5.3 Clinical Observation & Documentation

Clinical Observation & Documentation

As a Certified Nursing Assistant (CNA) in Oregon, you represent the primary line of clinical observation. Because you spend the most direct, hands-on time with residents during daily care activities, your ability to observe subtle changes in skin integrity, pain levels, and physical elimination is vital. Under Oregon Board of Nursing (OSBN) standards of care, any observed change must be documented objectively and reported promptly to the supervising nurse to prevent serious complications.

Skin Integrity and Pressure Injuries

Skin is the body's first line of defense against infection. Elderly residents often have thin, fragile skin that is highly susceptible to breakdown. A pressure injury (formerly called a pressure ulcer or decubitus ulcer) is localized damage to the skin and underlying soft tissue, usually over a bony prominence, resulting from prolonged pressure, shearing, friction, or moisture.

• Bony Prominences (High-Risk Sites): The sacrum (tailbone), heels, elbows, hips, shoulder blades (scapulae), and the back of the head.
• Friction and Shearing: Friction occurs when skin slides against another surface (like a bed sheet). Shearing occurs when the skin remains stationary while the underlying bones move (for example, when a resident slides down in bed when the head of the bed is elevated).
• Stages of Pressure Injuries:
  • Stage 1: Intact skin with a localized area of non-blanchable erythema (redness). When you press on the red area, it does not turn white (blanch). In dark-complexioned residents, the skin may not appear red but may have a different color (purple or dark brown) or feel warmer, cooler, or firmer than surrounding skin.
  • Stage 2: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, and moist. It may also present as an intact or ruptured serum-filled blister. Subcutaneous fat is not visible.
  • Stage 3: Full-thickness skin loss. Subcutaneous fat is visible in the injury, and slough (dead yellow/tan tissue) or eschar (tan/black crust) may be present. Muscle, tendon, ligament, or bone is not exposed.
  • Stage 4: Full-thickness skin and tissue loss. Muscle, tendon, ligament, cartilage, or bone is directly visible or palpable.
  • Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If the eschar is removed, a Stage 3 or Stage 4 injury will be revealed. (Note: Stable eschar on the heels should not be removed as it serves as a natural barrier).
  • Deep Tissue Pressure Injury (DTPI): Intact or non-intact skin with localized, persistent non-blanchable deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed.
• Prevention: Turn and reposition bedbound residents at least every 2 hours (and wheelchair-bound residents at least every 1 hour). Use a draw sheet (lift sheet) to lift and move residents, rather than dragging them, to prevent shearing. Keep skin clean and dry, promptly removing wet linens or incontinence briefs.

Pain Reporting

Pain is a subjective experience; it is whatever the resident says it is. CNAs do not assess pain (assessment is a licensed nurse function), but they are responsible for collecting pain data and reporting it immediately.

• Subjective Reporting: Ask the resident if they are in pain and have them rate it using the facility’s approved scale (such as a 0 to 10 numerical scale or the FACES visual scale).
• Objective (Non-Verbal) Indicators: Many residents, particularly those with advanced dementia, cannot verbally express pain. Watch for:
  • Grimacing, frowning, or wincing.
  • Guarding a specific body part or resisting movement.
  • Moaning, groaning, whimpering, or crying.
  • Increased restlessness, agitation, or sudden behavioral changes.
  • Changes in vital signs (elevated blood pressure or pulse).
• Action: Report all pain complaints or non-verbal signs of pain to the nurse immediately. Under OSBN rules, a CNA must never administer pain medications (unless they are also a Certified Medication Aide operating within their delegated scope).

Specimen Collection

Specimens must be collected using strict aseptic technique to prevent contamination and ensure accurate laboratory testing.

• Mid-Stream Clean-Catch Urine: Used to detect urinary tract infections (UTIs).
  • Procedure: Clean the perineal area thoroughly with antiseptic wipes (for females, wipe front-to-back; for males, clean the tip of the penis in a circular motion). Have the resident begin urinating into the toilet or bedpan. Once the stream is established, place the sterile specimen cup under the stream to collect the sample without touching the inside of the cup. Remove the cup before the resident finishes urinating.
• 24-Hour Urine Collection: Used to test kidney function over a full day.
  • Procedure: Ask the resident to void first thing in the morning. Discard this first specimen but record the exact time as the start of the 24-hour period. Collect all subsequent urine voided for the next 24 hours. Keep the collection container on ice or refrigerated as required. If any urine is accidentally discarded or contaminated with toilet paper, the test is ruined and must be restarted.
• Stool Specimen: Used to test for blood, fat, parasites, or pathogens.
  • Procedure: Have the resident defecate into a clean, dry bedpan or specimen collector ("hat"). The stool must not be contaminated with urine or toilet paper. Use a tongue blade to transfer a representative sample (about 1–2 tablespoons) from different parts of the stool into the container.
• Sputum Specimen: Mucus coughed up from the lungs (not saliva from the mouth).
  • Procedure: Collect first thing in the morning. Have the resident rinse their mouth with water first (no mouthwash or toothpaste, which can kill bacteria). Instruct the resident to take 2–3 deep breaths, cough deeply from the chest, and spit directly into the sterile container.

Bedmaking

Clean, dry, and wrinkle-free beds promote resident comfort, prevent skin breakdown, and maintain infection control.

• Occupied Bed: Changing sheets while the resident remains in the bed.
  • Safety: Always lock the bed wheels. Raise the side rail on the side the resident is turning toward to prevent falls. Work with the bed at a comfortable working height to protect your back, but return it to its lowest position when finished.
  • Procedure: Loosen top linens, keep the resident covered with a bath blanket for privacy and warmth. Roll the resident to one side. Roll soiled sheets inward (dirty side in) toward the resident's back. Place clean bottom sheets on the empty half of the bed, tucking them under the soiled sheets. Roll the resident over the "hump" onto the clean sheets. Remove soiled sheets, pull clean sheets taut, and secure them.
• Unoccupied Bed:
  • Closed Bed: Made for a discharged resident or when the bed will not be used immediately. Top covers are pulled all the way to the head of the bed.
  • Open Bed: Made for an active resident who is out of bed temporarily. The top sheet and blanket are fan-folded to the foot of the bed for easy access.
  • Surgical Bed: Top linens are folded to the side or fan-folded to the far side of the bed to allow easy transfer from a stretcher.
• Infection Control: Never shake linens, as this disperses microorganisms into the air. Never place clean or dirty linens on the floor or overbed tables. Hold dirty linens away from your uniform and place them directly into the linen hamper.