6.4 Observation & Reporting
Key Takeaways
- Objective observations are measured or directly observed facts; subjective observations are what the resident reports — record both, but never substitute opinion for fact.
- Use your senses on every interaction: look at skin and color, listen to breathing and speech, feel for temperature and swelling, smell for unusual odors.
- Report life-threatening changes immediately: chest pain, trouble breathing, unresponsiveness, severe bleeding, choking, signs of stroke.
- Report promptly (not end of shift): a fall, new confusion, fever, refusal to eat or drink, new skin breakdown, or any sudden change from baseline.
- Report observations to the nurse first; document factually and promptly after reporting — observation and reporting is core CNA work and a top exam domain.
The CNA Is the Eyes and Ears of the Care Team
CNAs spend more time with residents than any other team member, so they are usually the first to notice a change. Observation and reporting is woven through the Basic Nursing Care domain (26%) and is one of the highest-yield Florida exam themes. The CNA observes and reports; the nurse assesses and decides.
Objective vs. Subjective
| Type | Definition | Example |
|---|---|---|
| Objective (signs) | What you measure or directly observe | BP 168/96, reddened heel, vomiting, slurred speech |
| Subjective (symptoms) | What the resident tells you | "My chest hurts," "I feel dizzy," "I'm not hungry" |
Report both. Quote the resident for subjective data and state measured facts for objective data. Never replace a fact with an opinion or a label.
Observe With All Your Senses
- See: skin color, swelling, redness, bruising, posture, alertness, eating.
- Hear: breathing sounds, speech clarity, coughing, complaints.
- Feel: skin temperature, moisture, swelling, pulse quality.
- Smell: unusual body, breath, urine, or wound odors that can signal infection.
Prioritizing What to Report
Not every observation is equally urgent. The exam frequently asks you to choose what to report first. Use this priority order.
Report Immediately (Emergency)
| Finding | Why It Is Urgent |
|---|---|
| No response / not breathing / no pulse | Life-threatening — activate emergency response |
| Chest pain, severe shortness of breath | Possible cardiac or respiratory emergency |
| Severe or uncontrolled bleeding | Rapid blood loss |
| Choking that does not clear | Airway obstruction |
| Sudden facial droop, arm weakness, slurred speech | Possible stroke — note the time |
Report Promptly (Same Shift, Do Not Wait)
| Finding | Why It Matters |
|---|---|
| A fall, with or without apparent injury | Hidden injury possible; needs nurse assessment |
| New or worsening confusion | Can signal infection, low oxygen, or stroke |
| Fever or abnormal vital sign | Possible infection or instability |
| New skin redness or breakdown | Early pressure injury — early action prevents worsening |
| Refusal to eat or drink, low urine output | Dehydration and malnutrition risk |
| Any sudden change from the resident's baseline | A change is more meaningful than a single number |
Reporting Order
- Recognize the change.
- For an emergency, get help / activate the code first and stay with the resident.
- For a non-emergency, report to the nurse promptly and clearly — what you observed, when, and the resident's exact words.
- Document factually after reporting; never let documentation delay reporting an urgent change.
Exam Tip
When a question lists several findings and asks what to report first, choose the one that threatens airway, breathing, circulation, or consciousness. "Report it at the end of the shift" is almost always the wrong answer for a real change in condition.
Which of the following observations should the Florida CNA report to the nurse FIRST?
A resident tells the CNA, "I feel dizzy and my heart is racing." Which statement best describes this information and the correct action?