Assessment findingsDistinguishing health from disease

Assessment findings
Distinguishing health from disease

Normal findings

To distinguish between health and disease, you must be able to recognize normal assessment findings in each part of the body. When you perform a physical examination, use this head-to-toe roster of normal findings as a reference. It’s designed to help you quickly zero in on physical abnormalities and evaluate your patient’s overall condition.

Head and neck



♦ A symmetrical, lesion-free skull

♦ Symmetrical facial structures with normal variations in skin texture and pigmentation

♦ An ability to shrug the shoulders, a sign of an adequately functioning cranial nerve XI (accessory nerve)


♦ Unrestricted range of motion in the neck

♦ No bulging of the thyroid

♦ Symmetrical lymph nodes with no swelling

♦ Flat jugular veins



♦ No lumps or tenderness on the head

♦ Symmetrical strength in the facial muscles, a sign of adequately functioning cranial nerves V and VII (trigeminal and facial nerves)

♦ Symmetrical sensation when you stroke a wisp of cotton on each cheek


♦ Mobile, soft lymph nodes less than ½″ (1 cm) with no tenderness

♦ Symmetrical pulses in the carotid arteries

♦ A palpable, symmetrical, lesion-free thyroid with no tenderness

♦ Midline location of the trachea and absence of tracheal tenderness

♦ No crepitus, tenderness, or lesions in the cervical spine

♦ Symmetrical muscle strength in the neck



♦ Auscultate the temporal artery


♦ Auscultate for carotid bruits



♦ No edema, scaling, or lesions on eyelids

♦ Eyelids completely covering corneas when closed

♦ Eyelid color the same as surrounding skin color

♦ Palpebral fissures of equal height

♦ Margin of the upper lid falling between the superior pupil margin and the superior limbus

♦ Symmetrical, lesion-free upper eyelids that don’t sag or droop when the patient opens his eyes

♦ Evenly distributed eyelashes that curve outward

♦ Globe of the eye neither protruding from nor sunken into the orbit

♦ Eyebrows with equal size, color, and distribution

♦ Absence of nystagmus

♦ Clear conjunctiva with visible small blood vessels and no signs of drainage

♦ White sclera visible through the conjunctiva

♦ A transparent anterior chamber that contains no visible material when you shine a penlight into the side of the eye

♦ Transparent, smooth, and bright cornea with no visible irregularities or lesions

♦ Closing of the lids of both eyes when you stroke each cornea with a wisp of cotton, a test of cranial nerve V (trigeminal nerve)

♦ Round, equal-sized pupils that react to light and accommodation

♦ Constriction of both pupils when you shine a light on one

♦ Lacrimal structures free from exudate, swelling, and excessive tearing

♦ Proper eye alignment

♦ Parallel eye movement in each of the six cardinal fields of gaze


♦ No eyelid swelling or tenderness

♦ Globes that feel equally firm, but not overly hard or spongy

♦ Lacrimal sacs that don’t regurgitate fluid



♦ Bilaterally symmetrical, proportionately sized auricles with a vertical measurement of 1½″ to 4″ (4 to 10 cm)

♦ Tip of ear crossing eye-occiput line (an imaginary line extending from the lateral aspect of the eye to the occipital protuberance)

♦ Long axis of the ear perpendicular to (or no more than 10 degrees from perpendicular to) the eye-occiput line

♦ Color match between the ears and facial skin

♦ No signs of inflammation, lesions, or nodules

♦ No cracking, thickening, scaling, or lesions behind the ear when you bend the auricle forward

♦ No visible discharge from the auditory canal

♦ A patent external meatus

♦ Skin color on the mastoid process that matches the skin color of the surrounding area

♦ No redness or swelling

♦ Normal drum landmarks and a bright reflex, with no canal inflammation or drainage, seen on otoscopic examination


♦ No masses or tenderness on the auricle

♦ No tenderness on the auricle or tragus during manipulation

♦ Either small, nonpalpable lymph nodes on the auricle or discrete, mobile lymph nodes with no signs of tenderness

♦ Well-defined, bony edges on the mastoid process with no signs of tenderness

Nose and mouth



♦ Symmetrical, lesion-free nose with no deviation of the septum or discharge

♦ Little or no nasal flaring

♦ Nonedematous frontal and maxillary sinuses

♦ Ability to identify familiar odors

♦ Pink-red nasal mucosa with no visible lesions and no purulent drainage

♦ No evidence of foreign bodies or dried blood in the nose


♦ Pink lips with no dryness, cracking, lesions, or cyanosis

♦ Symmetrical facial structures

♦ Ability to purse the lips and puff out the cheeks, a sign of an adequately functioning cranial nerve VII (facial nerve)

♦ Ability to open and close the mouth easily

♦ Light pink, moist oral mucosa with no ulcers or lesions

♦ Visible salivary ducts with no inflammation

♦ White, hard palate

♦ Pink, soft palate

♦ Pink gums with no tartar, inflammation, hemorrhage, or leukoplakia

♦ All teeth intact, with no signs of occlusion, caries, or breakage

♦ Pink tongue that protrudes symmetrically and has no swelling, coating, ulcers, or lesions

♦ Ability to move the tongue easily and without tremor, a sign of a properly functioning cranial nerve XII (hypoglossal nerve)

♦ No swelling or inflammation on the anterior and posterior arches

♦ No lesions or inflammation on the posterior pharynx

♦ Lesion-free tonsils that are the appropriate size for the patient’s age

♦ A uvula that moves upward when the patient says “ah” and a gag reflex that occurs when a tongue blade touches the posterior pharynx. These are signs of properly functioning cranial nerves IX and X.



♦ No structural deviation, tenderness, or swelling on the external nose

♦ No tenderness or edema on the frontal and maxillary sinuses


♦ Lips free from pain and induration

♦ No tenderness on the posterior and lateral surfaces of the tongue

♦ No tenderness or nodules on the floor of the mouth



♦ Symmetrical side-to-side configuration of the chest

♦ Anteroposterior diameter less than the transverse diameter, with a 1:2 ratio in an adult

♦ Normal chest shape, with no deformities, such as a barrel chest, kyphosis, retraction, sternal protrusion, or depressed sternum

♦ Costal angle less than 90 degrees, with the ribs joining the spine at a 45-degree angle

♦ Quiet, unlabored respirations with no use of accessory neck, shoulder, or abdominal muscles. You should also see no intercostal, substernal, or supraclavicular retractions.

♦ Symmetrically expanding chest wall during respirations

♦ Normal adult respiratory rate of 12 to 20 breaths/minute, with some variation depending on the patient’s age

♦ Regular respiratory rhythm, with expiration taking about twice as long as inspiration. Men and children breathe diaphragmatically, whereas women breathe thoracically.

♦ Skin color that matches the rest of the body’s complexion


♦ Warm, dry skin

♦ No tender spots or bulges in the chest

♦ No asymmetrical expansion, fremitus, or subcutaneous crepitation


♦ Resonant percussion sounds over the lungs


♦ Loud, high-pitched bronchial breath sounds over the trachea

♦ Intense, medium-pitched bronchovesicular breath sounds over the mainstem bronchi, between the scapulae, and below the clavicles

♦ Soft, breezy, low-pitched vesicular breath sounds over most of the peripheral lung fields



♦ No visible pulsations, except at the point of maximum impulse (PMI)

♦ No lifts (heaves) or retractions in the four valve areas of the chest wall


♦ No detectable vibrations or thrills

♦ No lifts (heaves)

♦ No pulsations, except at the PMI and epigastric area. At the PMI, a localized (less than ½″ [1 cm] in diameter) tapping pulse may be felt at the start of systole. In the epigastric area, pulsation from the abdominal aorta may be palpable.


♦ A first heart sound (S1)—the lub sound heard best with the diaphragm of the stethoscope over the mitral area when the patient is in a left lateral position. It sounds longer, lower, and louder there than second heart sounds (S2). S1 splitting may be audible in the tricuspid area.

♦ An S2 sound—the dub sound heard best with the diaphragm of the stethoscope in the aortic area while the patient sits and leans forward. It sounds shorter, sharper, higher, and louder there than S1 sounds. Normal S2 splitting may be audible in the pulmonic area on inspiration.

♦ A third heart sound (S3). This sound is normal in children and slender, young adults with no cardiovascular disease. It usually disappears when adults reach ages 25 to 35. However, in an older adult, it may signify ventricular failure. S3 may be heard best with the bell of the stethoscope over the mitral area with the patient in a supine position and exhaling. It sounds short, dull, soft, and low.

♦ A murmur, which may be functional in children and young adults, but is abnormal in older adults. Innocent murmurs are soft and short, and they vary with respirations and patient position. They occur in early systole and are heard best in the pulmonic or mitral area with the patient in a supine position.



♦ Skin free from vascular lesions, jaundice, surgical scars, and rashes

♦ Faint venous patterns (except in thin patients)

♦ Flat, round, or scaphoid abdominal contour

♦ Symmetrical abdomen

♦ Umbilicus positioned midway between the xiphoid process and the symphysis pubis, with a flat or concave hemisphere

♦ No variations in skin color

♦ No apparent bulges

♦ Abdominal movement apparent with respirations

♦ Pink or silver-white striae from pregnancy or weight loss


♦ High-pitched, gurgling bowel sounds, heard every 5 to 15 seconds through the diaphragm of the stethoscope in all four quadrants of the abdomen

♦ Vascular sounds heard through the bell of the stethoscope

♦ Venous hum over the inferior vena cava

♦ No bruits, murmurs, friction rubs, or other venous hums


♦ Tympany predominantly over hollow organs, including the stomach, intestines, bladder, abdominal aorta, and gallbladder

♦ Dullness over solid masses, including the liver, spleen, pancreas, kidneys, uterus, and a full bladder


♦ No tenderness or masses

♦ Abdominal musculature free from tenderness and rigidity

♦ No guarding, rebound tenderness, distention, or ascites

♦ Unpalpable liver except in children (If palpable, the liver edge is regular, sharp, and nontender and is felt no more than ¾″ [2 cm] below the right costal margin.)

♦ Unpalpable spleen

♦ Unpalpable kidneys except in thin patients or those with a flaccid abdominal wall (The right kidney is felt more commonly than the left.)

Arms and legs


♦ No gross deformities

♦ Symmetrical body parts

♦ Good body alignment

♦ No involuntary movements

♦ Smooth gait

♦ Full range of motion in all muscles and joints

♦ No pain with full range of motion

♦ No visible swelling or inflammation of joints or muscles

♦ Equal bilateral limb length and symmetrical muscle mass


♦ Normal shape with no swelling or tenderness

♦ Equal bilateral muscle tone, texture, and strength

♦ No involuntary contractions or twitching

♦ Equally strong bilateral pulses

Exploring the most common chief complaints

A patient’s chief complaint is the starting point for almost every initial assessment. You may be the patient’s first contact, so you must recognize the condition and determine the need for medical or nursing intervention. To thoroughly evaluate the patient’s chief complaint, you must ask the right questions about the patient’s health history, conduct a physical examination based on the history data you collect, and analyze possible causes of the problem.

The following list examines the most common chief complaints encountered in nursing practice. For each one, you’ll find a concise description, detailed questions to ask during the history, areas to focus on during the physical examination, and common causes to consider.


A subjective reaction to a real or imagined threat, anxiety is a nonspecific feeling of uneasiness or dread. It may be mild to moderate or severe. Mild to moderate anxiety may cause slight physical or psychological discomfort. Severe anxiety may be incapacitating or even life-threatening.

Anxiety is a normal response to actual danger, prompting the body (through stimulation of the sympathetic nervous system) to purposeful action. It’s also a normal response to physical and emotional stress, which virtually any illness can produce. Anxiety may also be precipitated or exacerbated by many nonpathologic factors, including lack of sleep, poor diet, and excessive intake of caffeine or other stimulants. However, excessive, unwarranted anxiety may indicate an underlying psychological problem.

Health history

♦ What are you anxious about? When did the anxiety first occur? What were the circumstances? What do you think caused it?

♦ Is the anxiety constant or sporadic? Do you notice any precipitating factors?

♦ How intense is the anxiety on a scale of 0 to 10, with 10 being the worst? What decreases it?

♦ Do you smoke? Do you use caffeine? Alcohol? Drugs? What medications do you take?

Physical examination

Perform a complete physical examination, focusing on complaints that the anxiety may trigger or aggravate.



In allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.

Conversion disorder

Chronic anxiety is characteristic of conversion disorder, along with one or two somatic complaints that have no physiologic basis. Common complaints are dizziness, chest pain, palpitations, a lump in the throat, and choking.


Acute anxiety may be an early sign of hyperthyroidism. Classic signs include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur as well.

Hyperventilation syndrome

Hyperventilation syndrome produces acute anxiety, pallor, circumoral and peripheral paresthesia and, occasionally, carpopedal spasms.

Mitral valve prolapse

Panic may occur in patients with mitral valve prolapse, which is referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click followed by an apical systolic murmur.

Mood disorder

In the depressive form of mood disorder, chronic anxiety occurs with varying severity. The hallmark is depression on awakening that abates during the day. Associated findings include dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts.

Obsessive-compulsive disorder

Chronic anxiety occurs in obsessivecompulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational, but can’t control them. Anxiety builds if he can’t perform these acts and diminishes after he does.


In phobias, chronic anxiety occurs along with persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational, but can’t suppress it.

Postconcussion syndrome

Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated symptoms include irritability, insomnia, dizziness, and mild headache. The anxiety is usually most pronounced in situations that demand attention, judgment, or comprehension.

Posttraumatic stress disorder

Posttraumatic stress disorder produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event
in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.

Somatoform disorder

Most common in adolescents and young adults, somatoform disorder is characterized by chronic anxiety and various somatic complaints that have no physiologic basis. Anxiety and depression may be prominent or hidden by dramatic, flamboyant, or seductive behavior.

Other causes

Angina pectoris, chronic obstructive pulmonary disease, heart failure, hypochondrial neurosis, hypoglycemia, myocardial infarction (MI), pheochromocytoma, pneumothorax, and pulmonary embolism can cause anxiety. Certain drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. Also, many antidepressants can cause paradoxical anxiety.

Cough (nonproductive)

A nonproductive cough is a noisy, forceful expulsion of air from the lungs that doesn’t yield sputum or blood. One of the most common signs of a respiratory disorder, a nonproductive cough can be ineffective and cause damage, such as airway collapse, rupture of the alveoli, or blebs.

A nonproductive cough that later becomes productive is a classic sign of a progressive respiratory disease. An acute nonproductive cough has a sudden onset and may be self-limiting. A nonproductive cough that persists beyond 1 month is considered chronic; this type of cough commonly results from cigarette smoking.

Health history

♦ When did the cough begin? Does a certain body position or a specific activity relieve or exacerbate it? Does it get better or worse at certain times of the day? How does the cough sound? Does it occur often? Is it paroxysmal?

♦ Does pain accompany the cough?

♦ Have you noticed any recent changes in your appetite, energy level, exercise tolerance, or weight? Have you had surgery recently? Do you have any allergies? Do you smoke? Have you been exposed recently to fumes or chemicals?

♦ What medications are you taking?

Physical examination

Note whether the patient appears agitated, anxious, confused, diaphoretic, flushed, lethargic, nervous, pale, or restless. Is his skin cold or warm, clammy or dry?

Observe the rate and depth of his respirations, noting abnormal patterns. Then examine his chest configuration and chest wall motion.

Check the patient’s nose and mouth for congestion, drainage, inflammation, and signs of infection. Then inspect his neck for jugular vein distention and tracheal deviation.

As you palpate the patient’s neck, note enlarged lymph nodes or masses. Next, percuss his chest while listening for dullness, flatness, and tympany. Finally, auscultate his lungs for crackles, decreased or absent breath sounds, pleural friction rubs, rhonchi, and wheezes.



Typically, an asthma attack occurs at night, starting with a nonproductive cough and mild wheezing. Then it progresses to audible wheezing, chest tightness, a cough that produces thick mucus, and severe dyspnea. Other signs include accessory muscle use, cyanosis, diaphoresis, flaring nostrils, flushing, intercostal and supraclavicular
retractions on inspiration, prolonged expirations, tachycardia, and tachypnea.

Interstitial lung disease

With interstitial lung disease, the patient has a nonproductive cough and progressive dyspnea. He may also be cyanotic and fatigued and have fine crackles, finger clubbing, chest pain, and recent weight loss.

Other causes

A nonproductive cough may stem from airway occlusion, atelectasis, the common cold, hypersensitivity pneumonitis, pericardial effusion, pleural effusion, pulmonary embolism, Hantavirus infection, and sinusitis. Also, incentive spirometry, intermittent positive-pressure breathing, and suctioning can induce a nonproductive cough.

image Acute otitis media, which commonly occurs in infants and young children because of their short eustachian tubes, also produces nonproductive coughing.

Cough (productive)

With productive coughing, the airway passages are cleared of accumulated secretions that normal mucociliary action doesn’t remove. The sudden, forceful, noisy expulsion contains sputum, blood, or both.

Usually caused by a cardiopulmonary disorder, productive coughing typically stems from an acute or chronic infection that causes inflammation, edema, and increased production of mucus in the airways. Such coughing can also result from inhaling antigenic or irritating substances. The most common cause is cigarette smoking.

Health history

♦ When did the cough begin? How much sputum do you cough up daily? Is sputum production associated with the time of day, meals, activities, or the environment? Has it increased since coughing began? What are the color, odor, and consistency of the sputum? How does the cough sound and feel? Have you ever had a productive cough before?

♦ Have you noticed recent changes in your appetite or weight?

♦ Do you have a history of recent surgery or allergies? Do you smoke or drink alcohol? If so, how much? Do you work around chemicals or respiratory irritants?

♦ What medications are you taking?

♦ Do you currently or have you in the past lived with anyone diagnosed with tuberculosis?

Physical examination

As you examine the patient’s mouth and nose for congestion, drainage, and inflammation, note his breath odor. Then inspect his neck for jugular vein distention. As he breathes, observe the chest for accessory muscle use, intercostal and supraclavicular retractions, and uneven expansion.

Palpate his neck for enlarged lymph nodes, masses, and tenderness. Next, percuss his chest, listening for dullness, flatness, and tympany. Finally, auscultate for abnormal breath sounds, crackles, pleural friction rubs, rhonchi, and wheezes.


Bacterial pneumonia

With bacterial pneumonia, an initially dry cough becomes productive. Rustcolored sputum appears in pneumococcal pneumonia; brick-red or currantjelly sputum, in Klebsiella pneumonia; salmon-colored sputum, in staphylococcal pneumonia; and mucopurulent sputum, in streptococcal pneumonia.

Lung abscess

The cardinal sign of a ruptured lung abscess is coughing that produces
copious amounts of purulent, foulsmelling and, possibly, blood-tinged sputum. A ruptured abscess can also cause anorexia, diaphoresis, dyspnea, fatigue, fever with chills, halitosis, headache, inspiratory crackles, pleuritic chest pain, tubular or amphoric breath sounds, and weight loss.

Other causes

A productive cough can result from acute bronchiolitis, aspiration and chemical pneumonitis, bronchiectasis, the common cold, cystic fibrosis, lung cancer, pertussis, pulmonary embolism, pulmonary edema, and tracheobronchitis. Also, expectorants, incentive spirometry, and intermittent positive-pressure breathing can cause a productive cough.


Usually a chief sign of an intestinal disorder, diarrhea is an increase in the volume of stools compared with the patient’s normal bowel habits. It varies in severity and may be acute or chronic. Acute diarrhea may result from acute infection, stress, fecal impaction, or the effect of a drug. Chronic diarrhea may result from chronic infection, obstructive and inflammatory bowel disease, malabsorption syndrome, an endocrine disorder, or GI surgery. Periodic diarrhea may result from food intolerance or from ingestion of caffeine or spicy or highfiber foods.

Health history

♦ Do you have abdominal pain and cramps?

♦ Do you have difficulty breathing?

♦ Are you weak or fatigued?

♦ What medications do you take?

♦ Have you had GI surgery or radiation therapy recently?

♦ Describe your diet.

♦ Do you have any known food allergies?

♦ Have you been experiencing any unusual stress?

Physical examination

If the patient isn’t in shock, proceed with a brief physical examination. Evaluate hydration, check skin turgor and the mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient’s temperature and note chills or rash. Conduct a rectal examination and a pelvic examination if indicated.


Anthrax, GI

GI anthrax manifests after the patient has eaten contaminated meat from an animal infected with Bacillus anthracis. Early signs and symptoms include decreased appetite, nausea, vomiting, and fever. Later signs and symptoms include severe bloody diarrhea, abdominal pain, and hematemesis.

Carcinoid syndrome

With carcinoid syndrome, severe diarrhea occurs with flushing—usually of the head and neck—that’s commonly caused by emotional stimuli or the ingestion of food, hot water, or alcohol. Associated signs and symptoms include abdominal cramps, dyspnea, weight loss, anorexia, weakness, palpitations, valvular heart disease, and depression.


After ingesting water or food contaminated by the bacterium Vibrio cholerae, the patient experiences abrupt watery diarrhea and vomiting. Other signs and symptoms include thirst (caused by severe water and electrolyte loss),
weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Clostridium difficile infection

The patient may be asymptomatic or may have soft, unformed stools or watery diarrhea that may be foul-smelling or grossly bloody; abdominal pain, cramping, and tenderness; fever; and a white blood cell count as high as 20,000/µl. In severe cases, the patient may have toxic megacolon, colonic perforation, or peritonitis.

Crohn’s disease

Crohn’s disease is a recurring inflammatory disorder that produces diarrhea accompanied by abdominal pain with guarding, tenderness, and nausea. The patient may also have fever, chills, weakness, anorexia, and weight loss.

Escherichia coli 0157:H7

With E. coli infection, the patient has watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps after eating undercooked beef or other foods contaminated with this strain of bacteria. Hemolytic uremic syndrome, which causes red blood cell destruction and eventually acute renal failure, is a complication of E. coli 0157:H7 infection in children age 5 and younger and in elderly people.


Acute viral, bacterial, and protozoal infections (such as cryptosporidiosis) cause the sudden onset of watery diarrhea as well as abdominal pain, cramps, nausea, vomiting, and fever. Significant fluid and electrolyte loss may cause signs of dehydration and shock. Chronic tuberculosis and fungal and parasitic infections may produce less severe but more persistent diarrhea, accompanied by epigastric distress, vomiting, weight loss and, possibly, passage of blood and mucus.

Intestinal obstruction

Partial intestinal obstruction increases intestinal motility, resulting in diarrhea, abdominal pain with tenderness and guarding, nausea and, possibly, distention.

Irritable bowel syndrome

Diarrhea alternates with constipation or normal bowel function. The patient may have abdominal pain, tenderness, and distention; dyspepsia; and nausea.

Ischemic bowel disease

Ischemic bowel disease is a life-threatening disorder that causes bloody diarrhea with abdominal pain. If severe, shock may occur, requiring surgery.

Lactose intolerance

With lactose intolerance, diarrhea occurs within several hours of ingesting milk or milk products. It’s accompanied by cramps, abdominal pain, borborygmi, bloating, nausea, and flatus.

Large-bowel cancer

With large-bowel cancer, bloody diarrhea is seen with partial obstruction. Other signs and symptoms include abdominal pain, anorexia, weight loss, weakness, fatigue, exertional dyspnea, and depression.

Ulcerative colitis

The hallmark of ulcerative colitis is recurrent bloody diarrhea with pus or mucus. Other signs and symptoms include tenesmus, hyperactive bowel sounds, cramping lower abdominal pain, low-grade fever, anorexia and, at times, nausea and vomiting. Weight loss, anemia, and weakness are late findings.

Other causes

Many antibiotics—such as ampicillin, cephalosporins, tetracyclines, and clindamycin—cause diarrhea. Other drugs that may cause diarrhea include magnesium-containing antacids, colchicine, guanethidine, lactulose, dantrolene, ethacrynic acid, mefenamic acid, methotrexate, metyrosine and, in high doses, cardiac glycosides and quinidine. Laxative abuse can cause acute or chronic diarrhea. Foods that contain certain oils may inhibit absorption of food, causing acute, uncontrollable diarrhea and rectal leakage. Gastrectomy, gastroenterostomy, and pyloroplasty may produce diarrhea. High-dose radiation therapy may produce enteritis and diarrhea.

image Diarrhea in children commonly results from infection, although chronic diarrhea may result from malabsorption syndrome, an anatomic defect, or allergies. Because dehydration and electrolyte imbalance occur rapidly in children, diarrhea can be life-threatening. Diligently monitor all episodes of diarrhea, and immediately replace lost fluids.


A common symptom, dizziness is a sensation of imbalance or faintness that’s sometimes associated with blurred or double vision, confusion, and weakness. Dizziness may be mild or severe and may be aggravated by standing up quickly and alleviated by lying down. Onset may be abrupt or gradual. Episodes are usually brief.

Dizziness typically results from inadequate blood flow and oxygen supply to the cerebrum and spinal cord. It may occur with anxiety, respiratory and cardiovascular disorders, and postconcussion syndrome. Dizziness is also a key symptom of certain serious disorders, such as hypertension and vertebrobasilar artery insufficiency.

Health history

♦ When did the dizziness start? How severe is it? How often does it occur, and how long does each episode last? Does the dizziness abate spontaneously? Is it triggered by standing up suddenly or bending over?

♦ Do you have blurred vision, chest pain, a chronic cough, diaphoresis, a headache, or shortness of breath?

♦ Have you ever had hypertension or another cardiovascular disorder? What about diabetes mellitus, anemia, respiratory or anxiety disorders, or head injury?

♦ What medications and supplements are you taking?

image Many children have difficulty describing dizziness and instead complain of tiredness, stomachache, and feeling sick.

Physical examination

Assess the patient’s LOC, respirations, and body temperature. As you observe his breathing, look for accessory muscle use or barrel chest. Look also for finger clubbing, cyanosis, dry mucous membranes, and poor skin turgor. Evaluate the patient’s motor and sensory functions and reflexes.

Palpate the extremities for peripheral edema and capillary refill. Auscultate the patient’s heart rate and rhythm and his breath sounds. Take his blood pressure while he’s lying down, sitting, and standing. If the diastolic pressure exceeds 100 mm Hg, notify the physician immediately and instruct the patient to lie down.


Cardiac arrhythmias

With cardiac arrhythmias, dizziness lasts for several minutes or longer and may precede fainting. Other signs and
symptoms include blurred vision, confusion, hypotension, palpitations, paresthesia, weakness, and an irregular, rapid, or thready pulse.


With hypertension, dizziness may precede fainting, but may be relieved by rest. Other findings include blurred vision, elevated blood pressure, headache, and retinal changes, such as hemorrhage and papilledema.

Transient ischemic attack

Dizziness of varying severity occurs during a transient ischemic attack. Lasting from a few seconds to 24 hours, an attack may be triggered by turning the head to the side and may signal an impending stroke. During an attack, the patient may experience blindness or visual field deficits, diplopia, hearing loss, numbness, paresis, ptosis, and tinnitus.

Other causes

Dizziness may result from anemia, generalized anxiety disorder, orthostatic hypotension, panic disorder, or postconcussion syndrome. Also, dizziness may be an adverse reaction to certain drugs, such as anxiolytics, central nervous system depressants, narcotic analgesics, decongestants, antihistamines, antihypertensives, or vasodilators. Some herbal medications, such as St. John’s wort, can cause dizziness.


Difficulty swallowing, or dysphagia, is the most common—and sometimes the only—symptom of an esophageal disorder. This symptom may also result from oropharyngeal, respiratory, and neurologic disorders, or from exposure to toxins. Patients with dysphagia have an increased risk of aspiration and choking and of malnutrition and dehydration.

Health history

♦ When did your difficulty swallowing start? Is swallowing painful? If so, is the pain constant or intermittent? Can you point to the spot where you have the most trouble swallowing? Does eating alleviate or aggravate the problem? Do you have more trouble swallowing solids or liquids? Does the problem disappear after you try to swallow a few times? Is swallowing easier if you change position?

♦ Have you or has anyone in your family ever had an esophageal, oropharyngeal, respiratory, or neurologic disorder? Have you recently had a tracheotomy or been exposed to a toxin?

Physical examination

Evaluate the patient’s swallowing and his cough and gag reflexes. As you listen to his speech, note signs of muscle, tongue, or facial weakness; aphasia; or dysarthria. Is his voice nasal or hoarse? Check his mouth for dry mucous membranes and thick secretions.


Airway obstruction

A life-threatening condition, upperairway obstruction is marked by mild to severe wheezing and respiratory distress. Dysphagia occurs along with gagging and dysphonia.

Esophageal carcinoma

In the patient with esophageal carcinoma, painless dysphagia typically accompanies rapid weight loss. As the carcinoma advances, dysphagia becomes painful and constant. The patient has a cough with hemoptysis, hoarseness, sore throat, and steady chest pain.

image For patients older than age 50 with head or neck cancer, dysphagia is commonly the initial chief complaint.


A patient with corrosive esophagitis has dysphagia accompanied by excessive salivation, fever, hematemesis, intense pain in the mouth and anterior chest, and tachypnea. Candida esophagitis produces dysphagia and sore throat. In reflux esophagitis, dysphagia is a late symptom that usually accompanies stricture.

Hiatal hernia

The patient with a hiatal hernia may complain of belching, dysphagia, dyspepsia, flatulence, heartburn, regurgitation, and retrosternal or substernal chest pain that’s aggravated by lying down or bending over.

Other causes

Dysphagia results from botulism, esophageal diverticula or stricture, external esophageal compression, hypocalcemia, laryngeal nerve damage, and Parkinson’s disease. Radiation therapy and tracheotomy may also cause dysphagia.


Patients typically describe dyspnea as shortness of breath, but this symptom also refers to difficult or uncomfortable breathing. Its severity varies greatly and is generally unrelated to the seriousness of the underlying cause. Dyspnea may arise suddenly or slowly and may subside rapidly or persist for years.

Health history

♦ When did the dyspnea first occur? Did it begin suddenly or gradually? Is it constant or intermittent? Does it occur during activity or while you’re resting? Does anything seem to trigger, worsen, or relieve it? Have you ever had dyspnea before?

♦ Do you have chest pain or a productive or nonproductive cough?

♦ Have you recently had an upper respiratory tract infection or experienced trauma? Do you smoke? If so, how much and for how long? Have you been exposed to any allergens? Do you have any known allergies?

♦ What medications and supplements are you taking?

Physical examination

Observe the patient’s respirations, noting their rate and depth as well as breathing difficulties or abnormal respiratory patterns. Check for flaring nostrils, grunting respirations, inspiratory stridor, intercostal retractions during inspirations, and pursed-lip expirations.

Examine the patient for barrel chest, diaphoresis, jugular vein distention, finger clubbing, and peripheral edema. Note the color, consistency, and odor of sputum.

Palpate his chest for asymmetrical expansion, decreased diaphragmatic excursion, tactile fremitus, and subcutaneous crepitation. Also check the rate, rhythm, and intensity of his peripheral pulses.

As you percuss the lung fields, note dull, hyperresonant, or tympanic percussion sounds. Auscultate the lungs for bronchophony, crackles, decreased or absent unilateral breath sounds, egophony, pleural friction rubs, rhonchi, whispered pectoriloquy, and wheezing. Auscultate the heart for abnormal sounds or rhythms, such as ventricular or atrial gallop, and for pericardial friction rubs and tachycardia. Also monitor the patient’s blood pressure and pulse pressure.


Acute respiratory distress syndrome

In acute respiratory distress syndrome (ARDS), acute dyspnea is followed by accessory muscle use, crackles, grunting respirations, progressive respiratory distress, rhonchi, and wheezes. In the
late stages, anxiety, cyanosis, decreased mental acuity, and tachycardia occur. Severe ARDS can produce signs of shock, such as cool, clammy skin and hypotension. The typical patient has no history of underlying cardiac or pulmonary disease, but has had a recent pulmonary or systemic insult.

Airway obstruction (partial)

Inspiratory stridor and acute dyspnea occur as the patient tries to overcome the obstruction. Related findings include accessory muscle use, anxiety, asymmetrical chest expansion, cyanosis, decreased or absent breath sounds, diaphoresis, hypotension, and tachypnea. The patient may have aspirated vomitus or a foreign body or may have been exposed to an allergen.

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Aug 18, 2016 | Posted by in NURSING | Comments Off on Assessment findingsDistinguishing health from disease

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