The Importance of Observation in Health and Social Care Settings

As a health and social care practitioner working in a care home, observation is a crucial part of your job to monitor any changes or progression in older adults’ conditions.  This ensures that any symptoms indicating new and serious health conditions or any deterioration in current health conditions are recognised, reported and attended to. This blog will outline what observation is, why it is important in a care home setting, when to observe and how to document observations.

What is Observation?

Observation is constantly using sight, hearing, smell and touch combined with your knowledge of the older adult to monitor any changes to their health or social wellbeing.  In a care home setting observation is often separated into objective and subjective observation.  

Objective observation is visible and measurable signs that are usually factual.  This includes monitoring and recording vital signs, such as breathing, blood pressure, pulse and temperature, and input/output ratio, such as any blood in urine or stools, bruises, rashes and allergic reactions. By keeping a constant and accurate record of these readings, you can compare them against previous readings and monitor any changes or progression in the residents’ conditions.  

On the other hand, subjective observations are signs that cannot be measured, and are usually verbal communications from the older adult on how they feel, such as nausea, an upset stomach, sore muscles and headaches.  These signs should be reported to the registered nurse or doctor to be looked into further.

Why is Observation Important in Care Home Settings?

Practitioners working in care homes are often the staff that spend the most time with the residents.  This means they are usually the first to recognise any changes to the older adult’s health conditions or behaviour.  Therefore, their observation skills are extremely important.

Good observation skills are essential to:

• complete baseline observations to know what is normal for the older adult
• identify any patterns of behaviour that is normal  for the older adult
• establish a detailed and accurate treatment plan that provides the best care for the older adult
• identify any changes to an older adult’s health conditions or patterns of behaviour
• report any symptoms which indicate a new health condition or any deterioration in current health conditions 
• maintain the older adults’ independence as much as possible, and their privacy and dignity; and 
• provide care tailored to the older adults’ needs

All of these areas ensure that the older adult is getting the best care possible, and any negative changes to their health or behaviour is recognised and attended to as soon as possible.

When do Care Home Practitioners Observe?

Observation is a constant process, and there are vital signs that need to be regularly reviewed to keep an up-to-date record of a residents’ health and mental condition.

Practitioners also need to undertake an initial, or baseline, observation in order to monitor and compare new observations against this to identify any changes to the older adult’s physical or mental state.

There are some common vital signs and health conditions that need to be observed and recorded to provide baseline observations, and these include:

Breathing or Respiration

The rate and type of respiration provides important insights into people’s general health that allows care professionals to identify problems early on and attend to them.  There can also be influential factors that can affect an older adults breathing, including asthma, blocked nose, anxiety, certain medication, chest infections, cracked rib, lung disease or tumours, heart problems or brain problems.

The frequency of checking respiration depends upon the older adult’s health conditions, i.e. there should be more observations on respiration if a resident has a lung disease, long-term lung conditions, are susceptible to chest infections or have certain other physical disabilities.

The baseline observations on an older adult’s respiration will identify what the normal breathing pattern for them is.  This should be recorded on the resident’s chart, clearly and accurately, and all further observations should be compared against this.

Pulse

The heart contracts and pumps blood around the body, and a pulse is the feeling of blood passing through arteries over a solid structure, such as bone.  The rate (the number of pulses per minute), strength (strong or weak) and rhythm (regular or irregular) of a pulse are all factors that can reveal further information on an older adult’s state of health.

The pulse can be affected by whether the resident is feeling angry, nervous or anxious, has partaken in physical activity, or recently smoked a cigarette.  If this is the case, the pulse should be taken again once they have had adequate time to calm down or recover.

The regularity of checking a resident’s pulse depends upon whether the older adult has serious health conditions, which requires them to be monitored closely.  An older adult’s pulse should also be regularly checked after an operation, as a rapid pulse could indicate internal bleeding and require emergency assistance.

The baseline observations on an older adult’s pulse will identify what the normal pulse pattern for them is.  This should be recorded on the resident’s chart, clearly and accurately, and all further observations should be compared against this.

Blood Pressure

Blood pressure is the force that your heart uses to pump blood around your body, and the force blood exerts on the walls of the blood vessels and arteries.  High blood pressure (hypertension) can lead to serious illnesses such as heart disease, heart attacks and heart failure, and low blood pressure (hypotension) can cause heart attacks, strokes and kidney failure.

The regularity of checking a resident’s blood pressure depends upon their general health state.  Those who are obese or have a history of high blood pressure should be checked more frequently.

Blood pressure can be temporarily affected by an older adult smoking or drinking, and feeling stressed during the initial health check.  Therefore, there should be an awareness that the first reading might be misleadingly high when you compare any future observations.

The baseline observations on an older adult’s blood pressure will identify what their normal blood pressure is.  This should be recorded on the resident’s chart, clearly and accurately, and all further observations can be compared against this (though remember this initial reading might be higher than average).

Blood Glucose Testing

Knowing blood sugar levels is important to diagnose and monitor treatment for diabetes.  Those with the condition are unable to properly process glucose (sugar) in their bodies as there is an insufficient amount of the hormone insulin.  The levels of glucose can range from too high or too low, which can cause serious side effects on their bodies. By regularly monitoring residents’ glucose levels ensures they stay within safe limits.

There are different medications and testing for glucose levels, as diabetes comes in a variety of severities.  Most older adults will already have their own routine for checking their glucose levels, and this can be several times a day, once a week or once a month.

The most accurate and reliable way to test blood glucose levels and monitor diabetes is by testing the blood.  Diabetes can be managed through a mixture of diet, medication and physical activity, but they must all be in balance for each individual person.

The baseline observations on an older adult’s blood glucose levels will identify what the normal glucose levels for them is.  This should be recorded on the resident’s chart, clearly and accurately, and all further observations can be compared against this (though remember this initial reading might be higher than average).

Body Temperature

Bodies are complex, and there is a complex series of processes that are constantly underway within our bodies to keep our body temperature within the normal range (usually 37°C on average).  This includes sweating when we are too hot and shivering when we are too cold. The body needs to be kept within the normal range of body temperature in order for certain bodily processes and functions to take place.

Changes in temperature can be indicative of other health conditions, such as an infection if there is a rise in body temperature, or hypothermia if there is a reduction in body temperature.

An older adult’s temperature should be taken upon their arrival in the care home, so you have a basis for future observations.  The frequency of checking an older adult’s temperature depends upon their health, for example, if they are feeling unwell, look flushed, being to shiver, or complain about feeling cold.  

The baseline observations on an older adult’s temperature will identify what the normal body temperature for them is.  This should be recorded on the resident’s chart, clearly and accurately, and all further observations should be compared against this.

Other vital signs or conditions that health and social care practitioners will observe include:

• Oxygen levels
• Peak flow testing
• Urine testing
• Body Mass Index (BMI)
• Mental health
• Loneliness 

Whilst observation is a constant process, but there are also different levels of observation which depend upon the resident’s identified needs, behaviour and care plans.  Older adults in acute phases of their conditions can become a risk, as they could cause harm to themselves or others. This often means they are required to receive advanced observation to keep everyone in the care setting safe.

Any decisions to apply enhanced observation is made by adhering to a holistic risk and multidisciplinary assessment of the older adult’s physical and mental state, as well as the social and environmental factors at that moment in time.  All of this information needs to be clearly documented in the residents’ care plan, including the rationale for the level of observation clearly stated.

Level 1: General Observation

General observation is the minimum acceptable level of observation for residents in your care.  Staff should have a knowledge of the older adult’s whereabouts, as far as is reasonably practicable, but they do not need to be kept within sight.  At least once per shift a practitioner should sit down and talk with the resident to assess their mental state, and this should all be recorded in their notes.

Level 2: Intermittent Observation

Intermittent observation is applied for all residents who are potentially, but not immediately, at risk to themselves or others. The older adult must be regularly checked upon, usually every 10 minutes, but this can be undertaken during the normal activities in the care home, and the exact time should be specified in their notes.  

Level 3: Constant Observation

Constant observation is also known as Within Eyesight , and it is used for residents who could cause harm and present an immediate risk to themselves or others.  There should be a one-to-one practitioner/resident ratio, and the older adult should be kept within eyesight at all times whilst they are a risk.

Level 4: Close Proximity Observation

Close proximity observation, also known as Within Arms Length, is for residents who are at the highest level of risk of harming themselves or others, and more than one care staff may be necessary.  There should be an awareness on issues regarding the privacy, dignity and consideration of the gender in allocating staff, and a discussion on any environmental dangers, and all of this information should be outlined in the older adults’ care plan.

How to Document and Record Observations

The process of observation also involves documenting and recording all observations in order to gain a full picture of the older adults’ physical and mental health whilst they are in your care.  Every care home will have different policies and procedures for observation and documentation, so ensure you are following these rules.

Each resident will have a care plan and chart that will detail their health conditions, what medication they are on and all baseline recordings, and further regular observations should always be recorded here as well, including the date and time the observation took place.  By compiling an organised timeline with accurate and reliable observations, care home practitioners are able to easily examine the charts to identify any changes or progression of the older adults’ conditions.

If there are any changes in vital signs or conditions outwith the residents’ normal range, you should report these findings to the registered person in charge to make sure the older adult is attended to.