Observation of the patient
dictionary defines observation as "the act or power of noticing".
Nurses are with the patients throughout day and night. Your report of
observation is very valuable in helping the physician to arrive at proper
diagnosis and treatment.
essence of good nursing depends largely on intelligent observation. It is
through observation you notice your patients' deviations from normal condition.
observation and prompt actions may help patients from getting into serious
complications such as hemorrhage and other similar problems. Your plan of
nursing care also depends upon good observation.
observation depends on your intelligence and knowledge. Skill in observation is
acquired through careful training in using your senses namely, seeing, hearing,
touching and smelling.
is through the sense of seeing you observe whether the patient is walking with
difficulty, whether he is in pain and whether he has any other visible
hearing the sound of his breathing you will able to understand whether the
patient is having difficulty in breathing. Touching the patient reveals whether
his body temperature is raised above normal or whether the skin is of normal
texture or not.
sense of smell tells you the nature of discharge from wounds and body cavities.
is a continuous process as a patient's condition is never static. It changes
continuously. These changes are noticed through careful observation. A nurse's
observation includes not only the physical condition of the patient, but also
his psychological aspects.
observation becomes meaningful when it is accompanied by questioning. To come
to clear interpretations of your observations, you have to question you patient
so that you will be able to find out the problems experienced by the patient.
observation you identify the objective symptoms of your patient. Changes in
colour of the skin, pulse, respiration, discharges from body cavities and
changes in speech are some of the examples of objective symptoms.
nausea, fear, anxiety, dizziness and itching are identified by questioning the
patient. These are examples of subjective
Certain symptoms cannot be identified by observation or
questioning. For example, some special techniques are needed to note changes in
temperature, pulse respiration and blood pressure; X-rays and laboratory tests
are used for finding out changes in structure and functions of various systems
of the human body.
Physicians use methods such as inspection, palpation,
percussion and auscultation for observation of patient's condition.
Inspection is man's observing with eye.
is the art of feeling with the hand.
Percussion and auscultation depend on the production of
Percussion is tapping an area to produce sounds.
Auscultation is listening to sounds within the body with a
stethoscope. It is the art of hearing the heart sound, bowel movement etc.
Olfaction : Sense of smell. (odour)
a patient comes to the hospital or clinic, do an overall observation of the
patient, note down his problems, report to the senior nurse and write your
observations in the nurse's record sheet.
Use the following as a guide for your observation and for
estimation of your patient's condition.
general structure of the body
Ø Whether he is obese, malnourished,
acutely ill or chronically
Ø Whether he is weak and unable to
walk or walks with aid Ø Whether
he is in pain
Ø Note the colour of the skin-pale, jaundiced.
2. Mental status and level of consciousness
Whether the patient is cheerful or depressed, anxious and
worried, irritate, afraid or sad.
Whether oriented to place, person and time.
Whether fully conscious, drowsy or comatose.
Whether the hair is clean, thick, thin, matted, dirty or
there is any lesion, dandruff, pediculi or nits on the scalp.
Whether the eyes are protruding, sunken or crossed. Whether
the colour is abnormal - Reddish or yellow.
Whether there is swelling, discharge, abnormal watering,
pain, burning, itching, photophobia or headache.
Whether the vision is normal or poor.
Whether the patient uses glasses.
Whether the face is pale, flushed or jaundiced.
Whether there is swelling, ulcers, rashes or injuries.
Whether his checks are swollen or sunken.
Whether his breath smells of drugs or alcohol or has a bad
Whether the gum is inflamed, swollen, bleeding or uncrated.
Whether the lips are cyanotic, dry swollen, cracked or
Whether the teeth are loose, broken, artificial or
Whether he has any toothache.
Whether the taste is impaired or disturbed
Whether the tongue is dry, cracked, coated, inflamed,
ulcerated, blistered, fissured or swollen.
Whether the patient has any ulcer, inflammation or pain.
Whether he has any difficulty in swallowing.
Whether the speech is absent
he has any difficulty in speech-stammering or incoherent.
Whether the voice is hoarse or weak.
Whether there is any deformity, swelling or discharge of
mucous, blood or pus.
Whether the sense of smell is present or absent.
Whether he is able to hear or not
Whether there is collection of wax in the ear.
Whether the patient experiences any ringing or buzzing
sounds, dizziness, itching or pricking.
Whether the patient has pain and difficulty in moving the
Whether there is any swelling or distended vein.
Whether the patient suffers from cough
Whether the sputum is of abnormal colour or quantity
Whether the breathing is laboured or normal.
Whether there are any abnormalities in the shape and size.
Whether there are any lumps or discharge from the nipples.
Whether it is soft, tender, distended, hard, swollen, flabby
Whether he has any nausea, vomiting or pain.
Whether his appetite is normal or not.
Whether the nails are broken or brittle Whether there is
clubbing of fingertips, tremors of hands, swelling of extremities, pain in the
joints or any other abnormality.
Whether there are any sores, wounds, rashes or scales.
Whether the skin is dry, moist, hot, cold or clammy.
Whether the colour, consistency, amount, odour, and
characteristics of stools, urine, sputum, perspiration, vomitus and vaginal
discharge are normal or abnormal.
Whether patient gets any pain or any other discomfort during