Charlotte Eliopoulos RN, MPH, PhD Executive Director American Association for Long Term Care Nursing Observation refers to the use of all your senses in collecting information about a resident. Alertness and Orientation New or different: Dullness, drowsiness Confusion Slow responses Not recognizing you General Function Changes in ability to: move, transfer ambulate eat bathe dress toilet use any body part Skin New or worsened: Break in skin Rash Sore Discoloration Unusually warm or cold areas Joint Movement New or worsened: Stiffness of a joint Inability to move any body part Pain when using/moving any body part Intake and Output Excess thirst Reduced fluid intake Excess voiding Lack of voiding Urine that has a strong odor, is of a dark color, or contains pus or particles Eating Reduced or increased appetite Difficulty chewing Difficulty swallowing Choking Nausea, vomiting Reduced intake Weight More than 5 pounds increase or decrease in past month Breathing Difficulty breathing at rest Difficulty breathing with activity Wheezes or other sounds when breathing Coughing Complaints of not being able to breathe or get enough air Eyes and Vision New or worsened: Redness of eye Discharge from eye Itching of eye Inability to see Eye pain Ears and Hearing New or worsening Inability to hear Ear wax Discharge from ear Ear pain Mental Status and Mood New or worsened: Confusion Inability to recognize familiar people or objects Inability to perform routine tasks, activities Depression Fearfulness Anxiety Anger Gather as much information as you can Report all details to the nurse Thank you for all you do!