Observing and Reporting Changes in a Patient
Notice what is different, decide how fast it must be reported, and give a clear SBAR report or shift handoff.
Table of contents
You see patients more often than anyone else on the team, so you are often the first to notice that something has changed. A nurse cannot act on what nobody reports. Your job is not to work out the cause. Your job is to notice, describe what you saw and get it to the right person quickly.
What You Will Be Able to Do
- Watch for changes using your senses during normal care.
- Decide what needs 911, a call to the nurse now, or a report by the end of your shift.
- Give a clear report using SBAR.
- Give a complete shift handoff.
- Separate what you saw from what you think it means.
How to Observe
Watch while you do other tasks. Bathing, feeding and helping someone walk are the best times. Use your senses:
- See: skin color, swelling, bruises, rashes, how they move, how much they ate.
- Hear: coughing, wheezing, slurred speech, new confusion, complaints.
- Smell: strong urine odor, a sweet or fruity breath, foul wound odor.
- Feel: skin that is hot, cold, clammy or swollen.
The most important question is, "Is this different from this person's normal?" A blood pressure of 150/90 may be usual for one patient and alarming for another. Knowing someone's baseline, or usual state, is what makes your observations useful.
Mental Status
Mental status changes are easy to miss and can point to a medical problem such as an infection, low blood sugar or a stroke. Staff often describe a person's awareness as "oriented." A person who knows who they are, where they are and the date or time is "oriented times three," written as x3, for person, place and time. Report a person who was alert yesterday and is confused today, even if they say they feel fine.
How Fast to Report
| Urgency | Examples | Action |
|---|---|---|
| Call 911 | No response, not breathing normally, chest pain, severe trouble breathing, signs of stroke, severe bleeding, a severe allergic reaction, seizure over 5 minutes | Call 911 first, then the nurse or supervisor |
| Call the nurse now | New confusion, a fall, new or sudden pain, blood where it should not be, fever, vital signs outside the limits in the care plan, not urinating, skin breakdown | Stop and call right away |
| Report the same day | Eating or drinking less, mild swelling, sleeping poorly, mood changes, refusing care | Tell the nurse before you leave, and document |
If you are not sure, report it. A call that turns out to be nothing costs a few minutes. A missed change can cost a life. Follow the care plan and your employer's call list, which may set different limits for this person.
Warning: If a person looks seriously ill, do not wait for the nurse to call back. Call 911. In a home, stay with them until help arrives.
Giving an SBAR Report
SBAR is a structured way to report a patient change so the nurse or doctor gets what they need in under a minute.
- S, Situation: Who you are, who you are calling about and what is happening now.
- B, Background: The short context, such as age, diagnosis and what is usual for them.
- A, Assessment: What you observed and measured, and why you are worried. Aides report observations. Leave the diagnosis to the nurse.
- R, Request: What you need. "Can you come see her?" or "What would you like me to do?"
Here is an example from a home visit:
- S: "This is Dana, the aide at Mrs. Lee's home. She is much more confused than usual and has not eaten today."
- B: "She is 82 and has diabetes and high blood pressure. She knew me and the date on Monday."
- A: "She does not know the day. She has a new bruise on her forearm. Her temperature is 100.8, and her pulse is 104."
- R: "I'm worried something has changed. Can you call me back with what to do, or should I call 911?"
Before you call, have the chart or care plan, vital signs and the medication list handy. Write down what you are told, and read it back to confirm.
Saying What You Saw
Keep facts separate from guesses. A nurse can trust a fact and act on it.
| Instead of | Say |
|---|---|
| "She's dehydrated." | "Her mouth looks dry and her urine is dark. She drank one cup all morning." |
| "He had a stroke." | "The right side of his face is drooping and his speech is slurred." |
| "She's depressed." | "She has been crying and says she doesn't want to get up." |
| "He's being difficult." | "He pushed my hand away twice during his bath and said it hurt." |
Giving a Handoff
Most errors in care happen when information gets lost between people. At the end of a shift or visit, tell the next caregiver or the nurse:
- Who the patient is, and any changes during your time with them.
- Care you gave and how they responded.
- Vital signs and whether they differ from usual.
- Intake, output and meals if those are being tracked.
- Pain level and mood.
- Things still to do, such as tests or a visit coming up.
- Anything you are worried about.
Do not leave until someone has taken the report. If the next person has questions, answer them before you go.
Common Mistakes
| Mistake | What it costs |
|---|---|
| Assuming the nurse already knows | The change goes unnoticed |
| Waiting until the end of the shift to report a new problem | Hours lost when a treatment could help |
| Telling a family member but not the nurse | The right person never hears it |
| Giving a diagnosis instead of the facts | Confuses the nurse and steps outside your role |
| Saying "she seems off" with no details | The nurse has nothing to work with |
Check Your Understanding
1. A client who is usually chatty is quiet, won't eat, and you notice a new bruise. She says nothing is wrong. What do you do?
Report all of it to the nurse right away. A combination of changes needs attention, whatever she says.
2. A resident grabs his chest during breakfast, turns gray and can't catch his breath. Who do you call first?
- Then call your nurse or supervisor. Stay with the patient.
3. Which is better in a report: "She is depressed" or "She said, 'What's the point?' and has not eaten for two days"?
The second. It gives facts and the person's own words so the nurse can decide what it means.
4. It's the last ten minutes of your shift and the next aide has not arrived. Can you leave a note and go?
No. Do not leave until the report has been given. Call your supervisor if no one is coming.
Key Takeaways
- Compare what you see with what is normal for this person.
- Sudden changes in thinking are a medical concern and must be reported.
- Report early, and call 911 first when a life may be at risk.
- SBAR stands for Situation, Background, Assessment and Request.
- Describe what you saw and leave the diagnosis to the nurse.
- A shift is not over until the handoff is done.