When we think about it, DPS’s are the eyes, ears, hands and nose of clients’ medical teams (PCP, agency nurses). We use these senses when providing care and with the right skill, we can assist the team with valuable 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”
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).
Subjective observations are reported by the individual and are just as important as objective observations, except they are not measurable.
The medical team need to know when clients have complaints such as those listed above. DSP’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 DSP’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 DSP 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 DSP’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.
Observations must be accurate.
Observations must be made in a timely manner and when necessary the medical team 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.
