Being able to effectively communicate with patients and nursing staff is among the most important skill sets any CNA must master. While documenting your observations is an acquired skill, it’s one that essentially determines the quality of care a patient receives. In the medical industry, you’ll encounter two observation methods: subjective and objective. While subjective observations provide a hint at the underlining cause of illness might be, objective observations offer unbiased viewpoints into the current health of a patient.
Certified Nursing Assistant – Objective Observation Defined
In a nutshell, objective observations are any observations made through a measurable identifier*. For example, a patient is complaining of a headache. Their initial complaint is known as a subjective observation as there is no measurable way to calculate this complaint. However, as a certified nursing assistant you may use several identifying methods to create an objective, or unbiased, observation. As is generally accepted as best practices by industry leaders (visit homepage), if the patient is complaining of a headache, the CNA should perform a check on all vital signs as well as a physical examination. The results are then documented, which creates an objective observation.
Mastering Objective Observations as a Certified CNA
To master the art of creating an objective observation, you must marry your training with your intuition. What makes these observations so unique is the fact that they do not take any personal beliefs into consideration. In order to maintain pure objectivity, your report must only consist of information you gathered through measurable means.
In order to satisfy this requirement, you must use all of your senses and available medical equipment. There are four primary steps in creating an objective observation report:
1.) Physical Verification – While your patient may be complaining of a single physical symptom, you must check their entire body to determine if their illness is creating physical symptoms. Mark your findings in your observation report. Physical examinations are done periodically to monitor any changes, either positive or negative, in the patient.
2.) Listening to the Patient – While this may seem like a subjective way of observing a patient, it’s far from it. While a patient is recovering from surgery, or before a procedure, pay close attention to the physical attributes of the patient. How are they speaking? Have their speech patterns changed? Are they communicating in a uniform manner or is there a personality shift? These are all objective observations CNAs must monitor to create a detailed patient report.
3.) Documenting Vital Signs – While Registered Nurses may record vital signs, it’s typically the responsibility of CNAs to regularly take and document vital signs. This is among the most objective way to determine the health of a patient. While patients may lie or exaggerate their personal observations, it’s impossible to be subjective regarding bodily functions.
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Citation source: https://www.thinkcnaonline.com/