Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015

family history, medical and psychiatric disorders, and the use of certain drugs. It can also occur in the postpartum period. A complete psychiatric and physical examination should be conducted to exclude possible medical causes.

History and Physical Examination

During the examination, determine how the patient feels about herself, her family, and her environment. Your goal is to explore the nature of her depression, the extent to which other factors affect it, and her coping mechanisms and their effectiveness. Begin by asking what’s bothering her. How does her current mood differ from her usual mood? Then, ask her to describe the way she feels about herself. What are her plans and dreams? How realistic are they? Is she generally satisfied with what she has accomplished in her work, relationships, and other interests? Ask about changes in her social interactions, sleep patterns, appetite, normal activities, or ability to make decisions and concentrate. Determine patterns of drug and alcohol use. Listen for clues that she may be suicidal. (See Suicide: Caring for the High-Risk Patient.)

Ask the patient about her family — its patterns of interaction and characteristic responses to success and failure. What part does she feel she plays in her family life? Find out if other family members have been depressed and whether anyone important to the patient has been sick or has died in the past year. Finally, ask the patient about her environment. Has her lifestyle changed in the past month? Six months? Year? When she’s feeling blue, where does she go and what does she do to feel better? Find out how she feels about her role in the community and the resources that are available to her. Try to determine if she has an adequate support network to help her cope with her depression.

Suicide: Caring for the High-Risk Patient

One of the most common factors contributing to suicide is hopelessness, an emotion that’s common in a depressed patient. As a result, you’ll need to regularly assess her for suicidal tendencies.

The patient may provide specific clues about her intentions. For example, you may notice her talking frequently about death or the futility of life, concealing potentially harmful items (such as knives and belts), hoarding medications, giving away personal belongings, or getting her legal and financial affairs in order. If you suspect that a patient is suicidal, follow these guidelines:

First, try to determine the patient’s suicide potential. Find out how upset she is. Does she have a simple, straightforward suicide plan that’s likely to succeed? Does she have a strong support system — family, friends, a therapist? A patient with low to moderate suicide potential is noticeably depressed but has a support system. She may have thoughts of suicide, but no specific plan. A patient with high suicide potential feels profoundly hopeless and has little or no support system. She thinks about suicide frequently and has a plan that’s likely to succeed.

Next, observe precautions. Ensure the patient’s safety by removing objects she could use to harm herself, such as knives, scissors, razors, belts, electric cords, shoelaces, and drugs. Know her whereabouts and what she’s doing at all times; this may require one-on-one surveillance. Place the patient in a room that’s close to the nursing station, or ensure that a staff member is assigned to stay with her at all times. Always have someone accompany her

when she leaves the unit.

Be alert for in-hospital suicide attempts, which typically occur when there’s a low staff-to- patient ratio — between shifts, during evening and night shifts, or when a critical event, such as a code, draws attention away from the patient.

Finally, arrange for follow-up counseling. Recognize suicidal ideation and behavior as a desperate cry for help. Contact a mental health professional for a referral.

CULTURAL CUE

Patients who don’t speak English fluently may have difficulty communicating their feelings and thoughts. Consider using someone outside the family as an interpreter to allow the patient to express her feelings more freely.

Medical Causes

Organic disorders. Various organic disorders and chronic illnesses produce mild, moderate, or severe depression. Among these are metabolic and endocrine disorders, such as hypothyroidism, hyperthyroidism, and diabetes; infectious diseases, such as influenza, hepatitis, and encephalitis; degenerative diseases, such as Alzheimer’s disease, multiple sclerosis, and multi-infarct dementia; and neoplastic disorders such as cancer.

Psychiatric disorders. Affective disorders are typically characterized by abrupt mood swings from depression to elation (mania) or by prolonged episodes of either mood. In fact, severe depression may last for weeks. More moderate depression occurs in cyclothymic disorders and usually alternates with moderate mania. Moderate depression that’s more or less constant over a 2-year period typically results from dysthymic disorders. Also, chronic anxiety disorders, such as panic and obsessive-compulsive disorder, may be accompanied by depression.

Other Causes

Alcohol abuse. Long-term alcohol use, intoxication, or withdrawal commonly produces depression.

Drugs. Various drugs cause depression as an adverse effect. Among the more common are barbiturates; chemotherapeutic drugs, such as asparaginase; anticonvulsants, such as diazepam; and antiarrhythmics, such as disopyramide. Other depression-inducing drugs include centrally acting antihypertensives, such as reserpine (common in high dosages), methyldopa, and clonidine; beta-adrenergic blockers, such as propranolol; levodopa; indomethacin; cycloserine; corticosteroids; and hormonal contraceptives.

Postpartum period. Although the cause hasn’t been proved, depression occurs in about 1 in every 2,000 to 3,000 pregnancies and is characterized by various symptoms. Symptoms range from mild postpartum blues to an intense, suicidal, depressive psychosis.

Special Considerations

Caring for a depressed patient takes time, tact, and energy. It also requires an awareness of your own vulnerability to feelings of despair that can stem from interacting with a depressed patient. Help the patient set realistic goals; encourage her to promote feelings of self-worth by asserting her opinions and making decisions. Try to determine her suicide potential, and take steps to help ensure her safety. The patient may require close surveillance to prevent a suicide attempt.

Make sure that the patient receives adequate nourishment and rest, and keep her environment free from stress and excessive stimulation. Arrange for ordered diagnostic tests to determine if her depression has an organic cause, and administer prescribed drugs. Also arrange for follow-up counseling, or contact a mental health professional for a referral.

Patient Counseling

Teach the patient about depression; emphasize that effective methods are available to relieve symptoms. Reassure the patient that she can help to ease depression by expressing her feelings, engaging in pleasurable activities, and improving her grooming and hygiene. Stress the importance of compliance with antidepressant medications, and review adverse reactions.

Pediatric Pointers

Because emotional lability is normal in adolescence, depression can be difficult to assess and diagnose in teenagers. Clues to underlying depression may include somatic complaints, sexual promiscuity, poor grades, and alcohol or drug abuse.

Using a family systems model usually helps determine the cause of depression in adolescents. After family roles are determined, family therapy or group therapy with peers may help the patient overcome her depression. In severe cases, an antidepressant may be required.

Geriatric Pointers

Elderly patients typically present with physical complaints, somatic complaints, agitation, or changes in intellectual functioning (memory impairment), making the diagnosis of depression difficult. Depressed older adults at highest risk for suicide are those who are aged 85 and older, have low selfesteem, and need to be in control. Even a frail nursing home resident with these characteristics may have the strength to kill herself.

Diaphoresis

Diaphoresis is profuse sweating — at times, amounting to more than 1 L of sweat per hour. This sign represents an autonomic nervous system response to physical or psychogenic stress or to a fever or high environmental temperature. When caused by stress, diaphoresis may be generalized or limited to the palms, soles, and forehead. When caused by a fever or high environmental temperature, it’s usually generalized.

Diaphoresis usually begins abruptly and may be accompanied by other autonomic system signs, such as tachycardia and increased blood pressure. (See When Diaphoresis Spells Crisis, page 230.) However, this sign also varies with age because sweat glands function immaturely in infants and are less active in elderly patients. As a result, patients in these age groups may fail to display diaphoresis associated with its common causes. Intermittent diaphoresis may accompany chronic disorders characterized by a recurrent fever; isolated diaphoresis may mark an episode of acute pain or fever.

Night sweats may characterize intermittent fever because body temperature tends to return to normal between 2 a.m. and 4 a.m. before rising again. (Temperature is usually lowest around 6 a.m.)

When caused by a high external temperature, diaphoresis is a normal response. Acclimatization usually requires several days of exposure to high temperatures; during this process, diaphoresis helps maintain normal body temperature. Diaphoresis also commonly occurs during menopause, preceded by a sensation of intense heat (a hot flash). Other causes include exercise or exertion that accelerates metabolism, creating internal heat, and mild to moderate anxiety that helps initiate the fight-or-flight response. (See Understanding Diaphoresis, pages 232 and 233.)

EMERGENCY INTERVENTIONS When Diaphoresis Spells

Crisis

Diaphoresis is an early sign of certain life-threatening disorders. These guidelines will help you promptly detect such disorders and intervene to minimize harm to the patient.

HYPOGLYCEMIA

If you observe diaphoresis in a patient who complains of blurred vision, ask him about increased irritability and anxiety. Has he been unusually hungry lately? Does he have tremors? Take the patient’s vital signs, noting hypotension and tachycardia. Then, ask about a history of type 2 diabetes or antidiabetic therapy. If you suspect hypoglycemia, evaluate the patient’s blood glucose level using a glucose reagent strip, or send a serum sample to the laboratory. Administer I.V. glucose 50%, as ordered, to return the patient’s glucose level to normal. Monitor his vital signs and cardiac rhythm. Ensure a patent airway, and be prepared to assist with breathing and circulation if necessary.

HEATSTROKE

If you observe profuse diaphoresis in a weak, tired, and apprehensive patient, suspect heatstroke, which can progress to circulatory collapse. Take his vital signs, noting a normal or subnormal temperature. Check for ashen gray skin and dilated pupils. Was the patient recently exposed to high temperatures and humidity? Was he wearing heavy clothing or performing strenuous physical activity at the time? Also, ask if he takes a diuretic, which interferes with normal sweating.

Then, take the patient to a cool room, remove his clothing, and use a fan to direct cool air over his body. Insert an I.V. line, and prepare for electrolyte and fluid replacement. Monitor him for signs of shock. Check his urine output carefully along with other sources of output (such as tubes, drains, and ostomies).

AUTONOMIC HYPERREFLEXIA

If you observe diaphoresis in a patient with a spinal cord injury above T6 or T7, ask if he has a pounding headache, restlessness, blurred vision, or nasal congestion. Take the patient’s vital signs, noting bradycardia and extremely elevated blood pressure. If you suspect autonomic hyperreflexia, quickly rule out its common complications. Examine the patient for eye pain associated with intraocular hemorrhage and for facial paralysis, slurred speech, or limb

weakness associated with intracerebral hemorrhage.

Quickly reposition the patient to remove any pressure stimuli. Also, check for a distended bladder or fecal impaction. Remove any kinks from the urinary catheter if necessary, or administer a suppository or manually remove impacted feces. If you can’t locate and relieve the causative stimulus, start an I.V. line. Prepare to administer hydralazine for hypertension.

MYOCARDIAL INFARCTION OR HEART FAILURE

If the diaphoretic patient complains of chest pain and dyspnea or has arrhythmias or electrocardiogram changes, suspect a myocardial infarction or heart failure. Connect the patient to a cardiac monitor, ensure a patent airway, and administer supplemental oxygen. Start an I.V. line, and administer an analgesic. Be prepared to begin emergency resuscitation if cardiac or respiratory arrest occurs.

History and Physical Examination

If the patient is diaphoretic, quickly rule out the possibility of a life-threatening cause. Begin the history by having the patient describe his chief complaint. Then, explore associated signs and symptoms. Note general fatigue and weakness. Does the patient have insomnia, headache, and changes in vision or hearing? Is he often dizzy? Does he have palpitations? Ask about pleuritic pain, a cough, sputum, difficulty breathing, nausea, vomiting, abdominal pain, and altered bowel or bladder habits. Ask the female patient about amenorrhea and any changes in her menstrual cycle. Is she menopausal? Ask about paresthesia, muscle cramps or stiffness, and joint pain. Has she noticed any changes in elimination habits? Note weight loss or gain. Has the patient had to change her glove or shoe size lately?

Complete the history by asking about travel to tropical countries. Note recent exposure to high environmental temperatures or pesticides. Did the patient recently experience an insect bite? Check for a history of partial gastrectomy or of drug or alcohol abuse. Finally, obtain a thorough drug history.

Next, perform a physical examination. First, determine the extent of diaphoresis by inspecting the trunk and extremities as well as the palms, soles, and forehead. Also, check the patient’s clothing and bedding for dampness. Note whether diaphoresis occurs during the day or at night. Observe the patient for flushing, an abnormal skin texture or lesions, and an increased amount of coarse body hair. Note poor skin turgor and dry mucous membranes. Check for splinter hemorrhages and Plummer’s nails (separation of the fingernail ends from the nail beds).

Then, evaluate the patient’s mental status and take his vital signs. Observe him for fasciculations and flaccid paralysis. Be alert for seizures. Note the patient’s facial expression, and examine the eyes for pupillary dilation or constriction, exophthalmos, and excessive tearing. Test visual fields. Also, check for hearing loss and for tooth or gum disease. Percuss the lungs for dullness, and auscultate for crackles, diminished or bronchial breath sounds, and increased vocal fremitus. Look for decreased respiratory excursion. Palpate for lymphadenopathy and hepatosplenomegaly.

Medical Causes

Acquired immunodeficiency syndrome. Night sweats may be an early feature, occurring either as a manifestation of the disease itself or secondary to an opportunistic infection. The patient

also displays a fever, fatigue, lymphadenopathy, anorexia, dramatic and unexplained weight loss, diarrhea, and a persistent cough.

Acromegaly. With acromegaly, diaphoresis is a sensitive gauge of disease activity, which involves the hypersecretion of growth hormone and an increased metabolic rate. The patient has a hulking appearance with an enlarged supraorbital ridge and thickened ears and nose. Other signs and symptoms include warm, oily, thickened skin; enlarged hands, feet, and jaw; joint pain; weight gain; hoarseness; and increased coarse body hair. Increased blood pressure, a severe headache, and visual field deficits or blindness may also occur.

Understanding Diaphoresis

Anxiety disorders. Acute anxiety characterizes panic, whereas chronic anxiety characterizes phobias, conversion disorders, obsessions, and compulsions. Whether acute or chronic, anxiety may cause sympathetic stimulation, resulting in diaphoresis. The diaphoresis is most dramatic on the palms, soles, and forehead and is accompanied by palpitations, tachycardia, tachypnea, tremors, and GI distress. Psychological signs and symptoms — fear, difficulty concentrating, and behavior changes — also occur.

Autonomic hyperreflexia. Occurring after resolution of spinal shock in a spinal cord injury above T6, hyperreflexia causes profuse diaphoresis, a pounding headache, blurred vision, and dramatically elevated blood pressure. Diaphoresis occurs above the level of the injury, especially on the forehead, and is accompanied by flushing. Other findings include restlessness, nausea, nasal congestion, and bradycardia.

Drug and alcohol withdrawal syndromes. Withdrawal from alcohol or an opioid analgesic may cause generalized diaphoresis, dilated pupils, tachycardia, tremors, and an altered mental status (confusion, delusions, hallucinations, agitation). Associated signs and symptoms include severe muscle cramps, generalized paresthesia, tachypnea, increased or decreased blood pressure and, possibly, seizures. Nausea and vomiting are common.

Empyema. Pus accumulation in the pleural space leads to drenching night sweats and fever. The

patient also complains of chest pain, a cough, and weight loss. Examination reveals decreased respiratory excursion on the affected side and absent or distant breath sounds.

Heart failure. Typically, diaphoresis follows fatigue, dyspnea, orthopnea, and tachycardia in patients with left-sided heart failure and jugular vein distention and a dry cough in patients with right-sided heart failure. Other features include tachypnea, cyanosis, dependent edema, crackles, a ventricular gallop, and anxiety.

Heat exhaustion. Although heat exhaustion is marked by failure of heat to dissipate, it initially may cause profuse diaphoresis, fatigue, weakness, and anxiety. These signs and symptoms may progress to circulatory collapse and shock (confusion, a thready pulse, hypotension, tachycardia, and cold, clammy skin). Other features include an ashen gray appearance, dilated pupils, and a normal or subnormal temperature.

Hodgkin’s disease. Especially in elderly patients, early features of Hodgkin’s disease may include night sweats, a fever, fatigue, pruritus, and weight loss. Usually, however, this disease initially causes painless swelling of a cervical lymph node. Occasionally, a Pel-Ebstein fever pattern is present — several days or weeks of fever and chills alternating with afebrile periods with no chills. Systemic signs and symptoms — such as weight loss, a fever, and night sweats — indicate a poor prognosis. Progressive lymphadenopathy eventually causes widespread effects, such as hepatomegaly and dyspnea.

Hypoglycemia. Rapidly induced hypoglycemia may cause diaphoresis accompanied by irritability, tremors, hypotension, blurred vision, tachycardia, hunger, and loss of consciousness. Infective endocarditis (subacute). Generalized night sweats occur early with infective endocarditis. Accompanying signs and symptoms include an intermittent low-grade fever, weakness, fatigue, weight loss, anorexia, and arthralgia. A sudden change in a murmur or the discovery of a new murmur is a classic sign. Petechiae and splinter hemorrhages are also common.

Lung abscess. Drenching night sweats are common with lung abscess. Its chief sign, however, is a cough that produces copious purulent, foul-smelling, and typically bloody sputum. Associated findings include a fever with chills, pleuritic chest pain, dyspnea, weakness, anorexia, weight loss, a headache, malaise, clubbing, tubular or amphoric breath sounds, and dullness on percussion.

Malaria. Profuse diaphoresis marks the third stage of paroxysmal malaria; the first two stages are chills (first stage) and a high fever (second stage). A headache, arthralgia, and hepatosplenomegaly may also occur. In the benign form of malaria, these paroxysms alternate with periods of well-being. The severe form may progress to delirium, seizures, and coma.

Myocardial infarction (MI). Diaphoresis usually accompanies acute, substernal, radiating chest pain in MI, a life-threatening disorder. Associated signs and symptoms include anxiety, dyspnea, nausea, vomiting, tachycardia, an irregular pulse, blood pressure changes, fine crackles, pallor, and clammy skin.

Pheochromocytoma. Pheochromocytoma commonly produces diaphoresis, but its cardinal sign is persistent or paroxysmal hypertension. Other effects include a headache, palpitations, tachycardia, anxiety, tremors, pallor, flushing, paresthesia, abdominal pain, tachypnea, nausea, vomiting, and orthostatic hypotension.

Pneumonia. Intermittent, generalized diaphoresis accompanies a fever and chills in patients with pneumonia. They complain of pleuritic chest pain that increases with deep inspiration. Other features are tachypnea, dyspnea, a productive cough (with scant and mucoid or copious

and purulent sputum), a headache, fatigue, myalgia, abdominal pain, anorexia, and cyanosis. Auscultation reveals bronchial breath sounds.

Tetanus. Tetanus commonly causes profuse sweating accompanied by a low-grade fever, tachycardia, and hyperactive deep tendon reflexes. Early restlessness and pain and stiffness in the jaw, abdomen, and back progress to spasms associated with lockjaw, risus sardonicus, dysphagia, and opisthotonos. Laryngospasm may result in cyanosis or sudden death by asphyxiation.

Thyrotoxicosis. Thyrotoxicosis commonly produces diaphoresis accompanied by heat intolerance, weight loss despite increased appetite, tachycardia, palpitations, an enlarged thyroid, dyspnea, nervousness, diarrhea, tremors, Plummer’s nails and, possibly, exophthalmos. Gallops may also occur.

Tuberculosis (TB). Although many patients with primary infection are asymptomatic, TB may cause night sweats, a low-grade fever, fatigue, weakness, anorexia, and weight loss. In reactivation, a productive cough with mucopurulent sputum, occasional hemoptysis, and chest pain may be present.

Other Causes

Drugs. Sympathomimetics, certain antipsychotics, thyroid hormones, corticosteroids, and antipyretics may cause diaphoresis. Aspirin and acetaminophen poisoning also cause this sign. Dumping syndrome. The result of rapid emptying of gastric contents into the small intestine after partial gastrectomy, this syndrome causes diaphoresis, palpitations, profound weakness, epigastric distress, nausea, and explosive diarrhea. This syndrome occurs soon after eating. Pesticide poisoning. Among the toxic effects of pesticides are diaphoresis, nausea, vomiting, diarrhea, blurred vision, miosis, and excessive lacrimation and salivation. The patient may display fasciculations, muscle weakness, and flaccid paralysis. Signs of respiratory depression and coma may also occur.

Special Considerations

After an episode of diaphoresis, sponge the patient’s face and body and change wet clothes and sheets. To prevent skin irritation, dust skin folds in the groin and axillae and under pendulous breasts with cornstarch, or tuck gauze or cloth into the folds. Encourage regular bathing.

Replace fluids and electrolytes. Regulate infusions of I.V. saline or lactated Ringer’s solution, and monitor urine output. Encourage oral fluids high in electrolytes such as sports drinks. Enforce bed rest, and maintain a quiet environment. Keep the patient’s room temperature moderate to prevent additional diaphoresis.

Prepare the patient for diagnostic tests, such as blood tests, cultures, chest X-rays, immunologic studies, biopsy, a computed tomography scan, and audiometry. Monitor the patient’s vital signs, including temperature.

Patient Counseling

Explain the disease process and proper skin care. Discuss the importance of fluid replacement and how to make sure fluid intake is adequate.

Pediatric Pointers

Diaphoresis in children commonly results from environmental heat or overdressing; it’s usually most apparent around the head. Other causes include drug withdrawal associated with maternal addiction, heart failure, thyrotoxicosis, and the effects of such drugs as antihistamines, ephedrine, haloperidol, and thyroid hormone.

Assess the child’s fluid status carefully. Some fluid loss through diaphoresis may precipitate hypovolemia more rapidly in a child than in an adult. Monitor input and output, weigh the child daily, and note the duration of each episode of diaphoresis.

Geriatric Pointers

Fever and night sweats, the hallmark of TB, may not occur in elderly patients, who instead may exhibit a change in activity or weight. Also, keep in mind that older patients may not exhibit diaphoresis because of a decreased sweating mechanism. For this reason, they’re at increased risk for developing heatstroke in high temperatures.

Diarrhea

Diarrhea is loose, watery stools. 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 spicy or high-fiber foods or caffeine.

One or more pathophysiologic mechanisms may contribute to diarrhea. (See What Causes Diarrhea?) The fluid and electrolyte imbalances it produces may precipitate life-threatening arrhythmias or hypovolemic shock.

What Causes Diarrhea?

EMERGENCY INTERVENTIONS

If the patient’s diarrhea is profuse, check for signs of shock — tachycardia, hypotension, and cool, pale, clammy skin. If you detect these signs, place the patient in the supine position and elevate his legs 20 degrees. Insert an I.V. line for fluid replacement. Monitor him for electrolyte imbalances, and look for an irregular pulse, muscle weakness, anorexia, and nausea and vomiting. Keep emergency resuscitation equipment handy.