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Chapter 3
OBSERVATION AND REPORTING
What You Will Learn
• The four methods of observation used by health care providers
• What the In-home Aide should observe about the client’s appearance and
behavior
• Guidelines for reporting observations to a supervisor
Four Methods of Observation
You use your senses for observation every day. Observation techniques
must be practiced. When observing a client you will use your sense of sight,
smell, hearing, and touch.
Your eyes provide you with your sense of sight. Think about
what you see and what it means. Observe for anything new or
unusual.
Ears are used for hearing. Listen to a sound and try to understand what it
means. You may hear a cough or wheezing sound when the client breathes.
Some changes like pain, nausea, or dizziness can be felt and described only by
the client. Listen to what the client says. Some questions to ask your client
about his pain are found in box 3.1
Box 3.1: Questions to ask your client about pain
By using your sense of smell you can observe the odor of a discharge or the client’s
breath. Touching your client tells you if the skin is hot or cold, wet or dry. Your
observations provide important information for proper care of the client.
What the In-Home Aide Should Observe
The In-Home Aide spends more time with the client than any other member of the health
care team. Get in the habit of observing your client any time you are with him. Check
your client from head to toe each visit. Look for anything unusual or out of the ordinary.
• Where is your pain?
• How long have you had pain?
• How long does the pain last? Is it constant? Does it come and go?
• What does the pain feel like? Is it, sharp or dull, aching or knifelike?
• Have
y
ou taken
p
ain medicine? Has it relieved the
p
ain?
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Box 3.2 lists things you should look for. Your agency will provide you with a form on
which to write your observations.
Box 3.2: Observations
• Clean or dirty
• Alert, confused or drowsy
• Change in mental status
• Skin color and temperature
• Skin rashes or reddened areas
• Bruises
• Swelling
• Unsteady or shuffling gait
• Difficulty moving
• Loss of appetite or change in eating
habits
• Difficulty swallowing
• Abnormal elimination of urine or
stool
• Fatigue
• Unusual body discharge
• Tremors
• Grimacing or guarding can be a
reaction to pain
• Seizures, generalized or limited to one
part of the body
• Chills
• Accidents or injuries
• Complaints of pain or discomfort
• Mood such as angry, happy or
withdrawn
• Activity of the client including
dressing, bathing, eating, personal
hygiene, ambulation, continence
• Use of a cane or walker
• Posture changes
• Contractures
Guidelines for Reporting Observations
Observe for the unusual then report and document only what you observe or the client
tells you. Do not make judgments or try to diagnose. When in doubt, always report your
observations to the supervisor or nurse as soon as possible. When calling your supervisor
be prepared to give the following information:
• Your name
• Name of the client
• Abnormal signs
• Any symptoms the client mentions
• How long the client has had the problem
Making observations is an important part of your job as an In-Home Aide. Always be
alert for changes and abnormalities in the condition of each of your clients.
Chapter Review
1. What are the four methods of observation used by health care providers?
2. What should the In-Home Aide observe about the client’s appearance and
behavior?
3. What information do you need when reporting observations to a supervisor?
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Student Exercise
1. What are four methods of observation used when working with a client?
a.
b.
c.
d.
2. List five things an In-Home Aide should observe about a client's appearance and
behavior.
a.
b.
c.
d.
e.
Circle true (T) or false (F) for the following statements.
3. T / F Observe for things that are normal and report those observations to the
supervisor or nurse.
4. T / F The In-Home Aide should document only those things she observes.
5. T / F The In-Home Aide should be objective and avoid making judgments when
observing a client.
6. T / F The In-Home Aide is responsible for diagnosing the client.
7. T / F Abnormal signs or symptoms should be reported to the supervisor or nurse
at the end of the week.
8. T / F When in doubt; do not bother the supervisor by reporting observations.
9. T / F Making observations about a client is an important function of the In-Home
Aide.
10. T / F The In-Home Aide's observations provide important information essential to
the proper care of the client.
