163. CCA Study Notes: Observation, Objective and Subjective Data in the Care-Planning Process

The Big Picture

A CCA spends time with clients and pays attention to changes in their condition, behaviour, preferences, and reactions. Those observations give other health care team members information they use when reviewing the client’s care.

Some information comes from what you see, hear, touch, or smell. Other information comes directly from what the client tells you. Knowing the difference helps you describe information accurately without guessing what it means.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

Your Role in the Care-Planning Process

The care-planning process is the method nurses and case managers use with the health care team to plan a client’s care. It is also called the nursing process.

As a support worker, you contribute important information to this process. You:

• observe the client
• relate your observations to team members
• answer team members’ questions about the client
• give feedback about the client
• document the care you provide

Other team members use this information when reassessing the client’s progress, revising goals, and modifying the care plan.

Documentation is the record of the care provided, along with observations and basic assessments made during care. It is also called charting.

Why Careful Observation Matters

Support workers generally spend more time with clients than other health care providers. Because of this, a support worker may be the first person to notice a change in a client’s condition.

You may also notice the client’s preferences and reactions to interventions. Your observations need to be careful and accurate because they become part of the information used during care planning.

An observation is the active process of using your senses to gather information about the client’s current condition.

Watch for changes involving the client’s:

• physical condition
• mental condition
• emotional condition
• social condition
• new conditions or situations

For example, you might observe red and blistered skin, new difficulty using a toothbrush, crying during a meal, a change in a usual social visit, or repeated loose, watery stool.

Objective Data: Information You Observe

Objective data, also called signs, are information about the client that you obtain through observation and your senses.

You use:

• sight
• hearing
• touch
• smell

What You Might See

You might observe:

• how the client shows discomfort while lying down, sitting, or walking
• flushed or pale skin
• reddened areas
• swollen areas

What You Might Hear

You might hear abnormal sounds in the client’s chest during respiration.

What You Might Feel

Using touch, you might notice a change in the client’s skin temperature.

What You Might Smell

You might notice:

• body odours
• wound odours
• breath odours
• unusual urine odours
• unusual feces odours

The important point is that objective data come from information you directly observe.

Subjective Data: Information the Client Reports

Subjective data, also called symptoms, are information reported by the client that other people cannot directly observe.

A client might tell you:

• they stayed awake for most of the night
• they feel hopeless
• pain becomes worse with movement
• pain feels sharp
• pain travels from one area to another
• pain comes and goes

You cannot directly observe another person’s pain, hopelessness, or experience of poor sleep in the same way you observe skin colour or hear a sound.

Report and document subjective data using the client’s exact words. Do not interpret the client’s comments.

Objective Data and Subjective Data Side by Side

Objective Data	Subjective Data
Also called signs	Also called symptoms
Gathered through observation and the senses	Reported by the client
Directly observed	Not directly observed by others
Examples include skin colour, swelling, sounds, temperature, and odours	Examples include pain, poor sleep, and feelings reported by the client

Describe What You Observe, Not What You Think It Means

Your observations are used by nurses and case managers during the assessment and evaluation steps of care planning.

An assessment is the evaluation of information collected about a client through observation, reflection, and communication.

Evaluation involves assessing and measuring and is a step in the care-planning process.

When describing what you observe, focus on facts.

Be Precise and Accurate

Give details about what you:

• see
• hear
• touch
• smell

Measurements, calculations, and times must also be accurate.

When reporting subjective data, use the client’s exact words.

Do Not Interpret or Make Assumptions

Most of the time, your observations provide the information needed. Do not add your own interpretation.

An assumption is a guess that is usually based on insufficient evidence. Assumptions can lead to a wrong or hasty conclusion.

The support worker gives precise, accurate observations without adding assumptions. The social worker and nurse use those observations when making a judgement about the client’s mental health.

Basic Observations and Assessments

There are several areas you may need to observe when paying attention to a client’s condition.

Ability to Respond

Observe how the client responds and communicates.

Notice:

• whether the client is easy or difficult to rouse ⓘ
• whether the client can state their name, the time, and where they are
• whether the client answers questions correctly
• whether the client speaks clearly
• whether the client follows instructions correctly
• whether the client is calm, restless, or excited
• whether the client is conversing, quiet, or talking a lot

Movement

Initial observations include the client’s ability to perform movement-related tasks. These observations help show changes or progress in the client’s condition.

Observe or determine:

• whether the client can squeeze your fingers with either hand
• whether the client can walk
• whether the client can move their arms and legs
• whether movements are shaky or jerky
• whether the client reports stiff or painful joints

Pain or Discomfort

When a client reports pain or discomfort, gather clear details.

Find out:

• where the pain is located
• whether the pain goes anywhere else
• when the pain began
• what the client was doing when it began
• how long the pain lasts
• how the client describes the pain
• whether the client has felt the pain before
• what helped relieve it before, if applicable
• whether medication was given
• whether the medication helped
• whether the pain is still present
• whether the client is able to sleep and rest
• which position provides comfort

A client might describe pain as:

• sharp
• severe
• knifelike
• dull
• burning
• aching
• coming and going
• depending on position

When asking where pain is located, ask the client to point to the painful area.

Skin

Observe the client’s skin and note specific details.

Look for:

• pale or flushed skin
• cool, warm, or hot skin
• moist or dry skin
• the colour of the lips and nails
• whether the skin is intact ⓘ
• broken areas and their location
• sores or reddened areas
• bruises and their location

Also note if the client reports itching.

Eyes, Ears, Nose, and Mouth

Eyes

Observe or ask about:

• drainage and its colour
• whether the eyelids are closed
• reddened eyes
• reported spots, flashes, or blurring
• sensitivity to bright lights

Ears

Observe:

• drainage and its colour
• whether the client hears questions
• whether questions need to be repeated
• whether the client answers questions appropriately

Nose

Observe:

• drainage and its colour
• whether the client can breathe through the nose

Mouth

Notice or ask about:

• breath odour
• a reported bad taste
• painful gums
• painful teeth

Respirations

Observe the client’s breathing and related changes.

Notice:

• whether both sides of the chest rise and fall with respirations
• whether breathing is noisy
• whether the client reports difficulty breathing
• the amount and colour of sputum
• how often the client coughs
• whether the cough is dry or productive

Sputum is saliva mixed with mucus that is often coughed up.

Bowels and Bladder

Bowels

Observe or ask about:

• whether the abdomen is firm or soft
• reported gas, or flatulence
• the amount, colour, and consistency ⓘ of feces
• how often bowel movements occur
• whether the client can control bowel movements

Bladder

Observe or ask about:

• pain or difficulty urinating
• the amount and colour of urine
• whether urine is clear or cloudy
• whether urine has a foul smell
• whether the client can control the passage of urine
• how often the client urinates

Appetite, Food, and Fluids

Observe or ask about the client’s eating and drinking.

Notice:

• whether the client likes the diet
• how much of the meal is eaten
• food preferences
• whether the client can chew food
• how much liquid the client takes
• liquid preferences
• how often the client drinks liquids
• whether the client can swallow food and fluids
• reported nausea
• the amount and colour of vomited material, when vomiting occurs
• hiccups
• belching

Activities of Daily Living

Observe how much the client does independently and what assistance is needed.

Look at the client’s ability to:

• perform personal care without help
• bathe
• brush their teeth
• comb and brush their hair
• shave
• use the toilet, commode, bedpan, or urinal
• feed themselves
• walk

Also note the amount and kind of assistance the client needs.