Signs & symptoms : a 2-in-1 reference for nurses

768 Pages·2005·6.895 MB·English

by  Munden, Julie, Schaeffer, Liz

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Signs &
Signs &
Symptoms
Symptoms
A 2-in-1 Reference for Nurses
3181-FM.QXD 28/8/08 13:01PM Page ii
STAFF
Executive Publisher The clinical treatments described and recom-
Judith A.Schilling McCann,RN,MSN mended in this publication are based on research
and consultation with nursing,medical,and legal
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David Moreau procedures reflect currently accepted practice.
Nevertheless,they can’t be considered absolute
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and universal recommendations.For individual
Joan M.Robinson,RN,MSN applications,all recommendations must be
Senior Art Director considered in light ofthe patient’s clinical con-
dition and,before administration ofnew or
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infrequently used drugs,in light ofthe latest
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Marcy Caplin,RN,MSN the reader’s misunderstanding ofthe text.
Editors
© 2005 by Lippincott Williams & Wilkins.All
Julie Munden,Liz Schaeffer rights reserved.This book is protected by copy-
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Linda K.Ruhf Signs & symptoms :a 2-in-1 reference for nurses.
p.;cm.
Librarian
Includes bibliographical references and index.
Wani Z.Larsen 1. Nursing assessment—Handbooks,manuals,
Indexer etc.2.Symptoms—Handbooks,manuals,etc.I.
Title:Signs and symptoms.II.Lippincott
Barbara Hodgson
Williams & Wilkins.
[DNLM:1. Nursing Assessment—methods—
Handbooks.2. Signs and
Symptoms—Handbooks. WY 49 S578 2004]
RT48.S553 2004
616.07'5—dc22
ISBN 1-58255-318-1 (alk.paper) 2003023645
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Contents
Contributors iv
Foreword v
Signs and symptoms 1
Additional signs and symptoms 724
Selected references 734
Index 735
iiiiii
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Contributors
Peggy D.Baikie,RNC,MS,NNP,PNP Manuel D.Leal,PA-C,MPAS
Senior Instructor Department Head
University ofColorado Health Sciences Naval Medical Clinic
Center Pearl Harbor,Hawaii
School ofNursing
Eric G.Neilson,MD
Denver
Hugh Jackson Morgan Professor of
Barbara Broome,RN,PhD,CNS Medicine; Chairman,Department of
Assistant Dean and Chair— Medicine; Physician-in-Chief
Community/Mental Health Vanderbilt University School of
University ofSouth Alabama College of Medicine
Nursing Nashville,Tenn.
Mobile
Glenn H.Nordehn,DO
David J.Clugston,MSN,CRNP Assistant Professor
Director ofResident Care University ofMinnesota School of
Rydal (Pa.) Park Medicine
Duluth
Sue M.Enns,MHS,PA-C
Assistant Professor Marlene L.Roman,RN,MSN,ARNP
Wichita (Kans.) State University Medical-Surgical Clinical Nurse
Specialist
Kenneth R.Harbert,PhD,CHES,PA-C
North Broward Medical Center
Professor and Chair,Department ofPA
Pompano Beach,Fla.
Studies
Philadelphia College ofOsteopathic Barbara L.Sauls,EdD,PA-C
Medicine Clinical Director Physician Assistant
Program
Janice D.Hausauer,RN,MS,FNP
King’s College
Adjunct Assistant Professor
Wilkes Barre,Pa.
Montana State University College of
Nursing Alexander John Siomko,RN,MSN,
Bozeman BC,CRNP
StaffNursing—Telemetry
Bobbie L.Hunter,RN,MSN,CFNP
Methodist Hospital Division ofThomas
Nursing Instructor
Jefferson University Hospital
Columbus (Ga.) Technical College
Philadelphia
Nathan C.Kindig,PA-C
Dominique A.Thuriere,MD
Department Head
ChiefofMental Health and Behavioral
Branch Medical Annex Wahiawa
Sciences
Naval Medical Clinic
Bay Pines (Fla.) VA Medical Center
Pearl Harbor,Hawaii
David Toub,MD
Medical Director for Clinical Informatics
Doctor Quality
iv Conshohocken,Pa.
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Foreword
There’s no doubt that nurses have many important responsibilities.They serve as
the primary channel for assessing patients,implementing care,and providing pa-
tient teaching.In the past,these responsibilities were facilitated by extended hospital
stays and office visits.Nurses had more time to provide such care.
Today,however,nurses work in a much different environment.The demands are
greater.Patients live longer and therefore have greater health care needs.In addition,
the age oftechnology has increased the acuity ofpatients.Patients are more likely to
demand the most up-to-date information and expect to have such information avail-
able to them immediately.
Unfortunately,both the novice and the experienced clinician are constrained by
the amount oftime allotted to provide care.Nurses need to have immediate and easy
access to the most up-to-date information possible when assessing patients or care
may be misdirected.
Signs & Symptoms: A 2-in-1 Reference for Nursesresponds to this need for quick
and easy access to information.The book features a unique two-column format to
cover 215 common signs and symptoms.The inner column provides a comprehen-
sive explanation for each sign or symptom,covering all key nursing tasks from ob-
taining a history to providing patient counseling.Each entry includes an overview of
the main disorders associated with a particular sign or symptom.Within the entry,
Emergency actionsicons help identify critical situations and their appropriate inter-
ventions.Cultural cuesoffer tips and insights regarding how a patient’s cultural back-
ground may impact the assessment process or the presentation ofa sign or symptom.
Complementing the inner column text are easily scannable tables and illustrations
that help to clarify concepts.Assessment tips focus on building assessment skills.Asso-
ciated disorder sidebars offer an in-depth look at the most common causes ofcertain
signs or symptoms.
The outer bulleted columns contain summaries ofthe most important aspects of
the inner column text.The nurse can rapidly review key concepts,such as the prima-
ry causes ofa specific sign or symptom,questions to ask when obtaining a history,
and the special considerations associated with a sign or symptom.
In today’s complex work environments,nurses have less time,less backup,and
fewer resources on hand to provide quality patient care.It’s essential for them to have
the proper tools to assist them during the assessment process and the selection ofap-
propriate patient treatment.It’s equally essential for nurses to have a resource on
hand that can enhance their knowledge base and validate their decisions,for as we all
v
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vi FOREWORD
know,evidence-based practice is essential to providing the highest quality ofprofes-
sional patient care.So,whether you are an experienced clinician who needs to quickly
identify the common causes ofabdominal pain or you are a novice nurse who wants
more detailed information about tracheal deviation,Signs & Symptoms: A 2-in-1
Reference for Nurses is the all-in-one resource for you.
Elizabeth K.Hall,RN,MSN,CFNP,CGNP
Assistant Professor ofClinical Nursing
Columbia University School ofNursing
Director,Family Nurse Practitioner Program
Nagle Avenue Family Practice
New York
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AA
ABDOMINAL DISTENTION Key facts about
abdominal distention
Abdominal distention refers to increased abdominal girth—the result ofincreased
✦Increased abdominal girth
intra-abdominal pressure forcing the abdominal wall outward.Distention may be
✦Occurs when increased fluid and
mild or severe,depending on the amount ofpressure.It may be localized or diffuse
gas can’t pass freely through the
and may occur gradually or suddenly.Acute abdominal distention may signal life-
threatening peritonitis or acute bowel obstruction. GI tract
Fluid and gas are normally present in the GI tract but not in the peritoneal cavi- ✦Can be mild or severe
ty.However,iffluid and gas can’t pass freely through the GI tract,abdominal dis- ✦May reflect acute bleeding,ac-
tention occurs.In the peritoneal cavity,distention may reflect acute bleeding,accu- cumulation of ascitic fluid,or air
mulation ofascitic fluid,or air from perforation ofan abdominal organ. from perforation of an abdominal
Abdominal distention doesn’t always signal disease.For example,in anxious pa- organ
tients or those with digestive distress,localized distention in the left upper quad-
rant can result from aerophagia—the unconscious swallowing ofair.Generalized
distention can result from the ingestion offruits or vegetables with large quantities
ofunabsorbable carbohydrates,such as legumes,or from abnormal food fermenta-
tion by microbes.Don’t forget to rule out pregnancy in all females with abdominal
distention. In an emergency
EMERGENCY ACTIONS Ifthe patient displays abdominal distention, If you detect abdominal rigidity and
quickly check for signs ofhypovolemia,such as pallor;diaphoresis;hy- abnormal bowel sounds and the
potension;rapid,thready pulse;rapid,shallow breathing;decreased urine patient complains of pain:
output;poor capillary refill;and altered mentation.Ask the patient ifhe’s experi- ✦Place the patient in the supine
encing severe abdominal pain or difficulty breathing.Find out about any recent
position.
accidents,and observe the patient for signs oftrauma and peritoneal bleeding,
✦Administer oxygen.
such as Cullen’s sign or Turner’s sign.Then auscultate all abdominal quadrants,
✦Insert an I.V.line for fluid re-
noting rapid and high-pitched,diminished,or absent bowel sounds.(Ifyou don’t
placement.
hear bowel sounds immediately,listen for at least 5 minutes.) Gently palpate the
✦Prepare to insert an NG tube to
abdomen for rigidity.Remember that deep or extensive palpation may increase
pain. relieve acute intraluminal disten-
Ifyou detect abdominal distention and rigidity along with abnormal bowel tion.
sounds and the patient complains ofpain,begin emergency interventions.Place ✦Prepare the patient for surgery.
the patient in the supine position,administer oxygen,and insert an I.V.line for
fluid replacement.Prepare to insert a nasogastric tube to relieve acute intralumi-
nal distention.Reassure the patient,and prepare him for surgery.
HISTORY
Ifthe patient’s abdominal distention isn’t acute,ask about its onset and duration
and associated signs.A patient with localized distention may report a sensation of
1
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2 ABDOMINAL DISTENTION
ASSESSMENT TIP
Detecting ascites
To differentiate ascites from other causes of distention,check for shifting dullness and fluid
wave as described here.
SHIFTING DULLNESS
Step 1.With the patient in a supine position,
percuss from the umbilicus outward to the
flank,as shown at right.Draw a line on the
patient’s skin to mark the change from tympa-
ny to dullness.
Step 2.Turn the patient onto his side.(Note
that this positioning causes ascitic fluid to
Key history points
shift.) Percuss again,as shown at right,and
✦Onset and duration of distention mark the change from tympany to dullness.
✦Associated signs,including ab- Any difference between these lines can indi-
dominal pain,fever,nausea, cate ascites.
vomiting,anorexia,altered bowel
habits,and weight gain or loss
✦Medical history,including GI or
biliary disorders,chronic consti-
FLUID WAVE
pation,abdominal surgery,and
Have another person press deeply into the pa-
recent accidents tient’s midline to prevent vibration from travel-
ing along the abdominal wall.Place one of
your palms on one of the patient’s flanks,as
Critical shown at right.Strike the opposite flank with
assessment steps your other hand.If you feel the blow in the op-
posite palm,ascitic fluid is present.
✦Perform a complete physical ex-
amination.
✦Observe the recumbent patient
pressure,fullness,or tenderness in the affected area.A patient with generalized dis-
for abdominal asymmetry.
tention may report a bloated feeling,a pounding heart,and difficulty breathing
✦Assess abdominal contour.
when lying flat or breathing deeply.The patient may also feel unable to bend at his
✦Observe the umbilicus.
waist.Be sure to ask about abdominal pain,fever,nausea,vomiting,anorexia,al-
✦Inspect the abdomen for signs of tered bowel habits,and weight gain or loss.
inguinal or femoral hernia and Obtain a medical history,noting GI or biliary disorders that may cause peritoni-
for incisions. tis or ascites,such as cirrhosis,hepatitis,and inflammatory bowel disease.(See De-
✦Auscultate for bowel sounds,ab- tecting ascites.) Also note chronic constipation.Has the patient recently had ab-
dominal friction rubs,and bruits. dominal surgery,which can lead to abdominal distention? Ask about recent acci-
✦Percuss and palpate the ab- dents,even minor ones,like falling offa stepladder.
domen.
✦Prepare the patient for pelvic ex- PHYSICAL ASSESSMENT
amination or genital examination Perform a complete physical examination.Don’t restrict the examination to the pa-
as appropriate. tient’s abdomen because you could miss important clues to the cause ofhis abdom-
✦Measure abdominal girth for a inal distention.Stand at the foot ofthe bed and observe the recumbent patient for
abdominal asymmetry to determine ifdistention is localized or generalized.Then
baseline value.
assess abdominal contour by stooping at his side.Inspect for tense,glistening skin
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ABDOMINAL DISTENTION 3
and bulging flanks,which may indicate ascites.Observe the umbilicus.An everted
umbilicus may indicate ascites or umbilical hernia.An inverted umbilicus may in-
dicate distention from gas;it’s also common in obesity.Inspect the abdomen for
signs ofinguinal or femoral hernia and for incisions that may point to adhesions.
Both may lead to intestinal obstruction.Then auscultate for bowel sounds,abdom-
inal friction rubs (indicating peritoneal inflammation),and bruits (indicating an
aneurysm).Listen for succussion splash—a splashing sound normally heard in the
stomach when the patient moves or when palpation disturbs the viscera.However,
an abnormally loud splash indicates fluid accumulation,suggesting gastric dilation
or obstruction.
Next,percuss and palpate the abdomen to determine ifdistention results from
air,fluid,or both.A tympanic note in the left lower quadrant suggests an air-filled
descending or sigmoid colon.A tympanic note throughout a generally distended
abdomen suggests an air-filled peritoneal cavity.A dull percussion note throughout
a generally distended abdomen suggests a fluid-filled peritoneal cavity.Shifting of
dullness laterally with the patient in the decubitus position also indicates a fluid-
filled abdominal cavity.A pelvic or intra-abdominal mass causes local dullness
upon percussion and should be palpable.Obesity causes a large abdomen without
Medical causes
shifting dullness,prominent tympany,or palpable bowel or other masses,and with
generalized,rather then localized,dullness. Abdominal cancer
Palpate the abdomen for tenderness,noting whether it’s localized or general- ✦Generalized distention may re-
ized.Watch for peritoneal signs and symptoms,such as rebound tenderness,guard- sult from cancer-produced as-
ing,rigidity,McBurney’s point,obturator sign,and psoas sign.Female patients cites.
should undergo a pelvic examination;males,a genital examination.All patients ✦Associated signs and symptoms
who report abdominal pain should undergo a digital rectal examination with fecal may include severe abdominal
occult blood testing.Finally,measure abdominal girth for a baseline value.Mark
pain,an abdominal mass,
the flanks with a felt-tipped pen as a reference for subsequent measurements.
anorexia,jaundice,GI hemor-
rhage (hematemesis or melena),
MEDICAL CAUSES
dyspepsia,weight loss,and
Abdominal cancer muscle weakness and atrophy.
Generalized abdominal distention may occur when the cancer—most commonly
ovarian,hepatic,or pancreatic—produces ascites (usually in a patient with a
Abdominal trauma
known tumor).It’s an indication ofadvanced disease.Shifting dullness and a fluid
✦Acute and dramatic distention
wave accompany distention.Associated signs and symptoms may include severe ab-
may occur with brisk internal
dominal pain,an abdominal mass,anorexia,jaundice,GI hemorrhage (hemateme-
bleeding.
sis or melena),dyspepsia,and weight loss that progresses to muscle weakness and
atrophy. ✦Associated signs and symptoms
include abdominal rigidity with
Abdominal trauma
guarding,decreased or absent
When brisk internal bleeding accompanies trauma,abdominal distention may be
bowel sounds,vomiting,tender-
acute and dramatic.Associated signs and symptoms ofthis life-threatening disor-
ness,abdominal bruising,pain
der include abdominal rigidity with guarding,decreased or absent bowel sounds,
over the trauma site or scapula,
vomiting,tenderness,and abdominal bruising.Pain may occur over the trauma site
and signs of hypovolemic shock
or over the scapula ifabdominal bleeding irritates the phrenic nerve.Signs ofhy-
povolemic shock (such as hypotension and rapid,thready pulse) appear with sig- (if blood loss is significant).
nificant blood loss.
Bladder distention
Bladder distention
✦Lower abdominal distention re-
Various disorders cause bladder distention which,in turn,causes lower abdominal
sults from bladder distention.
distention.Slight dullness on percussion above the symphysis pubis indicates mild
✦Additional signs and symptoms
bladder distention.A palpable,smooth,rounded,fluctuant suprapubic mass sug-
gests severe bladder distention;a fluctuant mass extending to the umbilicus indi- depend on the severity of disten-
tion.
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4 ABDOMINAL DISTENTION
Medical causes cates extremely severe bladder distention.Urinary dribbling,frequency,or urgency
(continued) may occur with urinary obstruction.Suprapubic discomfort is also common.
Cirrhosis Cirrhosis
✦Ascites causes generalized dis- With cirrhosis,ascites causes generalized distention and is confirmed by a fluid
tention. wave and shifting dullness.Umbilical eversion and caput medusae (dilated veins
✦The patient may report a feeling around the umbilicus) are common.The patient may report a feeling offullness or
of fullness or weight gain. weight gain.Associated findings include vague abdominal pain,fever,anorexia,
nausea,vomiting,constipation or diarrhea,bleeding tendencies,severe pruritus,
palmar erythema,spider angiomas,leg edema and,possibly,splenomegaly.He-
Gastric dilation (acute)
matemesis,encephalopathy,gynecomastia,or testicular atrophy may also be seen.
✦Left-upper-quadrant distention is
Jaundice is usually a late sign.Hepatomegaly occurs initially;however,the liver may
characteristic,but presentation
not be palpable ifthe patient has advanced disease.
varies.
Gastric dilation (acute)
Left-upper-quadrant distention is characteristic ofacute gastric dilation,but the
Heart failure
presentation varies.The patient usually complains ofepigastric fullness or pain and
✦Ascites causes generalized dis-
nausea (with or without vomiting).Physical examination reveals tympany,gastric
tention.
tenderness,and a succussion splash.Initially,visible peristalsis may occur.Later,hy-
✦Hallmark signs and symptoms
poactive or absent bowel sounds confirm ileus.The patient may be pale and dia-
include peripheral edema,jugu- phoretic and may exhibit tachycardia or bradycardia.
lar vein distention,dyspnea,and
Heart failure
tachycardia.
Generalized abdominal distention due to ascites typically accompanies severe car-
diovascular impairment and is confirmed by shifting dullness and a fluid wave.
Irritable bowel syndrome
Signs and symptoms ofheart failure are numerous and depend on the disease stage
✦Periodic intestinal spasms may
and degree ofcardiovascular impairment.Hallmarks include peripheral edema,
cause intermittent,localized dis- jugular vein distention,dyspnea,and tachycardia.Common associated signs and
tention. symptoms include hepatomegaly (which may cause right-upper-quadrant pain),
✦Lower abdominal pain or cramp- nausea,vomiting,productive cough,crackles,cool extremities,cyanotic nail beds,
ing typically accompanies in- nocturia,exercise intolerance,nocturnal wheezing,diastolic hypertension,and car-
testinal spasms. diomegaly.
Irritable bowel syndrome
Large-bowel obstruction Irritable bowel syndrome may produce intermittent,localized distention—the re-
✦Constipation precedes dramatic sult ofperiodic intestinal spasms.Lower abdominal pain or cramping typically ac-
distention. companies these spasms.The pain is usually relieved by defecation or by passage of
✦Loops of the large bowel may intestinal gas and is aggravated by stress.Other possible signs and symptoms in-
become visible on the abdomen. clude diarrhea that may alternate with constipation or normal bowel function;
nausea;dyspepsia;straining and urgency at defecation;feeling ofincomplete evac-
uation;and small,mucus-streaked stools.
Mesenteric artery
occlusion (acute) Large-bowel obstruction
✦Abdominal distention usually oc- Dramatic abdominal distention is characteristic oflarge-bowel obstruction,a life-
curs several hours after the sud- threatening disorder;in fact,loops ofthe large bowel may become visible on the
den onset of severe,colicky abdomen.Constipation precedes distention and may be the only symptom for
periumbilical pain and rapid or days.Associated findings include tympany,high-pitched bowel sounds,and the
sudden onset ofcolicky lower abdominal pain that becomes persistent.Fecal vom-
forceful bowel evacuation.
iting and diminished peristaltic waves and bowel sounds are late signs.
Mesenteric artery occlusion (acute)
In acute mesenteric artery occlusion,a life-threatening disorder,abdominal disten-
tion usually occurs several hours after the sudden onset ofsevere,colicky perium-
bilical pain accompanied by rapid (even forceful) bowel evacuation.The pain later
becomes constant and diffuse.Related signs and symptoms include severe abdomi-