Observation of a Patient 2019.pptx

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

5. 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

6. 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. .

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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.

13. Sample of Observation chart

14. 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

15. 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

16. 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).