Patient Needs
Careful observation and timely reporting help the healthcare team recognize changes in a resident’s condition and respond appropriately.
CNAs are responsible for observing residents during assigned care and communicating important findings to the nurse.
Subjective vs. Objective Data
| Type | Meaning | Examples |
|---|---|---|
| Subjective | Information reported by the resident about their own experiences | Pain, nausea, sadness, dizziness |
| Objective | Information directly observed or measured | Urine output, distance walked, meal percentage, visible bleeding |
Important: A resident’s reported symptom is subjective data. Documenting their exact words in quotation marks accurately records what they said without implying that the symptom was independently measured or verified.
Examples
Subjective:
- Resident states, “My stomach hurts.”
- Resident reports feeling dizzy.
- Resident says, “I feel sad today.”
Objective:
- Resident consumed approximately 50% of lunch.
- Urine output measured at 250 mL.
- Resident ambulated 30 feet with assigned assistance.
- Resident winced and held their abdomen while repositioning.
Avoid unsupported interpretations such as “resident is being difficult” or “resident is pretending to be sick.”
What Should I Assess?
Observe changes from the resident’s usual baseline.
Respiratory
- Shortness of breath.
- Rapid, slow, or labored breathing.
- New or worsening cough.
- Blue or gray discoloration of lips or skin.
Urinary
- Pain or burning during urination.
- Blood in urine.
- Difficulty urinating.
- Frequent, small-volume urination.
- Marked changes in output, color, or odor.
General Condition
- Fever or chills.
- Unusual sweating.
- Increased thirst.
- Drowsiness or changes in alertness.
- Weakness or reduced mobility.
- New or worsening pain.
Digestive
- Nausea or vomiting.
- Diarrhea or constipation.
- Abdominal discomfort.
- Changes in intake or elimination.
Important: No single observation necessarily identifies the cause of a condition. Report findings without independently diagnosing.
How Do I Provide Care?
Routine Observation & Reporting
- Review the resident’s current care plan.
- Observe the resident while providing assigned care.
- Compare findings with known baseline information.
- Record relevant measurements and observations.
- Communicate important changes to the nurse.
- Follow nursing direction and facility procedures.
What should I report immediately?
- Blood or sediment in urine,
- Blue color to lips,
- Chills,
- Coughs,
- Difficulty urinating
- Drowsiness
- Excessive thirst
- Fever
- Frequent urination in small amounts
- Nausea
- Pain
- Pain or burning on urination
- Pains in chest
- Pus
- Rapid respiration
- Shortness of breath
- Sweating
- Urine with dark color or strong odor
- Vomiting
Verbal / Oral Reporting
Use clear, factual communication.
Include:
- Resident: Whom are you reporting about?
- Concern: What happened or changed?
- Time: When was it observed?
- Observations: What did you see, hear, or measure?
- Action: What assistance or care was provided?
- Response: How did the resident respond?
Example
“At 10:15 AM, the resident reported dizziness while sitting at the bedside. I remained with the resident, assisted them back to a supported lying position, and notified the nurse.”
Avoid:
“The resident seemed weird and probably had low blood pressure.”
Care Plans
The resident’s care plan identifies:
- Required assistance with ADLs.
- Mobility and transfer precautions.
- Nutrition and fluid restrictions.
- Safety precautions.
- Monitoring and reporting instructions.
Follow the current care plan. Notify the nurse when instructions are unclear, outdated, or inconsistent with the resident’s condition.
Safety & Precautions
Report Promptly
- New pain or worsening discomfort.
- Changes in urine output or urinary symptoms.
- Fever, chills, or new illness symptoms.
- Persistent nausea or vomiting.
- Unexpected changes in mobility.
- New drowsiness or behavioral changes.
Activate Emergency Response When Indicated
- Severe breathing difficulty.
- Chest pain suggesting a medical emergency.
- New stroke-like symptoms.
- Unresponsiveness or sudden collapse.
- Significant uncontrolled bleeding.
- Other severe or rapidly worsening conditions.
Do not delay urgent reporting until the end of a shift or until charting is complete.
CNA Scope
- Observe and report findings.
- Record accurate measurements.
- Do not independently diagnose medical conditions.
- Do not independently alter treatment plans or orders.
What Should I Report?
Report:
- What changed from the resident’s baseline.
- When it happened.
- Measurable or observable findings.
- Relevant direct statements from the resident.
- Actions you performed.
- The resident’s response to those actions.
What to watch out for
- If a mistake is made, strikethrough once, fix, and write your initials.
Related
- Documentation & Charting
- Vital Signs
- Recognizing Patient Distress
- Patient Rights
- Measuring Intake & Output
- Therapeutic Communication
Sources
- CNA Module 15A — Observation and Reporting
- 42 CFR §483.70 — Medical Records
- Facility reporting and emergency-response procedures
Flashcards
What is subjective data?01-foundations / patient-care
Information reported by the resident about their own experience.
What is objective data?01-foundations / patient-care
Information that can be directly observed or measured.
Is a resident's statement that they are in pain subjective or objective?01-foundations / patient-care
The pain is subjective; the exact statement can be documented as a quote.
Why should observations be compared with the resident's baseline?03-application / patient-care
To recognize meaningful changes in condition.
Should a CNA wait until the end of the shift to report chest pain?03-application / patient-care
No. Report urgently and activate emergency procedures when indicated.
What information should a verbal report include?03-application / patient-care
Resident, concern, time, observations, actions, and response.
What should a CNA do if the care plan seems outdated?03-application / patient-care
Notify the nurse and request clarification.