Essential Reporting: 10 Things Every CNA Must Communicate to Nurses

You know that feeling when you notice something is just “off” with a patient, but you can’t quite put your finger on it? That instinct is one of your most powerful tools. As a CNA, you spend more hands-on time with residents than almost anyone else on the healthcare team. This makes your observations absolutely critical. Understanding what should a CNA report to a nurse isn’t just about following a checklist—it’s about being the eyes and ears that protect patient safety and improve outcomes.

Effective CNA communication with nurses forms the bedrock of quality patient care. Your reports can be the first step in catching a serious infection, preventing a fall, or identifying a new health concern. It’s not just task completion; it’s active, life-saving participation in the care plan. Let’s dive into the essential information you must communicate.

The Foundation: Why Your Voice is Critical

Before we get to the list, let’s establish one thing: your observations matter. Research consistently shows that proactive reporting from CNAs leads to faster interventions and better patient outcomes. Nurses rely on you to provide the detailed, minute-by-minute picture they can’t always see themselves. Your cna reporting responsibilities are a vital part of the healthcare process.

10 Critical Reports Every CNA Must Make

Here are the non-negotiable pieces of information you must report, prioritized by their potential impact on your patient’s well-being.

1. Vital Signs Outside Normal Parameters

This goes beyond just writing down the numbers. You need to recognize when those numbers signal a problem. Always report vital signs that fall outside the facility’s established parameters.

Blood Pressure: A sudden spike (e.g., over 160/90) or a significant drop
Temperature: Any fever over 100.4°F (38°C) or a below-normal temperature
Heart Rate: Persistently high (over 100 bpm) or low (below 60 bpm) rates
Oxygen Saturation: anything consistently below the prescribed level (often 92%)
Respirations: Rates that are unusually fast (over 20) or slow (under 12)

Pro Tip: Don’t just report the single number. Trends are often more telling. Saying “Mrs. Gable’s blood pressure was 150/90 this morning, but it’s been 110/70 for the last three days” is much more powerful than just reporting the current reading.

2. Any Significant Change from Baseline

This is perhaps the most important item on the list. Every patient has a “baseline”—their normal state of health, behavior, and ability. Your job is to spot deviations from that norm. This is where your critical thinking skills truly shine.

Imagine this scenario: Mr. Peterson is usually alert, oriented, and loves chatting about baseball. Today, he’s withdrawn,answers your questions with one-word answers, and can’t recall what he had for breakfast. This is a significant change from his baseline and must be reported immediately, even if his vital signs are perfect.

3. Skin Integrity Issues: The First Line of Defense

You are on the front lines of pressure injury prevention. Skin breakdown can happen quickly, leading to pain, infection, and long hospital stays. Report any skin abnormalities the moment you see them.

Any new redness on bony areas (heels, tailbone, hips, elbows) that doesn’t fade when you press it (this is called non-blanchable erythema)
Tears, cuts, blisters, or rashes
Existing wounds that look worse (more redness, swelling, drainage, or a bad smell)
Dry, flaky skin that is cracking or breaking open

Clinical Pearl: When you check skin, look and feel. Gently touch areas over bony prominences. Skin that feels warmer or firmer than surrounding tissue can be an early sign of a deep tissue injury, even before you see redness.

4. Elimination Changes and Problems

Bathroom habits tell a huge story about a person’s health. Sudden changes in what comes out (or doesn’t) can signal dehydration, infection, bowel impaction, or medication side effects. This is a cornerstone of cna to nurse handoff.

Report these immediately:

No urine output for over 8 hours
Dark, concentrated, or foul-smelling urine
Blood in urine or stool
Sudden, severe diarrhea
No bowel movement for 3+ days (especially if the patient seems uncomfortable or is vomiting)
New or frequent incontinence in a previously continent patient

5. Behavioral and Mental Status Shifts

Changes in the brain often show up before physical symptoms. A sudden shift in mood, personality, or cognition can be the first clue to a serious underlying issue like a urinary tract infection (UTI), stroke, or medication problem.

Look for:

New confusion or disorientation
Increased agitation, aggression, or restlessness
Sudden withdrawal or unusual lethargy
Paranoia or hallucinations
Inability to follow simple commands they could handle before

Common Mistake: Writing off confusion in an older adult as “just dementia.” An acute change in mental status, known as delirium, is often a medical emergency and is frequently caused by a treatable condition like a UTI.

6. Patient Safety Concerns and Fall Risks

Your most proactive reports prevent injuries before they happen. When you see a safety issue, don’t just fix it—report it so the nurse can assess the situation and update the care plan if needed.

A patient who is newly dizzy, weak, or unsteady on their feet
A faulty or out-of-reach call light
Clutter or trip hazards in the patient’s room or bathroom
A patient who is trying to get out of bed alone when they require assistance
Assessive equipment (like a walker or cane) that is broken, too low, or not being used correctly

7. Pain Reports and Non-Verbal Cues

If a patient tells you they are in pain, believe them and report it. Period. You are their advocate. It’s not your job to decide if their pain is “real” or “bad enough.” It’s your job to report it so the nurse can assess it.

For patients who can’t communicate verbally, you must be their voice. Watch for these non-verbal pain cues:

Facial grimacing
Moaning, groaning, or crying
Guarding or rubbing a painful area
Restlessness or fidgeting
Withdrawn or aggressive behavior

8. Signs of Fluid Imbalance

Fluid status is a delicate balance. Dehydration and fluid overload are both serious conditions. You’re in a perfect position to spot the early warning signs.

Signs of Dehydration:

Dry, sticky mouth
Sunken eyes
Dark urine
Thirst
Skin that stays “tented” after you pinch it

Signs of Fluid Overload:

New or worsening swelling in legs, ankles, or feet
Shortness of breath, especially when lying flat
A cough that seems worse than usual

9. Nutrition and Hydration Intake Issues

Food and water are medicine. Consistently poor intake is a major red flag for malnutrition, dehydration, and a decline in health status.

A patient refusing meals or fluids for more than 24 hours
Significant difficulty swallowing (coughing, choking, gurgly voice after eating/drinking)
A patient who consistently eats less than half of their meals
Frequent nausea or vomiting

10. Family or Patient Concerns

Family members and patients are part of the care team, and they often notice subtle changes. If a family member pulls you aside with a concern like, “He just seems weaker today than yesterday,” that is valuable information that must be passed on to the nurse. You act as the professional bridge for this conversation.

Pro Tip: When relaying a family concern, be objective. Excellent communication sounds like: “Mrs. Smith stopped me and stated she is concerned about her husband being weaker today than yesterday,” rather than “I think Mr. Smith is weaker because his wife said so.”

How to Communicate Effectively: Making Your Report Count

Knowing what to report is half the battle. How you report it is the other half. Clear, professional cna communication with nurses gets faster, better results. A simple framework like SBAR (Situation, Background, Assessment, Recommendation) can be a lifesaver, but you don’t need to use it formally every time. Just think about the components in your head.

A Simple CNA Report Example using SBAR principles:

S (Situation): “Hi, I’m calling about Mr. Jones in 3B.”
B (Background): “He’s usually very independent and uses a walker to get around. His baseline is alert and cheerful.”
A (Assessment): “Just now, he seemed very dizzy when he tried to stand, and when I helped him back to bed, he couldn’t tell me what day it is.”
R (Recommendation): “I think you should come and assess him. I’ve lowered the bed and put his call bell within reach.”

This report is fast, factual, and gives the nurse everything they need to prioritize their response. Good cna documentation flows from these same clear communication principles.

CNA Reporting FAQ

Q: What if I think I’m overreacting or bothering the nurse with a small issue?

You are never a bother for reporting a concern you feel is important. The goal is to catch issues early, which can save a patient’s life. A thousand “false alarms” are worth it to prevent one emergency. Trust your instincts. That’s what experienced CNAs do.

Q: How do I know if it’s an emergency that requires immediate attention?

Think about the ABCs: Airway, Breathing, Circulation. Is the patient having trouble breathing? Is their chest in pain? Are they unresponsive? Are they bleeding heavily? If yes to any of these, activate the emergency response (call a code, pull the emergency alarm) and then get help. When in doubt, it’s always better to act immediately.

Q: What if the nurse doesn’t seem to listen or dismisses my concerns?

This can be incredibly frustrating. Document your observation and the time you reported it. If you still feel uneasy, you can politely rephrase your concern. Try saying, “I understand you’re busy, but I am really worried about [specific observation] because it is such a change from his normal.” If the situation is urgent and not addressed, you must follow your facility’s chain of command.

Key Takeaways

Key Takeaway: You are the primary observer, and your detailed reports are a critical component of the nursing process.

Key Takeaway: Always report changes from a patient’s baseline, not just tasks completed or vitals taken.

Key Takeaway: Clear, objective, and timely communication—about everything from skin integrity to mental status—directly saves lives and improves care.

Conclusion

Your role as a CNA is so much more than a list of tasks. Your consistent, detailed observations and your courage to speak up when something is wrong form the foundation of safe and effective patient care. Embrace your responsibility as the eyes and ears of the nursing team. Every time you make a clear, professional report, you are actively protecting a life and making a profound difference.

Have you used these reporting techniques in your practice? What’s the most important observation you’ve ever reported as a CNA? Share your story in the comments below—your insights could help a fellow CNA!

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