Lesson 2: Observation Title Slide Welcome Transcript Hello. My name is Jill Morrow, I am the Medical Director for the Office of Developmental Programs. I will be your narrator for this webcast. Lesson Objectives At the end of this lesson you will be able to describe your responsibilities for observing. Explain the differences between subjective and objective information, and give examples of each. Explain why you need to know the people that you support. Explain how medications affect a person s body. Explain desired effect, no effect, and unwanted or side effect. And understand the importance of interactions between medications. Medication Cycle This lesson focuses on observation. Remember in Lesson 1 you learned about the Medication Cycle. The Medication Cycle is a series of actions that promote safe administration of medication. In order to implement and carry out these actions, however, you need to understand each individual action and the part it plays in the overall cycle. So let s start our discussion with observation. What is Observation? Observation refers to your ability to recognize how medications affect the people you work with. In order to assure that the person is responding to the medication in a beneficial way you must watch the individual to identify these responses. Observations are a combination of both objective facts and subjective information. Using both of these tools provides a more comprehensive picture of what is happening for you to communicate to others working with the individual. Objective information is factual and often includes things that can be measured. It is something that you have first-hand knowledge of. It is based on four of your five senses: vision, hearing, smell, or touch. Vision or what you see includes sleepiness, high temperature, crying, unsteady walking or rash. Noisy breathing, screaming, or crying are examples of what you might hear a person express. You also might observe foot or body odor through your sense of smell. How something feels when you touch it also provides observation information. For example, a joint may be hot and swollen. So let s talk a little more about how the concept of observation of objective findings can help you communicate information about a person. If you see a person fall and you go to help them, what might you observe? You might observe a cut or abrasion where they fell. They might be crying because it hurt to fall. They might have a bruise forming and when you touch it you might feel that it is swollen. Remember, that each objective observation can involve more than one sense.
What if the person that fell says to you, I felt dizzy before I fell? You heard them say this, but is this an objective observation? This is not an objective observation because it is not something that you can verify. You can t measure it or take a picture of it. You can only say that this person said this and it is second-hand information. What a person tells you about how they feel is a subjective observation. Subjective observation is as important as objective observation. The best way to observe is to include both objective and subjective information. Observation is merely what you saw, heard, etc. It does not include determining or making a guess about what is going on. So observing that the person has a swollen ankle is your job, but determining that the ankle is sprained is not. Be careful not to confuse your observation by including impressions of what you think they mean. Your role is to observe, not to determine the reason for what you observed. So in the case of the situation that we talked about before, what should your observation include? It would be important to include the following information: The person fell. This is something that you saw. The person has a cut, an abrasion, and a swollen ankle. This is also something that you saw but you may have felt it as well. The person is hurt. You observed their facial expression and heard them crying. They may also have told you that they hurt themself. The person told you that they felt dizzy before they fell. If your observation includes this information, then it has both the subjective and objective details critical to what happened. If you included something like you thought that the person tripped, but didn t observe that, then that should not be included since it can t be verified. On the other hand if the person told you that they tripped, then that is subjective observation and should be included. The observations you make have a direct impact on the decisions that a health care practitioner makes related to treatment for the person. If inaccurate or incomplete information is given it could result in the person receiving medication they don t really need, increasing or decreasing medication inappropriately, discontinuing medication or not getting the right medication. Let s check your understanding of objective and subjective information. Read the statement on the slide, and then indicate if it is an objective or subjective observation. Click [Submit] to go to the next slide. Getting to Know People
Learning about the people that you work with will help you better identify changes in them including effects of medication. In order to do this you need to become knowledgeable not only about the person s health, but also about what is important to them and how they interact and communicate. Learning about their personality and their capabilities assists you to be a better observer of that person. Safe medication administration is important for all people taking medications administered by another person. You may work with people with differing ages, abilities and needs, however, your role and the skills you need including observation are the same. What are some of the characteristics of the people that you might work with that would impact on what you would observe related to medication? Some of the people may not use words to communicate and be unable to tell you how a medication is affecting them. They may not be able to say that it is giving them a headache, blurred vision, ringing in their ears, etc. Instead the person may hit their head with their hand to indicate a head ache. As you work with the person you will begin to learn this person s non-verbal language or behavior and become more accurate and confident in knowing what the person is trying to express. Observing non-verbal language or behavior is important when working with any person. However, particular attention to behavior and body language may help when working with adults or children with challenging behaviors like refusals and aggression. Some challenging behaviors are related to how people communicate while others can be attributed to a mental illness. Dementia is often associated with challenging behaviors related to confusion and memory loss. It affects how people respond to what happens to them and sometimes makes that response difficult to predict. This poses a particular problem and requires that you observe in a manner that takes these factors into consideration. When you are observing behavior, there are other things that you have to think about such as the loss of the ability to hear or see well in some people as they age. This can cause increased anxiety and impact on their behavior. Other people exhibit difficulties with motor functioning such as walking or using their hands. Arthritis, strokes or cerebral palsy with the ability to use only one side of the body, and progressive neurologic conditions like Parkinson, Huntington s disease, Multiple Sclerosis, or Muscular Dystrophy all contribute to difficulties performing motor skills. For some conditions this impacts how they take medication and for others it may impact how they swallow. Dysphagia or swallowing problems are common in many people that have motor problems regardless of their age. For older people there are additional factors like dry mouth that lead to or add to swallowing problems. It will be important for you to be observant for choking and aspirating for the person with swallowing problems. You may have to use special procedures for the preparation and administration of medication in individuals with these kinds of problems. So now you have a sense of the kinds of characteristics that may impact on your role in observation. Let s look in more detail how you can learn about these for the people that you are working with. There are many resources that you can use to find out who the person is.
For all people there should be some written records. These may be medical in nature or they may be a plan or other document outlining program goals. Whether it is called an Individual Support Plan or an Individual Education Plan or a nursing care plan, each of these types of documents contains valuable information about the person. The other important way to get information about a person and learn who they are is through talking to them and the people around them including their family, friends and other people that work with them. Asking questions like what they like or don t like, what they can tell you about how their medication makes them feel, and many others will help you get to know that person. It is also important to ask about what may change their behavior or what to expect about how they respond to different situations. Observations and Effects of Medication & Scenarios The purpose about learning about observation in this lesson is how it relates to medication administration and management. Think about the reason that you take medication. In lesson 1 we talked about what medication is and some of the different uses for medication. Have you ever had a head ache? If you haven t, do you know someone that has? What did they do? Did they take medication to make the head ache go away? Did the head ache go away? If it did, then that was the desired effect. If it didn t go away, then there was no effect. You take medication for a specific reason. That is the desired effect. In the head ache example, pain relief was the desired effect. Sometimes people don t get the desired effect when they take medication. There may be many reasons for this like not giving the medication enough time to work. If someone gets no effect from a drug it doesn t mean that the drug won t work, it could also mean that it is not working at that dose. However, the important observation is that the medication had no desired effect. In this case the head ache did not go away. Responses to medication may be physical like lowering blood pressure or temperature. Or they may be behavioral like a decrease in pacing related to treating anxiety. Most people respond to medications in similar manners. Occasionally people will have an unusual response to medication which is referred to as an unwanted or side effect. All medications have multiple potential side effects. Even if you get the desired effect you may get an unwanted or side effect. Some people are more likely to develop side effects such as people that are on higher doses of medication. Side effects vary depending on the medication. They also vary in severity and significance for the person s health. Let s look at some examples of medication effects. Mary has recently been diagnosed with depression. Her doctor put her on sertraline a type of antidepressant to treat her depression. After taking the medication for a while she began to feel less depressed. One sunny day she went outside to work in her garden. After half an hour she noticed that her skin was turning bright red. What was the effect? Click on the effect and click [Submit].
Mary had both the desired effect, treatment of her depression and an unwanted, side effect sun sensitivity or photo toxicity. For medications like sertraline that are known to make people more sensitive to the sun, people should take precautions to protect themselves from the sun. This includes sun screen and avoidance of the sun either by remaining indoors or in the shade or by wearing clothing that covers the skin. Let s look at another example. Matt went camping and came back with an itchy red rash. The doctor identified an allergic reaction and ordered diphenhydramine to treat the allergic reaction and decrease the itching. He took two tablets but continued to itch. What was the effect? Matt did not appear to have the desired effect which would have been to decrease the itching although he only took a single dose. While he did not have any side effect to the medication, diphenhydramine usually makes people sleepy. However, some people experience increased irritability which is a particular kind of side effect known as a paradoxical effect. A paradoxical effect or paradoxical reaction is one where the effect is the opposite of the one expected. For Matt, the expected side effect was sleepiness, however, he had a paradoxical effect which was that he became irritable. John, a 75 year old man with chronic lung disease, developed coughing and fever. He went to see his doctor who diagnosed pneumonia and put him on an antibiotic levofloxacin. He started to take the medication and he began having difficulty breathing. He was taken to the emergency room for treatment. John had an unwanted, side effect known as anaphylaxis or a severe life-threatening allergic reaction. These reactions are common with antibiotics and documentation of allergies to particular antibiotics is critical to avoid future events. Some individuals have less severe allergic reactions which might be a mild rash. Now we have talked about a range of side effects from different medications. We ve looked at paradoxical effects like the irritability with diphenhydramine as well as a more common side effect for this drug sleepiness. The side effect of sleepiness is a nuisance, but not typically harmful. We ve looked at range of severity from mild rash to life threatening emergency such as the allergic reaction to an antibiotic. In addition to these kinds of side effects, people may have other reactions. For example, some people develop side effects with a very small dose of a medication while others won t show any effects until the dose is much higher. Some medications work by maintaining a certain level of the medication in the blood. If that level is disrupted by illness or taking too much medicine, then the person may develop a high level and exhibit side effects or toxicity. Thus, unwanted or side effects differ depending on the medication involved and the particular individual taking the medication. In every instance, observation is critical to identify and address side effects. Effects of Medication Interactions
Up to now we have talked about the effects and side effects of single medications. In addition to individual medications having side effects, unwanted effects may result from the interaction of multiple medications. People with multiple chronic health conditions like the elderly often take multiple medications and are more likely to have medication interactions. A medication interaction occurs when one medication affects how another medication acts. That action may be to increase the level of the drug which might cause toxicity. Another possibility is that the level of the drug is decreased and the second drug no longer has the desired effect. There are other ways that medications can affect each other s actions. Medications that work in the same way in the body may have an additive effect. For example, many seizure medications like valproic acid (Depakote) and carbamazepine (Tegretol) are broken down in the liver. Alone they each have the chance of causing liver problems, but together they have an even greater chance. Therefore, liver function tests which measure how the liver is working are done to follow potential effects of some of the seizure medications. This impact on liver is possible with any two drugs that are broken down in the liver. Some combinations of medications can interfere with the activity of each other. For example, using antacids to treat heart burn with digoxin used to treat heart failure can decrease the activity of the digoxin. Other compounds can also interfere with the activity of a medication. Taking tetracycline which is an antibiotic with dairy products such as milk blocks the antibiotic from being absorbed so that it can t work to treat the infection. Food substances like dairy products and grapefruit juice commonly interfere with the absorption of some medications. Many herbal or dietary supplements like St. John s Wort also interact with medications like Coumadin sometimes blocking their desired effect. Because of this it is important to read the instructions and warnings related to the medications that people are taking. How do you avoid potential medication interactions? Make sure that all of the health care practitioners that a person sees know all of the medication that they are taking. Make sure that the pharmacist filling a prescription knows all of the medications. It is sometimes best to use the same pharmacy as they will keep a record of what people are taking. The use this information to identify potential interactions and to provide information for people about medications. Any changes that are observed should be reported as they might be due to an interaction. Let s take some time to check your understanding of the effects of medications. Please answer the following true and false questions. Click [Submit] to go to the next slide. Summary
This lesson about Observation covered key points that included: Observation is important in order to identify responses to medications. Accurate observation is crucial to communicate with the health care practitioner and obtain appropriate care. Getting to know the people that you support will help you better observe changes in their physical condition or behavior. Medications have three possible effects: desired, none, and unwanted or side effects. Side effects include allergic or anaphylactic reactions, medication sensitivity, toxicity, and paradoxical responses. Medications can interact with each other and affect how they work.