General observation of clients

Observation of clients is a very important part of care. Individuals, especially in an acute care setting, can change very rapidly from one moment to the next. Subtle changes can be indicative of some very dangerous medical conditions.

The following can indicate that problems may be imminent:-

• Changes in general appearance of the client
• Flushed àpyrexia, stroke, infection, pre-ichtal
• PailàMI, chest pain, faint, hypovolaemia/bleeding
• CyanosedàReduce Oxygen saturations
• ClammyàMI, chest pain, hypoglycaemia
• SweatyàMI, chest pain, hyperglycaemia
• Changes in behaviour/mood
• Anxious for no reasonà pre-ichtal, pre-CVE, pre-TIA
• Disorientationà pre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance
• Suddenly quiet/noisy à pre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance
• Extrovert/introvertà pre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance, pain
• Unusual/bazaar behaviour à pre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance, pain, needing the toilet
• Violent, aggressiveàpre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance, pain, needing the toilet
• Changes in clinical observations
• Changes in respiratory rate
1. increaseàinfection, trauma, pre-event (ie, cardiac, cerebral vascular) needing the toilet, hypovolaemia/bleeding, anxiety
2. decreaseàcerebral vascular damage, opiate administered
3. shallowàshock
4. deepà insufficient Oxygen intake,
5. wheezyàallergen present, chest infection, asthma
6. labouredàinsufficient Oxygen intake,
7. irregularàanxiety

• Changes in blood pressure
1. both figures increase significantlyàStoke, anxiety
2. both figures decrease significantlyàhypovolaemia/bleeding, poor cardiac output
3. decreasing blood pressure on standingàdehydration, old age, Parkinson’s disease, long periods of lying/sitting down.
4. significant increases in systolic accompanied by significant increases in diastolic readingsàVascular insufficiencies
5. significant increases in diastolic accompanied by significant increases in systolic readingsàVascular insufficiencies
6. Significantly increased blood pressure in one arm onlyàdissecting aortic aneurism (usually associated with EXTREME pain in chest radiating through to the back)

• Changes in pulse rate
1. increaseàhypovolaemia/bleeding, infection, cardiac problems, certain medication, shock, MI
2. decreaseàcardiac problems, opiate use, digoxin use, stroke
3. irregularàAtrial fibrillation, other cardiac problems,
4. differences between radial pulse and apex beatà atrial fibrillation, poor cardiac output
5. thready (slight, difficult to detect)àshock, poor cardiac output, hypotension
6. bounding (very strong)àhigh blood pressure, stoke

• Changes in temperature
1. increasedàfever, infection, brain injury, general malaise, stroke
2. decreasedàhypothermia, MI, shock,
3. swinging pyrexia (temperature fluctuates between normality and pyrexia)àburst or bursting abscess

• Changes in pulse oximatry
1. decreasedàcompromised airway, asthma, COPD, opiate use, Oxygen administration not working properly
2. increased àcleared airway, Oxygen administration is successful

posted by alanpjack  # 6:38 AM