling hot • Warm and dry skin • Increased pulse and respiration • Increased thirst • Loss of appetite • Drowsiness • mild to moderate dehydration

50. VITAL SIGNS • Flushed skin • Restlessness, • Delirium and confusion may occur • Convulsion may occur especially in children • Malaise, • weakness and • aching of the muscles