As a certified nursing assistant, you’ll work hand-in-hand with a variety of patients. A primary function of your career is to perform patient assessments upon arrival and throughout the duration of the patient’s stay. Because of this, it’s vital to master subjective observations as these observations made by the patient may provide key elements to accurately diagnose health problems.
Objective vs Subjective Observations
In the nursing world, you’re faced with two common observation types: objective and subjective. Objective observations are those made by medical staff or those unaffiliated with the patient as these observations are created through measurement systems. For example, vital signs, blood in urine and open wounds are all objective observations; however, if a patient complains of a headache, stomachache or a generalized strange feeling, they’re providing you a subjective observation as there’s no real method of objectively measuring these statements. As a CNA, you must learn how to take a subjective statement and combine it with objective observations to create a well-rounded, and accurate, diagnosis.
Mastering Subjective Observations
While it’s not your responsibility to make an official diagnosis, you must learn how to communicate subjective patient observations to registered nurses and physicians in the clearest way possible. For example, you have a patient who comes in complaining of abdominal pain. After performing a physical examination and recording vital signs, you still aren’t sure what could be causing the pain. Therefore, in your report you’d write, “Throughout the examination, Mr. Smith complained of abdominal pain.” While this may seem simplistic, the fact that you did not elaborate further indicates to the nursing staff that they must perform further testing to find the source of the pain.
How to Objectively Observe Subjective Statements
This can be one of the most difficult challenges as a certified nursing assistant must undergo. While you may not be able to clarify a subjective observation, you can use objective measurement procedures to help isolate potential problems. CNAs go about this process using four observation pillars:
1.) Visual Inspection – CNAs must use their eyes to visually inspect a patient’s body as well as the patients bodily fluids to isolate potential issues. For example, review the patient for broken skin, changes in patient behavior and whether or not blood is found in urine or fecal matter.
2.) Physically Touch the Patient – Nursing assistants must use their ability to teach patients to monitor their current health. For example, you’ll use your hands to determine skin surface temperature, lumps underneath the skin and pulse rate.
3.) Listen to the Patient – While you must listen to patient statements, use your ears to monitor vitals such as blood pressure and respiratory system functionality.
4.) Your Sense of Smell – Although inhaling unpleasant odors is just that, unpleasant, it’s an essential window into current patient health. Monitor a patient for abnormal body odors and foreign smells such as gasoline or chemicals. These may indicate a more serious underlining cause of their illness.