B G I S Ariyarathne Nursing officer

1. Observation of a Patient
Fundamentals of Nursing
Unit XVI
B G I S ARIYARATHNE
Nursing Tutor G-1, RN, DIP in NSg, Dip in
T&S, dip in Mw, BSc nsg (Hon) 1st class

2. Unit Outcome
•At the end of this unit students should be able to
develop skills in observing patient’s vital sings

3. Specific outcomes
At the end of this unit students should be able to
•Discus importance of observation skill as a nurse
•Explain the difference between sing and
symptoms
•List out vital sings
•Describe the importance of observe vital sings

4. Specific outcomes cont..
•Describe the physiological progress underling
the vital sings
•Ability to check and report vital sings accurately
•Ability to appreciate the nurse’s role in accuracy
reliability checking and report

6. Observation
•It is define as act of taking notice of something
•Observation is gathering data by using one or
more of the five senses (sight, hearing, touch,
smell and taste ) with an understanding of what
has been detected.
• Knowledge, interest and attention are necessary
for correct observation

7. Observation cont....
•Nursing observation means the purposeful
gathering of information from people receiving
care to inform clinical decision making.
•One of the most valuable qualities of a nurse is
that he/she must be observant
•Observing a patient’s physical, behavioural
condition is an important responsibility of nurses
•It is an essential component of their
competence.

8. Observation cont......
•Without an understanding/ interpretation of
what has been observed, the act of observation
is useless.
•It is a highly developed skill that uses knowledge
from the physical and social science as its basis.
•Thus when a nurse must have a sound
understanding of normal condition, then be able
to recognize an abnormal one.

9. Observation cont.....
•Nurse is the person who stay 24 hours with
patient
•She/he is the person in closest contact with the
individual experiencing physical and behavioral
changes
•So it is paramount that observations made on
patients are accurately communicated from
the nurse who made the observation to other
members of staff

10. Observation cont.....
•Observations and descriptions of physical and
behavioral changes contribute to
•Patient/client/ safety and quality of care
•Plan nursing care
•Continuity of care
•Adjust the planned nursing care
•Diagnose and treat illness
•Adjust medical actions

11. Observation cont.....
•On account of this, observations made are
written for keeping as records.
•Records from Observation should be
•Factual
•Accurate
•Current
•Organized
•Confidential
•Standard

12. What do we observe in our patients/clients?
•Vital signs
•Level of consciousness
•Amount of fluids input and output
•Blood sugar level
•Appearance of the client
•Activity level of the client

13. What do we observe in our patients/clients?
cont....
•Mental state of the patient
•Nutritional status of the client
•Facial expression
•Gestures
•Effects of medications Etc.

14. Sample of Observation
chart

15. OBSERVATION CHART
Name of the Patient: Mr. A.B.C.Silva
Age: 44 yrs
BHT No:00400
WD: 04
Bed No:04
Date&
Time
Pulse
(bpm)
Res
(bpm)
BP
(mmHg)
SpO2
%
Remarks
3.3.2022
3.00 am
70 20 110/70 98 No active
bleeding
Patient
conscious

16. Sings vs Symptoms
•Signs and symptoms are abnormalities that can
indicate a potential medical condition.
•A symptom is subjective, that is, apparent only
to the patient
Example: back pain or fatigue
•A sign is any objective evidence of a disease that
can be observed, felt, heard or measured by
others
Example :a skin rash, lump, Blood Pressure

17. Sings vs Symptoms cont....
•In some cases, data collected during health
observation and assessment may be both a
symptom and a sign.
•Example, a client may say that she "feels sweaty"
(a symptom), and the nurse
observes diaphoresis (a sign).