Data collection findings



Data collection findings







Normal findings

To distinguish between health and disease, you must be able to recognize normal data collection findings in each part of the body. When you perform a physical examination, use this head-totoe 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


Inspection

♦ A symmetrical, lesion-free skull

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

♦ An ability to shrug the shoulders, a sign that cranial nerve XI (accessory nerve) is functioning normally


Palpation

♦ No lumps or tenderness on the head

♦ Symmetrical strength in the facial muscles, a sign that cranial nerves V and VII (trigeminal and facial nerves) are functioning normally

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


Auscultation

♦ No bruits audible when auscultating the temporal artery


Neck


Inspection

♦ Unrestricted range of motion in the neck

♦ No bulging of the thyroid

♦ Symmetrical lymph nodes with no swelling

♦ Flat jugular veins


Palpation

♦ Mobile, soft lymph nodes less than 1/2″ (1 cm) in diameter with no tenderness

♦ Symmetrical pulses in the carotid arteries

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

♦ Trachea that follows the midline of the neck and isn’t tender

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

♦ Symmetrical muscle strength in the neck


Auscultation

♦ No audible carotid bruits


Eyes


Inspection

♦ No edema, inflammation, or lesions on eyelids

♦ Eyelids that cover corneas completely 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 eyes are open

♦ 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

♦ 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: one-third of the way down the face and about one eye’s width apart from each other.

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


Palpation

♦ No eyelid swelling or tenderness

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

♦ Lacrimal sacs that don’t regurgitate fluid


Ears


Inspection

♦ Bilaterally symmetrical, proportionately sized auricles with a vertical measurement of 11/2″ to 4″ (4 to 10 cm)

♦ Ear tips that cross the eye-occiput line (an imaginary line extending from the lateral aspect of the eye to the occipital protuberance)

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

♦ Color of ear and facial skin match

♦ 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 mastoid process and surrounding area matches

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


Palpation

♦ 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 that aren’t tender


Nose


Inspection

♦ Symmetrical, lesion-free nose with no discharge or septal deviation

♦ Little or no nasal flaring

♦ Nonedematous frontal and maxillary sinuses

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

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


Palpation

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

♦ No tenderness or edema of the frontal or maxillary sinuses


Mouth


Inspection

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

♦ Ability to purse the lips and puff out the cheeks, a sign that cranial nerve VII (facial nerve) is functioning normally

♦ Ability to open and close the mouth easily

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

♦ Visible salivary ducts with no inflammation

♦ Pale 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 that cranial nerve XII (hypoglossal nerve) is functioning normally

♦ No swelling or inflammation on the anterior and posterior arches

♦ No lesions or inflammation on the posterior pharynx

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

♦ A uvula that moves upward when the patient says “ah” and a gag reflex that can be triggered by touching a tongue blade to the posterior pharynx, both signs that cranial nerves IX and X are functioning normally


Palpation

♦ 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


Lungs


Inspection

♦ Symmetrical side-to-side configuration of the chest

♦ Diameter of the chest from front to back about half the width

♦ 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

♦ Symmetrical expansion of chest wall during respirations

♦ Quiet, unlabored respirations with no use of accessory neck, shoulder, or abdominal muscles

♦ No intercostal, substernal, or supraclavicular retractions

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

♦ Regular respiratory rhythm, with expiration taking about twice as long as inspiration

♦ Diaphragmatic breathing in men and children and thoracic breathing in women


Palpation

♦ Warm, dry skin

♦ No tender spots or masses in the chest

♦ No asymmetrical expansion, fremitus, or subcutaneous crepitation


Auscultation

♦ 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


Heart


Inspection

♦ 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


Palpation

♦ No detectable vibrations or thrills

♦ No lifts (heaves)

♦ No pulsations except at PMI and epigastric area


♦ At the PMI, a localized (less than 1/2″ [1 cm] in diameter) tapping pulse possible at the start of systole

♦ In the epigastric area, possible pulsation from the abdominal aorta


Auscultation


S1

♦ First heart sound (lub)

♦ Regular rate and rhythm

♦ Heard best with the diaphragm of the stethoscope held over the mitral area with the patient in a left-lateral position

♦ In this position, sounds longer, lower, and louder than second heart sound

♦ May be split in the tricuspid area


S2

♦ Second heart sound (dub)

♦ Regular rate and rhythm

♦ Heard best with the diaphragm of the stethoscope held over the aortic area with the patient sitting and leaning forward

♦ In this position, sounds shorter, sharper, higher, and louder than S1

♦ May be split in the pulmonic area on inspiration


S3

♦ Third heart sound

♦ Normal in children and slender, young adults with no cardiovascular disease

♦ Usually disappears by age 25 to 35

♦ In an older adult, may signify ventricular failure

♦ Heard best with the bell of the stethoscope held over the mitral area with the patient in a supine position and exhaling

♦ Sounds short, dull, soft, and low


Murmur

♦ May be functional in children and young adults

♦ Abnormal in older adults

♦ Duration, intensity, and location related to type of murmur


Abdomen


Inspection

♦ No vascular lesions, jaundice, surgical scars, or rashes

♦ Faint venous patterns (more prominent in slender patients)

♦ Flat, round, or scaphoid abdominal contour

♦ Symmetrical abdomen

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

♦ No variations in skin color

♦ No apparent bulges or pulsations

♦ Abdominal movement apparent with respirations

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


Light palpation

♦ No tenderness or masses

♦ Abdominal muscles neither tender nor rigid

♦ No guarding, distention, or ascites


Auscultation

♦ 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


Arms and legs


Inspection

♦ No gross deformities

♦ Symmetrical body parts

♦ Good body alignment

♦ No involuntary movements


♦ Smooth gait

♦ Full range of motion (ROM) in all muscles and joints

♦ No pain with full ROM

♦ No visible swelling or inflammation of joints or muscles

♦ Equal bilateral limb length and symmetrical muscle mass


Palpation

♦ Normal shape with no swelling or tenderness

♦ Equal bilateral muscle tone, texture, and strength

♦ No involuntary contractions or twitching

♦ Equally strong bilateral pulses


Common chief complaints

A patient’s chief complaint is the starting point for almost every initial examination. You may be the patient’s first contact, so you’ll need a good working knowledge of common chief complaints, what might cause them, which examination steps to pursue, and whether the patient needs medical or nursing intervention.

This alphabetical 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.


Anxiety

♦ Subjective reaction to a real or imagined threat

♦ Nonspecific feeling of uneasiness or dread

♦ Prompts the body to purposeful action by stimulating the sympathetic nervous system

♦ Normal response to danger and to the physical and emotional stress of illness

♦ May be caused or worsened by many nonpathologic factors, including lack of sleep, poor diet, and excessive intake of caffeine or other stimulants

♦ If mild to moderate, may cause slight physical or psychological discomfort

♦ If severe, may be incapacitating or even life-threatening

♦ If excessive or unwarranted, 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? Has this occurred before?

♦ 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? What has helped in the past?

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


Physical examination

♦ Perform a complete physical examination.

♦ Focus on problems that may be caused or worsened by anxiety.


Causes


Asthma

♦ With an acute asthma attack, sudden anxiety with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis



Conversion disorder

♦ Chronic anxiety expressed through somatic complaints that have no physiologic basis

♦ Commonly sensorimotor deficits such as blindness and paralysis, but possibly dizziness, chest pain, palpitations, a lump in the throat, or choking


Mood disorders

♦ Chronic anxiety of varying severity

♦ Hallmark: Depression on awakening that abates during the day

♦ Other findings: Dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; suicidal thoughts


Hyperthyroidism

♦ Acute anxiety a possible early sign

♦ Classic signs: Heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, diarrhea and, possibly, exophthalmos


Hyperventilation syndrome

♦ Acute anxiety, pallor, circumoral and peripheral paresthesia, occasionally carpopedal spasms


Mitral valve prolapse

♦ May cause panic

♦ Hallmark: Midsystolic click followed by an apical systolic murmur (clickmurmur syndrome)

♦ May also cause paroxysmal palpitations with sharp, stabbing, or aching precordial pain


Obsessive-compulsive disorder

♦ Chronic anxiety with recurrent, unshakable thoughts or impulses to perform ritualistic acts that patient recognizes as irrational but can’t control

♦ Anxiety that builds if patient can’t perform these acts and diminishes after the action


Phobias

♦ Chronic anxiety with persistent fear of an object, activity, or situation

♦ Result is a compelling desire for avoidance that the patient recognizes as irrational but can’t suppress


Postconcussion syndrome

♦ Possible chronic anxiety or periodic attacks of acute anxiety

♦ Anxiety that’s usually most pronounced in situations that demand attention, judgment, or comprehension

♦ Associated symptoms: irritability, insomnia, dizziness, mild headache


Posttraumatic stress disorder

♦ Chronic anxiety of varying severity

♦ Intrusive, vivid memories and thoughts of the traumatic event

♦ Reliving of the event in dreams and nightmares

♦ May include insomnia, depression, and feelings of numbness and detachment


Somatoform disorder

♦ Chronic anxiety and various somatic complaints that have no physiologic basis

♦ Anxiety and depression that may be prominent or hidden by dramatic, flamboyant, or seductive behavior

♦ Most common in adolescents and young adults


Other causes

♦ Angina pectoris

♦ Antidepressants (may cause paradoxical anxiety)

♦ Central nervous system stimulants

♦ Chronic obstructive pulmonary disease

♦ Heart failure

♦ Hypochondrial neurosis

♦ Hypoglycemia

♦ Myocardial infarction

♦ Pheochromocytoma

♦ Pneumothorax


♦ Pulmonary embolism

♦ Sympathomimetic drugs


Cough, nonproductive

♦ Noisy, forceful expulsion of air that doesn’t yield sputum or blood

♦ One of the most common signs of a respiratory disorder

♦ Sudden onset

♦ May be self-limiting

♦ If persists beyond 1 month, considered chronic

♦ May cause damage, such as airway collapse, rupture of the alveoli, or blebs

♦ If eventually productive, a classic sign of progressive respiratory disease


Health history

♦ When did your cough start? Does a certain body position or a specific activity cause or relieve it? Does it get better or worse at certain times of the day? How does the cough sound? Is it constant or intermittent? Is it annoying or tiring? Does it keep you awake?

♦ Do you have pain with the cough?

♦ Have you noticed recent changes in appetite, energy level, exercise tolerance, or weight? Have you had surgery recently? Do you have allergies? Do you smoke? Have you been recently exposed 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 respirations, noting abnormal patterns. Then examine the patient’s chest configuration and chest wall motion.

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

♦ As you palpate the patient’s neck, note enlarged lymph nodes or masses.

♦ Finally, auscultate the lungs for crackles, decreased or absent breath sounds, pleural friction rubs, rhonchi, and wheezes.


Causes


Asthma

♦ Attack that typically starts with a nonproductive cough and mild wheezing, and progresses to audible wheezing, chest tightness, a cough that produces thick mucus, and severe dyspnea

♦ Other signs: Accessory muscle use, cyanosis, diaphoresis, flaring nostrils, flushing, intercostal and supraclavicular retractions on inspiration, prolonged expirations, tachycardia, tachypnea


Interstitial lung disease

♦ Nonproductive cough and progressive dyspnea

♦ May also include cyanosis, fatigue, fine crackles, finger clubbing, chest pain, and recent weight loss


Other causes

♦ Airway occlusion

♦ Atelectasis

♦ Cigarette smoking

♦ Common cold

♦ Hypersensitivity pneumonitis

♦ Pericardial effusion

♦ Pleural effusion

♦ Pulmonary embolism

♦ Hantavirus infection

♦ Sinusitis

♦ Suctioning

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



Cough, productive

♦ Sudden, forceful, noisy expulsion of air that contains sputum, blood, or both

♦ Clears airways of secretions that normal mucociliary action doesn’t remove

♦ Most common cause: Cigarette smoking

♦ Commonly caused by a cardiopulmonary disorder, such as an acute or a chronic infection that causes inflammation, edema, and increased mucus production in the airways

♦ Also caused by inhalation of antigenic or irritating substances


Health history

♦ When did your cough start? How much sputum do you cough up daily? Have you ever had a productive cough before?

♦ How does your cough sound and feel? Does it tend to produce more sputum at certain times of day, with certain meals or activities, in certain environments?

♦ What are the color, odor, and consistency of the sputum you cough up? Has the amount increased over time?

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

♦ Do you have a recent history of 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 live or have you lived with anyone diagnosed with tuberculosis?


Physical examination

♦ Examine the patient’s mouth and nose for congestion, drainage, and inflammation. Note his breath odor.

♦ Inspect the patient’s neck for jugular vein distention.

♦ As he breathes, observe the chest for accessory muscle use, intercostal and supraclavicular retractions, and uneven expansion.

♦ Palpate the patient’s neck for enlarged lymph nodes, masses, and tenderness.

♦ Finally, auscultate for abnormal breath sounds, crackles, pleural friction rubs, rhonchi, and wheezes.


Causes


Bacterial pneumonia

♦ Initial dry cough that becomes productive

♦ Other signs and symptoms: fever, dyspnea, anxiety, crackles, diminished breath sounds, and pleuritic chest pain


Lung abscess

♦ Cardinal sign: Coughing with copious amounts of purulent, foulsmelling, possibly blood-tinged sputum

♦ Ruptured abscess: May 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

♦ Acute bronchiolitis

♦ Aspiration and chemical pneumonitis

♦ Bronchiectasis

♦ Common cold

♦ Cystic fibrosis

♦ Lung cancer

♦ Pertussis

♦ Pulmonary embolism

♦ Pulmonary edema

♦ Tracheobronchitis


Diarrhea

♦ Usually a chief sign of an intestinal disorder

♦ Increased volume of stool compared with usual bowel habits


♦ Varies in severity, and may be acute or chronic

♦ Acute diarrhea: May result from acute infection, stress, fecal impaction, or drug effect

♦ 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 high-fiber foods


Health history

♦ Do you have abdominal pain and cramps?

♦ Describe your stool’s color, consistency, and frequency. Describe your normal bowel pattern.

♦ 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 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 mucous membranes, and take blood pressure with the patient lying, sitting, and standing.

♦ Take the patient’s temperature and note chills or rash.

♦ Auscultate bowel sounds.

♦ Inspect the abdomen for distention, auscultate for bowel sounds, and palpate for tenderness.


Causes


Anthrax, GI

♦ Caused by eating contaminated meat from an animal infected with


Bacillus anthracis

♦ Early signs and symptoms: Decreased appetite, nausea, vomiting, fever

♦ Later signs and symptoms: Severe bloody diarrhea, abdominal pain, hematemesis


Carcinoid syndrome

♦ Severe diarrhea with flushing— usually of the head and neck—commonly caused by emotional stimuli or ingestion of food, hot water, or alcohol

♦ Other signs and symptoms: Abdominal cramps, dyspnea, weight loss, anorexia, weakness, palpitations, valvular heart disease, depression


Cholera

♦ Caused by ingesting water or food contaminated by the bacterium Vibrio cholerae

♦ Abrupt watery diarrhea and vomiting

♦ Other signs and symptoms: Thirst (from severe water and electrolyte loss), weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, hypotension

♦ Without treatment, may be fatal within hours


Clostridium difficile infection

♦ May cause no symptoms

♦ May cause soft, unformed stools; watery diarrhea that may be foulsmelling or grossly bloody; abdominal pain, cramping, and tenderness; fever; and a white blood cell count as high as 20,000/µl.

♦ Severe infection: May cause toxic megacolon, colon perforation, or peritonitis


Crohn’s disease

♦ Recurring inflammatory disorder that produces diarrhea and abdominal pain with guarding, tenderness, and nausea


♦ May also cause fever, chills, weakness, anorexia, weight loss


Colon cancer

♦ Bloody diarrhea with partial obstruction

♦ Other signs and symptoms: Abdominal pain, anorexia, weight loss, weakness, fatigue, exertional dyspnea, and depression


Escherichia coli 0157:H7 infection

♦ Watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps after eating undercooked beef or other foods contaminated with this strain of bacteria

♦ May be complicated by hemolytic uremic syndrome, which causes red blood cell destruction and eventually acute renal failure, in children age 5 and younger and in elderly people


Acute viral, bacterial, and protozoal infections (such as cryptosporidiosis)

♦ Sudden onset of watery diarrhea, abdominal pain, cramps, nausea, vomiting, and fever

♦ If significant fluid and electrolyte loss, may cause dehydration and shock


Chronic tuberculosis and fungal and parasitic infections

♦ Less severe but more persistent diarrhea

♦ Accompanied by epigastric distress, vomiting, weight loss and, possibly, passage of blood and mucus


Intestinal obstruction

♦ Partial obstruction: Increased intestinal motility, resulting in thinstooled diarrhea, abdominal pain with tenderness and guarding, nausea and, possibly, distention


Irritable bowel syndrome

♦ Diarrhea alternating with constipation or normal bowel function

♦ May cause abdominal pain, tenderness, and distention; dyspepsia; and nausea


Ischemic bowel disease

♦ A life-threatening disorder that causes bloody diarrhea with abdominal pain

♦ If severe, may cause shock and require surgery


Lactose intolerance

♦ Diarrhea within several hours of ingesting milk or milk products

♦ Accompanied by cramps, abdominal pain, loud gurgling bowel sounds, bloating, nausea, and flatus


Ulcerative colitis

♦ Hallmark: Recurrent bloody diarrhea with pus or mucus

♦ Other signs and symptoms: Tenesmus, hyperactive bowel sounds, cramping lower abdominal pain, lowgrade fever, anorexia and, at times, nausea and vomiting

♦ Late findings: Weight loss, anemia, and weakness


Other causes

♦ Enteric feedings

♦ Food poisoning

♦ Foods containing oils that inhibit food absorption, causing acute, uncontrollable diarrhea and rectal leakage

♦ Gastrectomy, gastroenterostomy, pyloroplasty

♦ High-dose radiation therapy (enteritis and diarrhea)

♦ Laxative abuse (acute or chronic diarrhea)

♦ Many antibiotics, such as ampicillin, cephalosporins, tetracyclines, and clindamycin

♦ Other drugs, such as magnesiumcontaining antacids, colchicine, guanethidine, lactulose, dantrolene, ethacrynic acid, mefenamic acid,
methotrexate, metyrosine and, in high doses, cardiac glycosides and quinidine

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.


Dizziness

♦ Sensation of imbalance or faintness that may include blurred or double vision, confusion, and weakness

♦ May start abruptly or gradually, and may be worsened by standing up quickly and eased by lying down

♦ May be mild or severe, with usually brief episodes

♦ Typically results from inadequate blood flow and oxygen supply to the cerebrum and spinal cord

♦ May occur with anxiety, respiratory and cardiovascular disorders, and postconcussion syndrome

♦ May be 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?

♦ Which medications are you taking?

♦ For family members: How would you describe the patient’s usual level of consciousness (LOC)?

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


Physical examination

♦ Check the patient’s current LOC, respirations, and body temperature. As you watch his breathing, look for accessory muscle use or barrel chest. Also look for finger clubbing, cyanosis, dry mucous membranes, and poor skin turgor.

♦ Take the patient’s blood pressure while he’s lying down, sitting, and standing. A drop of more than 20 mm Hg of systolic pressure or 10 mm Hg of diastolic pressure with position change may indicate orthostatic hypotension.

♦ 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.


Causes


Cardiac arrhythmias

♦ Dizziness lasting for several minutes or longer that may precede fainting

♦ Other signs and symptoms: Blurred vision, confusion, hypotension, palpitations, paresthesia, weakness, and an irregular, rapid, or thready pulse


Hypertension

♦ Dizziness that may precede fainting and may be relieved by rest

♦ Other findings: Blurred vision, elevated blood pressure, headache, and retinal changes, such as hemorrhage and papilledema



Transient ischemic attack

♦ Dizziness of varying severity, lasting from a few seconds to 24 hours

♦ May include blindness or visual field deficits, diplopia, hearing loss, numbness, paresis, ptosis, and tinnitus

♦ May be triggered by turning the head to the side

♦ Typically signals an impending stroke


Other causes

♦ Anemia

♦ Certain drugs, such as antihistamines, antihypertensives, anxiolytics, central nervous system depressants, decongestants, opioid analgesics, or vasodilators

♦ Ear conditions

♦ Generalized anxiety disorder

♦ Meniere’s disease

♦ Orthostatic hypotension

♦ Panic disorder

♦ Postconcussion syndrome

♦ Some herbal supplements such as St. John’s wort


Dysphagia

♦ Difficulty swallowing

♦ The most common—and sometimes the only—symptom of an esophageal disorder

♦ May also result from oropharyngeal, respiratory, and neurologic disorders, thyroid enlargement, anxiety, or from exposure to toxins

♦ Increased risk of aspiration, choking, malnutrition, and dehydration


Health history

♦ When did you start having trouble swallowing? Can you point to the spot where you have the most trouble swallowing?

♦ Is swallowing painful? If so, is the pain constant, or does it come and go?

♦ Does eating make the problem better or worse? Do you have more trouble swallowing solids or liquids? Does the problem go away after you try to swallow a few times? Is swallowing easier if you change position?

♦ Have you or anyone in your family ever had an esophageal, oropharyngeal, respiratory, or neurologic disorder?


Physical examination

♦ Evaluate the patient’s swallowing and his cough and gag reflexes.

♦ Listen to his speech, noting signs of muscle, tongue, or facial weakness; aphasia; or dysarthria.

♦ Is the patient’s voice nasal or hoarse?

♦ Check his mouth for dry mucous membranes and thick secretions.

♦ Check thyroid size and for presence of masses.


Causes


Airway obstruction

♦ A life-threatening condition

♦ Marked by mild to severe wheezing, respiratory distress, and dysphagia with gagging and dysphonia


Esophageal cancer

♦ Painless dysphagia, usually with rapid weight loss

♦ Dysphagia that becomes painful and constant as cancer advances

♦ Also 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.


Esophagitis

♦ Corrosive esophagitis: Dysphagia with excessive salivation, fever, hematemesis, intense pain in the mouth and anterior chest, and tachypnea

♦ Candida esophagitis: Dysphagia and sore throat


♦ Reflux esophagitis: A late symptom that usually accompanies stricture


Hiatal hernia

♦ May cause belching, dysphagia, dyspepsia, flatulence, heartburn, regurgitation, and retrosternal or substernal chest pain that’s aggravated by lying down or bending over


Other causes

♦ Botulism

♦ Esophageal diverticula

♦ External esophageal compression

♦ Hypocalcemia

♦ Laryngeal nerve damage

♦ Parkinson’s disease

♦ Radiation therapy

♦ Stroke


Dyspnea

♦ Typically described as shortness of breath

♦ Also includes difficult or uncomfortable breathing

♦ May vary greatly in severity, which usually isn’t related to seriousness of underlying cause

♦ 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, while you’re resting, or when you’re lying flat? Does anything seem to trigger, worsen, or relieve it? Have you ever had dyspnea before?

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

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

♦ Which medications are you taking?


Physical examination

♦ Observe the patient’s respirations, noting their rate and depth as well as breathing difficulties or abnormal respiratory patterns. Obtain a pulse oximetry reading. 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 the patient’s chest for asymmetrical expansion, decreased diaphragmatic excursion, tactile fremitus, and subcutaneous crepitation. Also check the rate, rhythm, and intensity of the peripheral pulses.

♦ Auscultate the lungs for bronchophony; crackles; decreased, absent, or unilateral breath sounds; egophony; pleural friction rubs; rhonchi; whispered pectoriloquy; and wheezing.

♦ Auscultate the heart for abnormal sounds or rhythms and for pericardial friction rubs and tachycardia. Also monitor the patient’s blood and pulse pressures.


Causes


Acute respiratory distress syndrome

♦ Acute dyspnea followed by accessory muscle use, crackles, grunting respirations, progressive respiratory distress, rhonchi, and wheezes

♦ Late stages: Anxiety, cyanosis, decreased mental acuity, and tachycardia

♦ Severe acute respiratory distress syndrome: Signs of shock, such as cool, clammy skin and hypotension

♦ Typically, no history of underlying cardiac or pulmonary disease but a recent pulmonary or systemic insult



Airway obstruction, partial

♦ Inspiratory stridor and sudden shortness of breath

♦ Related findings: Accessory muscle use, anxiety, asymmetrical chest expansion, cyanosis, decreased or absent breath sounds, diaphoresis, hypotension, tachypnea

♦ Possibly caused by aspirated vomitus, a foreign body, or exposure to an allergen

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Aug 18, 2016 | Posted by in NURSING | Comments Off on Data collection findings

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