Hospital and Nursing - Observation of the patient

Observation of the patient

 

Webster's 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.

 

The essence of good nursing depends largely on intelligent observation. It is through observation you notice your patients' deviations from normal condition.

 

Your 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.

 

Good 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.

 

It 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 problems.

From 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.

 

Your sense of smell tells you the nature of discharge from wounds and body cavities.

 

Observation 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.

 

Your 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.

 

Through 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.

 

Pain nausea, fear, anxiety, dizziness and itching are identified by questioning the patient. These are examples of subjective symptoms.

 

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.

 

Palpation is the art of feeling with the hand.

Percussion and auscultation depend on the production of sound.

 

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)

 

Specific observations

 

When 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.

 

The general structure of the body

 

Ø Whether he is obese, malnourished, acutely ill or chronically ill.

 

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.

 

Hair and scalp

 

Whether the hair is clean, thick, thin, matted, dirty or coarse.

 

Whether there is any lesion, dandruff, pediculi or nits on the scalp.

Eyes

 

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.

 

Face

 

Whether the face is pale, flushed or jaundiced.

 

Whether there is swelling, ulcers, rashes or injuries.

 

Whether his checks are swollen or sunken.

 

Mouth

 

Whether his breath smells of drugs or alcohol or has a bad smell.

 

Whether the gum is inflamed, swollen, bleeding or uncrated.

 

Whether the lips are cyanotic, dry swollen, cracked or ulcerated.

 

Whether the teeth are loose, broken, artificial or irregularly arranged

 

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.

 

Throat

 

Whether the patient has any ulcer, inflammation or pain. Whether he has any difficulty in swallowing.

 

Speech

 

Whether the speech is absent

 

Whether he has any difficulty in speech-stammering or incoherent.

Whether the voice is hoarse or weak.

 

Nose

 

Whether there is any deformity, swelling or discharge of mucous, blood or pus.

 

Whether the sense of smell is present or absent.

 

Ears

 

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.

 

Neck

 

Whether the patient has pain and difficulty in moving the neck.

 

Whether there is any swelling or distended vein.

 

Chest

 

Whether the patient suffers from cough

 

Whether the sputum is of abnormal colour or quantity

 

Whether the breathing is laboured or normal.

 

Breast

 

Whether there are any abnormalities in the shape and size.

 

Whether there are any lumps or discharge from the nipples.

 

Abdomen

 

Whether it is soft, tender, distended, hard, swollen, flabby or protruding.

 

Whether he has any nausea, vomiting or pain.

 

Whether his appetite is normal or not.

 

Extremities

 

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.

 

Skin

 

Whether there are any sores, wounds, rashes or scales.

 

Whether the skin is dry, moist, hot, cold or clammy.

 

Excretions and discharges

 

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 excretion.