Chapter 2: Admissions and assessment
Skip chapter table of contents and go to main content
Observation
Definition
Observation is the conscious, deliberate use of the physical senses to gather data from the patient and the environment. Observation occurs whenever the nurse is in contact with the patient. At each patient contact, it is important for the nurse to try to develop a sequence of observations. These might include the following:
- On approaching the patient, observe for signs of distress, such as pallor, laboured breathing, and behaviours indicating pain or emotional distress.
- Scan the area for safety hazards, such as any floor spillages.
- Look at the equipment, such as urinary catheter, intravenous pumps, oxygen and monitors.
- Notice other people in the area – who is there and how do these people interact with the patient?
- Observe the patient more closely for physical data such as skin temperature, breath sounds, drainage and dressing odours, condition of drains and dressings, and need for repositioning (Wilkinson [91]).
Accurate measurements of the patient's vital signs provide crucial information about body functions (see Chapter c14: Observations).
