Observation Skills For CNA's

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
• Bruises
• 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:
Incorrect:
“Mrs. Smith says she has a headache. She does this whenever it’s her bath time!”
Correct:
“When I went to assist Mrs. Smith with her bath she stated that she had a headache.”

Incorrect:
“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.”
Correct:
“Mr. Jones ambulated ten feet today.”

Incorrect:
“Ms. Hawthorne had a really loose BM and it smells like C Diff.”
Correct:
“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:
• Pulse
• 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.

© 2007. All Rights Reserved Nursing Assistant Resources On The Web
This material can be used freely for educational purposes.

Horizontal Violence

Horizontal Violence

The stories are all too familiar. CNA's treating each other poorly. New CNA's often receive the worst assignments and are blamed when things go awry. Experienced CNA's participate with this "hazing" of new staff. The overwhelming need to fit in is important. But at what cost? Does anyone consider the consequences of their actions? Increased turnover is the result of Horizontal Violence and job dissatisfaction. This means increased workloads for those left behind and this results in poorer quality care for the residents. Another possible ramification is the image the general public has of CNA's and of Nursing in general. CNA's aren't considered to be professionals. A case for professionalism isn't made when patients hear CNA's telling each other off or arguing with nurses. All CNA's should work together to stop Horizontal Violence. What can the CNA do to help stop this?

It is easy to say: "I refuse to participate in any activities that may undermine another person's worth"...But some lack the courage to say this. A lot of changes must take place in workplaces to create an environment in which CNA's need not fear communicating the truth, and where others invite their input and listen to it. In reality, actions speak loader than words. Those who are looked to as role models or have the courage of their convictions should act to create such a workplace. It is acknowledged that where Horizontal Violence occurs management is a part of the problem. Behaviors begin at the top. If their is a perceived lack of support then there is little likelihood for change. Policies need to be in place, and supported, which clearly state the work ethics of the institution. Change is difficult but it is to the advantage of the CNA, the resident and the entire facility.

The average CNA can contribute. Follow the simple Golden Rule: Do onto others what you would want them to do to you. Treat people the way you want to be treated.

Try adopting the following into your everyday work habits:
Use kindness, concern and respect in all dealings with others.
Respectful listening-look peers in the eye when talking
Lead By Example (Make a bed for another CNA who is behind)
Own up to your mistakes, don't attempt to shift the blame
When making requests, be polite, be tactful.
Use a positive and respectful tone
Don't participate in gossip
Invite loners and newcomers to breaks and meals
Tell the nurse she did a great job or compliment her for something extra special she did to help.
When others do a kind act, thank them in front of others,
Bring your whole self to work and give it your best shot
Accept your fair share of the work load.
Respect others privacy
Be respectful of shared working conditions
Be willing to help when requested
Work together despite personal dislikes
Don't denigrate to superiors
Address peers by their first name
Ask for help and advice when needed.
Repay debts promptly
Stand up for peers in their absence, don't be critical of them.
Smile

Some of the effects of the above acts:
Increased job satisfaction
Higher self esteem
Personal power
Happiness
Faith in Self and in Others
Lower absenteeism rates
Work environment deemed more "family like" than"just another job"

A Note About Vertical Violence (from nurses to CNA's):
The manner in which nurses treat each other as well as CNA's needs to be addressed. How do we handle a situation such as being yelled at by a nurse because we didn't get something done? When a nurse (or CNA) is yelling at us, it is virtually impossible to maintain any sense of control. We get embarrassed, we are humiliated and get red faces. While being yelled at we cannot even begin to defend ourselves or explain what has happened. The best thing to do at this point is to ask the nurse, in a respectful manner, to leave the area and go to a private place. This is where these discussions should take place in the first place, and CNA's should always insist on this. Ask the nurse to restate her concern without the load body languages and tones. Once you think you understand what the nurse is saying to you, rephrase it back to her. This is called validating. Once she agrees that you understand each other, explain to her what happened. Remember that nurses are also victims of Horizontal and Vertical Violence; they get yelled at by doctors, DON's, administrators, patients. Collectively we are get yelled at and we are all victims. Together we can work to bring an end to this, and maybe someday we can say with pride that we are professionals.


The CNA can do all these simple things to bring about change within their work units. By refusing to undermine others, and by maintaining a high work ethic, CNA's are in a good position to help create a positive and enriching environment in which to work. CNA's should consider meeting with management to discuss "Horizontal Violence" and describe it's negative impact upon quality care.

Some things to consider when meeting with management:
Look at turnover rates...Ask why so many leave. The usual high ratios and low pay are always there, but look into the way staff treat each other. Honest and open discussion are required in order to truly change. If staff feel a sense of belonging and personal satisfaction they will continue to work under less than perfect conditions.

Ask management to add a lecture about HV in CNA Training Classes
Ask management to form an Employee Mentor Program(for new staff)
Ask management to form Quality Teams (who will tackle all areas of quality within the facility)
Ask management to consider forming a policy about all forms of Workplace Violence- Horizontal,
& Vertical. The benefits will outweigh the costs involved.
Ask management to write a statement of position about workplace violence.

Bring to management's attention the following early warning signs of impending physical violence:
Weak or non-existent policy against all forms of workplace violence-physical as well as horizontal and downward.
Negligent Human Resource Practices: (weak hiring practices, negligent training, poor supervision)
Ineffective or non-existent reporting procedures for violence and threats
An autocratic or abusive management style (unfortunately, typical in nursing)
An atmosphere of indignity tolerating sexual and non-sexual harassment, disrespect and intolerance.

Many nursing homes have adopted the following list of "Rights of The Employee":

YOU HAVE THE RIGHT...
1) To insist on a reasonable workload and fair expectations
2) To put family obligations first when necessary
3) To refuse to do something that conflicts with your principles
4) To receive fair compensation and increases for the work you perform
5) To be treated with dignity and respect
6) To refuse to be responsible for someone else's performance
7) To be kept informed about decisions that impact your job
To refuse to participate in office politics without fear of emotional or economic retaliation
9) To stand up and take action against any kind of harrasment, threats, intimidation attempts and discriminatory behavior, verbal abuse, violations of trust and confidentiality.
10) To performance expectations that are clear, consistant, rational,honest, stated up front, and free of unwritten rules.
11) To adequate training
12) To question procedures that seem contradictory, overly complex or excessively bureaucratic.
13) To be treated as an individual, and to refuse to be treated as a unit or a statistic.
14) To insist that stated or implied promises and commitments be kept
15) To move on if your job doesn't meet your needs

***UPDATED***

Some links to workplace violence, Horizontal Violence and Nursing:
Ending Nursing Violence

Horizontal Violence: A Male Nurse's Perspective

Are you being bullied?

The Costs of Workplace Discontent

A Management Toolkit: Ending Nurse-to-Nurse Hostility

And remember that by complaining about the situation at work and not doing anything towards changing it you are contributing to a negative work environment. Each CNA had within them the capacity to help make a difference.

Try it....Today.


© Originally printed: 1998. All Rights Reserved Nursing Assistant Resources On The Web
This material can be used freely for educational purposes.

The Nursing Process & The CNA

The Nursing Process, And The CNA

In my experience working as a CNA in a nursing home, I rarely heard the term “Nursing Process”; I often heard about care plans- but that was about as descriptive as things would get. I remember asking a nurse- “Just what is a care plan, anyway?”- and she didn’t know how to answer me! So I have spent a long time researching this elusive term- “Nursing Process”- and trying to figure out exactly where the CNA fits in with it.

First, the medical team is broken into several layers. At the top is the patient- who has an illness, or condition requiring on going care. The Doctors are next- we all know they are well educated and have spent years learning how to diagnose and treat problems, illnesses, disease ect. Doctors are the only person within the medical team who can actually diagnose. Nurse Practitioners- in reality- cannot DX anything without checking with the MD. Physician Assistants often will see a patient and DX simple problems such as ear infections, but an MD will always go over the PA’s notes to make sure nothing has been missed. Same with Nurse Practitioners- the MD always double-checks the work.

So this brings us to the next point: A patient, client, resident is admitted to a nursing unit. This can be in a hospital, nursing home, rehab center, even to the patient’s own home. Nurses are called upon to perform several steps to assist with the healthful and positive outcomes for these patients. The nursing process is a relatively new thing; in the 1960′s team based nursing came into fashion, but nurses had no way to let other team members know what to do with patients.
A process, based upon what scientists use, was developed. Over the years this process has been refined to what we know today.

The nursing process is divided into five steps.
1) Assessment
2) Nursing Diagnoses
3) Planning
4) Intervention
5) Evaluation

Where does the work of the CNA fall here, you may ask yourself? Let’s see if we can find some pretty common things CNA’s are asked to do, that are a part of helping the nurses with this process. It is assumed here that the patient/resident/client has a top level diagnoses from an MD, and a treatment plan is in place from the MD. This plan would include medications, treatments, special diets, procedures ordered by a doctor.

Step One: Assessment
Assessment involves continuous data collection to identify a patient’s actual and potential health problems. This data should be as objective as possible, and nurses should be as non-judgmental as possible as well. To perform the assessment, nurses should:
· Get Nursing History from patient
· Perform a physical examination
· Review lab and medical information

The nursing history is mostly subjective data. Often, the patient’s perception of his health problems makes up a large portion of the health history. Nurses should find out how the patient coped with a similar illness, what interventions worked, didn’t work ect.

A physical exam is the next step. This is where the CNA often assists the nurse. When we are asked to get heights and weights, vital signs, record food/fluid intake and output, it is almost always for the purpose of assessment. Although CNA’s do not make assessments, nurses depend upon us to report timely and accurate data. Things we see, smell, hear, feel and touch should be reported.

Nurses should perform a thorough exam by doing the following:
· Body Inspection- observation of patient- direct and indirect
· Palpation- feeling body regions for masses, smoothness, muscle tone
· Percussion-using fingers in a tapping motion to feel for abnormal sounds over body regions
· Auscultation- listening for sounds over body regions such as lungs, bowels…

Nurses are taught skills to perform a physical assessment in their schools.

Step Two: Nursing Diagnoses
Nurses are licensed to identify and treat certain human reactions and potential health problems associated with the illness, disease ect.
As we see, nurses have a huge responsibility when it comes to giving accurate diagnoses of a health/potential health problem. All the care given is based upon the proper Dx, the proper plan of care being written and the right interventions.
Based upon all the data collected- both subjective and objective, the nurse next will form a nursing diagnoses drawing from the above list of possible problems.

It is these terms in the list that we will often see when we look at a care plan. It isn’t something that comes lightly for nurses- this is one of the big reasons they need a college degree. Assessment is a big part of being a nurse, and it is an even bigger part of what we, CNA’s, do. It is absolutely vital that we report back accurate information. The care a patient gets, and hence the outcome of his health, depends upon good sound information.

Step Three: Care Planning
The Care Plan is a term we should all be familiar with. We all should know that the care plan is the bible for nursing care of patients, but what else should we know about this document? It is a legal document promising care being delivered as written; the nurse can get into huge amounts of trouble if her care plan isn’t followed. The care plan is designed to assist team members in delivering high quality, consistent care that is needed. Time spent performing tasks and care that is not needed results in wastes of money, resources. Effective care plans take into account unit staffing patterns, patient wishes and abilities, and should reflect who the patient is. A good nurse will seek the opinion of the CNA when writing the care plan. CNA’s can offer invaluable insights into the patient’s abilities and desires. All facilities should encourage CNA participation in care plan conferences.

Cookie cutter care plans are easily recognizable:
· They have the same nursing Dx
· They have the same interventions for all patients (seen often in nursing homes, where all residents have been known to be on a two hour bladder program)
· They don’t work!

A good care plan will be specific, realistic, clear and brief. It doesn’t need to be a long novel.
Anyone who is expected to deliver care from a care plan should be able to read the plan and understand it, including the patient when applicable, as well as the patient’s family.

Step Four: Interventions
This is where the CNA really comes into play! Often, the interventions are WHAT we do. All that turning, repositioning, toileting- are all interventions listed in the care plan. Also, a great amount of the documenting we do is designed to assist the nurse with evaluating these interventions. So it really makes sense to document accurately- in time- if an intervention IS NOT working, it will be noted (and perhaps removed from future care plans). Interventions can be anything from special baths to back rubs to repositioning, to toileting, to using special creams and lotions, to offering certain supplements. Often, an intervention must have an MD order along with it. This is kind of strange I think- if nurses are allowed to formulate their own Dx then they shouldn’t need an MD’s order to carry out some of the treatments to reach the goals. The most important part a CNA can play in this intervention stage is to accurately report all reactions to the interventions. Be as specific and objective as possible.

Step Five: Evaluation
This is the final step in the nursing process. This is the time when nurses look at their care plans and check to see if the plan has “worked” in solving the patients’ health issues, concerns, ect. As stated before, a good plan will work and a poor plan will not. Nurses will check to see if the interventions have been effective- they look at subjective as well as objective data. This is when they will see your good documentation! For example, if a patient were incontinent, and the patient wasn’t so until recent illness, the nurse might try a timed program approach to help the patient gain control again. IF the initial voiding assessments, done by the CNA, were not accurate (i.e.- CNA just wrote in times she guessed patient voided)- and the nurse put the resident on a two-hour program…when patient actually needed to go every hour- you can see how this intervention would fail.

The nursing process doesn’t end here- it continues until the patient is discharged or passes on or whatever. Sometimes a patient goes home with a care plan, and this is especially challenging for staff. If the nurse never saw the home environment, then chances are good that the care plan won’t work. Usually home health nurses do the plans for this population.

Some thoughts to Ponder…
As I said in the beginning of this page, I never knew what the nursing process was. I still have my books from my CNA classes, and I have several newer additions. It wasn’t until very recently that CNA’s were taught this process. This is too bad. I fear there are too many CNA’s out there who do not have a clue how important their work is. All the work, the documenting- would certainly take on a new meaning if CNA’s really understood their role, within the nursing process, as a whole. It would make a good in-service for any facility to offer: Nursing Process- What Is it?

Even of greater concern for me is the apparent lack of concern on the part of nurses who are charged with this process. Never mind those who don’t seem to know what it is, but what about those who DO know, yet follow their own approaches to deliver care. Hmm. I challenge all CNA’s to hold their nurses up to the standard when it comes to the Nursing Process. After all, if our work is to have any meaning at all, then the Process should be the standard. When a new patient is admitted onto a unit you work on, watch to see if a complete physical assessment is done by the nurse; see if any of the things you are asked to do may have a part in the assessment. Ask questions. Expect answers that make sense to you. A lot is at stake here, the patient’s well being. See if all your good documenting is worthwhile. Ask the nurses what will become of the notes you have written- those flow sheets should become a tool, not some paper put into a chart.

See if the system really works, or if it is just another process that is meaningless.

© 2006. All Rights Reserved Nursing Assistant Resources On The Web
This material can be used freely for educational purposes.