In the most basic of terms, certified nursing assistants are the eyes and ears of a healthcare system. The ability to property investigate a patient helps determine a host of essential aspects of patient care and treatment effectiveness. When carried out in an effective manner, the observational skills of a certified nursing assistant can actually save the life of patients. However, things can often become confusing when a CNA is in charge of dictating their observations.
The most important element to remember as a certified nursing assistant is to ensure your findings from observations are based in reality and truth. Although these findings may not be scientifically measurable, such as a patient saying they simply don't feel right, calling upon your investigative powers can help ensure a patient receives the necessary treatment and care for a swift recovery.
While there are some observations that cant be measured via scientific means, there are many others that are physically verifiable. These include: blood in the patients urine, an unexplained rash, the development of bruises and a severe alteration is the output/volume of urine via a catheter. The most important element when dictating a verifiable observation is that they're not opinionated and are supported via physical evidence.
An unverifiable observation can be just as important as a verifiable finding; however, the main difference is these observations are unable to be scientifically measured. For example, a patient states they simply feel weird, have a newly developed pain or begin to undergo psychological changes. If a certified nursing assistant investigates an unverifiable observation, its essential to immediately involve a superior nurse. Never attempt to pass judgment on these observations. Simply make note of what your investigation reveals and allow a more seasoned medical professional take the necessary steps to uncover the underlining causes of these ailments.
Remember, your job as a certified nursing assistant isn't to uncover why a patient is experiencing a specific symptom, but rather to report the claims as accurately and without your own judgment.
When working as a certified nursing assistant, follow these tips as outlined by the National Council of State Boards of Nursing to ensure your investigative nature is effective and accurate:
- Findings should not be based upon your own opinions.
- Observations should be reported and documented in a timely manner to your superior nurse or physician.
- Findings should be free from prejudice.
- When possible, make sure your findings are backed up by physical evidence, such as newly formed skin lesions, blood in the urine or a spike in temperature.
If findings are unverifiable, do your best to record your findings in a factual, non-opinion-based manner.