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Nasal flaring
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Nasal flaring is the abnormal dilation of the nostrils. Usually occurring during inspiration, nasal
flaring may occasionally occur during expiration
or throughout the respiratory cycle. It indicates
respiratory dysfunction, ranging from mild difficulty to potentially life-threatening respiratory
distress.
EMERGENCY INTERVENTIONS If you
note nasal flaring in the patient, quickly evaluate his respiratory status. Absent breath sounds,
cyanosis, diaphoresis, and tachycardia point to
complete airway obstruction. As necessary, deliver
abdominal thrusts (Heimlich maneuver) to relieve
the obstruction. If these don’t clear the airway,
emergency intubation or tracheostomy and mechanical ventilation may be necessary.
If the patient’s airway isn’t obstructed but he
displays breathing difficulty, give oxygen by nasal
cannula or face mask. Intubation and mechanical
ventilation may be necessary. Insert an I.V.
catheter for fluid and drug access. Begin cardiac
monitoring. Obtain a chest X-ray and samples for
arterial blood gas and electrolyte studies.
H
ISTORY AND PHYSICAL
EXAMINATION
Once the patient’s condition is stabilized, obtain
a pertinent history. Ask about cardiac and pulmonary disorders such as asthma. Does the patient have allergies? Has he experienced a recent illness, such as a respiratory tract infection,
or trauma? Does the patient smoke or have a
history of smoking? Obtain a drug history.
N
M
EDICAL CAUSES
◆ Acute respiratory distress syndrome
(ARDS). ARDS causes increased respiratory difficulty and hypoxemia, with nasal flaring, dyspnea, tachypnea, diaphoresis, cyanosis, scattered
crackles, and rhonchi. It also produces tachycardia, anxiety, and decreased level of consciousness.
◆ Airway obstruction. Complete obstruction
above the tracheal bifurcation causes sudden
nasal flaring, absent breath sounds despite intercostal retractions and marked accessory
muscle use, tachycardia, diaphoresis, cyanosis,
decreasing level of consciousness and, eventually, respiratory arrest.
Partial obstruction causes nasal flaring with
inspiratory stridor, gagging, wheezing, violent
cough, marked accessory muscle use, agitation,
cyanosis, and hoarseness.
◆ Anaphylaxis. Severe reactions can produce
respiratory distress with nasal flaring, stridor,
wheezing, accessory muscle use, intercostal retractions, and dyspnea. Associated signs and
symptoms include nasal congestion, sneezing,
pruritus, urticaria, erythema, diaphoresis, angioedema, weakness, hoarseness, dysphagia
and, rarely, vomiting, nausea, diarrhea, urinary
urgency, and incontinence. Cardiac arrhythmias
and signs of shock may occur late.
◆ Asthma (acute). An asthma attack can
cause nasal flaring, dyspnea, tachypnea, prolonged expiratory wheezing, accessory muscle
use, cyanosis, and a dry or productive cough.
Auscultation may reveal rhonchi, crackles, and
decreased or absent breath sounds. Other
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findings include anxiety, tachycardia, and
increased blood pressure.
◆ Chronic obstructive pulmonary disease.
This disorder can lead to acute respiratory failure secondary to pulmonary infection or edema.
Nasal flaring is accompanied by prolonged
pursed-lip expiration; accessory muscle use;
loose, rattling, productive cough; cyanosis; reduced chest expansion; crackles; rhonchi;
wheezing; and dyspnea.
◆ Pneumonia (bacterial). With this condition,
nasal flaring occurs with dyspnea, tachypnea,
high fever, and sudden shaking chills. An initially dry and hacking cough later becomes productive. Stabbing chest pain worsens with movement and respirations. Auscultation reveals
decreased or absent breath sounds, fine crackles, and pleural friction rub. Percussion reveals
dullness.
◆ Pneumothorax. This acute disorder can re-
sult in respiratory distress with nasal flaring,
dyspnea, tachypnea, shallow respirations, hyperresonance or tympany on percussion, agitation, distended jugular veins, tracheal deviation,
and cyanosis. Other findings typically include
sharp chest pain, tachycardia, hypotension, cold
and clammy skin, diaphoresis, subcutaneous
crepitation, and anxiety. Breath sounds may be
decreased or absent on the affected side; similarly, chest-wall motion may be decreased on
the affected side.
Similar findings can occur with hydrothorax,
chylothorax, or hemothorax, depending on the
amount of fluid accumulation.
◆ Pulmonary edema. This disorder typically
produces nasal flaring, severe dyspnea, wheezing, and a cough that produces frothy, pink sputum. Increased accessory muscle use may occur
with tachycardia, cyanosis, hypotension, crackles, jugular vein distention, peripheral edema,
and decreased level of consciousness.
◆ Pulmonary embolus. Signs of this potential-
ly life-threatening disorder may include nasal
flaring, dyspnea, tachypnea, wheezing,
cyanosis, pleural friction rub, and productive
cough (possibly hemoptysis). Its other effects include sudden chest tightness or pleuritic pain,
tachycardia, atrial arrhythmias, hypotension,
low-grade fever, syncope, marked anxiety, and
restlessness.
O
THER CAUSES
◆ Diagnostic tests. Pulmonary function tests,
such as vital capacity testing, can produce nasal
flaring with forced inspiration or expiration.
◆ Treatments. Certain respiratory treatments,
such as deep breathing, can cause nasal flaring.
S
PECIAL CONSIDERATIONS
To help ease breathing, place the patient in a
high Fowler’s position. If he’s at risk for aspirating secretions, place him in a modified Trendelenburg’s or side-lying position. If necessary,
suction frequently to remove oropharyngeal secretions. Administer humidified oxygen to thin
secretions and decrease airway drying and irritation. Provide adequate hydration to liquefy secretions. Reposition the patient every hour, and
encourage coughing and deep breathing and incentive spirometry use. Avoid administering
sedatives or opiates, which can depress the
cough reflex or respirations. Continually assess
the patient’s respiratory status, and check his vital signs and oxygen saturation every 30 minutes, or as necessary.
Prepare the patient for diagnostic tests, such
as chest X-rays, lung scan, pulmonary arteriography, sputum culture, complete blood count,
arterial blood gas analysis, and 12-lead electrocardiogram.
P
EDIATRIC POINTERS
Nasal flaring is an important sign of respiratory
distress in infants and very young children, who
can’t verbalize their discomfort. Common causes include airway obstruction, hyaline membrane disease, croup, and acute epiglottiditis.
Use oxygen and cool humidifiers to help improve oxygenation.
Nasal obstruction
Nasal obstruction may result from an allergic,
inflammatory, neoplastic, endocrine, or metabolic disorder; a structural abnormality; a
traumatic injury; or a mechanical obstruction
(foreign objects). It may cause discomfort, alter a person’s sense of taste and smell, and
cause voice changes. Although a frequent and
typically benign symptom, nasal obstruction
may herald certain life-threatening disorders,
such as a basilar skull fracture or malignant
tumor.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin the history by asking the patient about
the duration and frequency of the obstruction.
Did it begin suddenly or gradually? Is it intermit-
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tent or persistent? Unilateral or bilateral?
Inquire about the presence and character of
drainage. Is it watery, purulent, or bloody? Does
the patient have nasal or sinus pain or headaches? Ask about recent travel, the use of drugs
or alcohol, and previous trauma or surgery.
Examine the patient’s nose; assess airflow
and the condition of the turbinates and nasal
septum. Evaluate the orbits for any evidence of
dystopia, decreased vision, excess tearing, or
abnormal appearance of the eye. Palpate over
the frontal and maxillary sinuses for tenderness.
Examine the ears for signs of middle ear effusions. Inspect the oral cavity, pharynx, nasopharynx, and larynx to detect inflammation,
ulceration, excessive mucosal dryness, and
neurologic deficits. Lastly, palpate the neck for
adenopathy.
M
EDICAL CAUSES
◆ Basilar skull fracture. A tear in the dura
can lead to cerebrospinal rhinorrhea, which increases when the patient lowers his head. Associated findings may include epistaxis, otorrhea,
and a bulging tympanic membrane from blood
or fluid. A fracture may also cause headache, facial paralysis, nausea, vomiting, impaired eye
movement, ocular deviation, vision and hearing
loss, depressed level of consciousness, Battle’s
sign, and raccoon eyes.
◆ Common cold. Onset of the common cold is
typified by a watery discharge along with sneezing and nasal obstruction. Edema of the nasal
mucosa may lead to sinus pain and infection as
well as loss of smell and taste. Related findings
include sore throat, malaise, myalgia, arthralgia,
and mild headache.
◆ Hypothyroidism. An underactive thyroid
gland may lead to a generalized hypoactive
state. This can lead to vascular dilation in the
nasal mucosa, resulting in nasal obstruction.
Associated findings include fatigue, weight gain
despite anorexia, cold intolerance, facial edema,
impaired memory, brittle hair, thick skin and
tongue, bradycardia, and a hoarse voice.
◆ Nasal deformities. Deviation of the nasal
septum may cause unilateral or bilateral nasal
obstruction, snoring, and postnasal drip. Perforation of the nasal septum may result in a sensation of nasal congestion due to altered air
flow.
◆ Nasal fracture. Nasal obstruction develops
because of trauma that results in nasal mucosal
swelling, epistaxis, abscess, or a septal deviation. Periorbital ecchymoses and edema, nasal
deformity and pain, and crepitation of the nasal
bones may occur as well.
◆ Nasal polyps. The most common signs and
symptoms are nasal obstruction, anosmia, and
clear, watery drainage. The patient may have a
history of allergies, chronic sinusitis, trauma,
cystic fibrosis, or asthma. Translucent, pearshaped polyps that are unilateral or bilateral
occur.
◆ Nasal tumors. Benign and malignant nasal
tumors may cause unilateral or bilateral nasal
obstruction, rhinorrhea, epistaxis, pain, foul discharge, and cheek swelling. Most of these tumors are benign papillomas and minor salivary
gland tumors; malignant ones are rare. Kaposi’s
sarcoma of the nose may occur in acquired immunodeficiency syndrome.
◆ Nasopharyngeal tumors. Benign and ma-
lignant tumors of the nasopharynx may cause
nasal obstruction, rhinorrhea, epistaxis, otitis
media, and nasal speech. Tumors usually reach
a considerable size before symptoms develop.
Cancer of the nasopharynx is the most common
malignancy of the nasopharynx and may present first with a neck mass or conductive hearing loss.
◆ Pregnancy. High levels of estrogen during
pregnancy may cause vascular engorgement of
the nasal mucosa, resulting in nasal obstruction. Associated findings include clear or bloodtinged drainage, sneezing, and edematous and
bluish turbinates.
◆ Rhinitis. Allergic rhinitis produces intermit-
tent watery discharge and nasal obstruction.
Common signs and symptoms include sneezing,
increased lacrimation, decreased sense of
smell, postnasal drip, and itching of the eyes,
nose, or ears. The mucosa is edematous and
pale.
Vasomotor rhinitis produces a profuse watery
nasal discharge in addition to nasal obstruction.
Sneezing, postnasal drip, and swollen
turbinates occur as well.
With atrophic rhinitis, nasal obstruction is
chronic and continuous. Associated findings include intermittent, purulent drainage, foul
drainage odor, and nasal crusts that bleed on
removal. The mucosa is pale pink and shiny.
◆ Sarcoidosis. This systemic granulomatous
disease occasionally affects the nasal tissues.
Nasal membranes appear firm, woody, and erythematous, and their surfaces may be covered
by foul-smelling, crusty secretions. These features may occur with a nonproductive cough,
substernal pain, malaise, and weight loss.
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Related findings include tachycardia, arrhythmias, parotid enlargement, cervical lymphadenopathy, skin lesions, hepatosplenomegaly, and
arthritis in the ankles, knees, and wrist.
◆ Sinusitis. With acute sinusitis, the usual find-
ings are marked nasal obstruction along with
thick, purulent drainage and severe pain over
the involved sinuses. Fever, inflamed nasal mucosa with purulent mucus, and facial tenderness and pressure occur.
With chronic sinusitis, nasal obstruction can
be persistent or recurrent. Thick, intermittently
purulent rhinorrhea and low-grade discomfort
over the involved sinuses are also seen.
Chronic fungal sinusitis is clinically similar to
chronic bacterial sinusitis. However, in immunocompromised patients the disease may
rapidly progress to proptosis, blindness, and
death.
◆ Wegener’s granulomatosis. Besides nasal
obstruction, other nasal findings include crusting, epistaxis, mucopurulent discharge, and cartilaginous necrosis of the septum and bridge of
the nose.
O
THER CAUSES
◆ Drugs. Topical nasal vasoconstrictors may
cause rebound rhinorrhea and nasal obstruction
if used longer than 5 days. Antihypertensives
may cause nasal congestion as well.
◆ Surgery. Nasal obstruction may occur
after sinus or cranial surgery, or even after
rhinoplasty.
S
PECIAL CONSIDERATIONS
Prepare the patient for X-rays or computed tomography scans of the nose, sinuses, or skull.
Promote fluid intake to thin secretions, as needed. Give an antihistamine, a decongestant, an
analgesic, or an antipyretic.
P
EDIATRIC POINTERS
Acute nasal obstruction in children commonly
results from the common cold. In infants and
children, especially between ages 3 and 6,
chronic nasal obstruction typically results
from large adenoids. In neonates, choanal
atresia is the most common congenital cause
of nasal obstruction and can be unilateral or
bilateral. Cystic fibrosis may cause nasal
polyps in children, resulting in nasal obstruction. However, if the child has unilateral nasal
obstruction and rhinorrhea, you should assume that a foreign body is in the nose until
proven otherwise.
P
ATIENT COUNSELING
Tell the patient not to use over-the-counter nasal
vasoconstrictor sprays for more than 5 days.
Nausea
Nausea is a sensation of profound revulsion to
food or of impending vomiting. Often accompanied by autonomic signs, such as hypersalivation, diaphoresis, tachycardia, pallor, and
tachypnea, it’s closely associated with both
anorexia and vomiting.
Nausea, a common symptom of GI disorders, also occurs with fluid and electrolyte
imbalance; infection; and metabolic, endocrine, labyrinthine, and cardiac disorders;
and as a result of drug therapy, surgery, and
radiation. Often present during the first
trimester of pregnancy, nausea may also arise
from severe pain, anxiety, alcohol intoxication, overeating, or ingestion of distasteful
food or liquids.
H
ISTORY AND PHYSICAL
EXAMINATION
Begin by obtaining a complete medical history.
Focus on GI, endocrine, and metabolic disorders;
recent infections; and cancer and its treatment.
Ask about drug use and alcohol consumption. If
the patient is a female of childbearing age, ask if
she is or could be pregnant. Have the patient describe the onset, duration, and intensity of the
nausea, as well as what causes or relieves it.
Ask about related complaints, particularly vomiting (color, amount), abdominal pain, anorexia
and weight loss, changes in bowel habits or
stool character, excessive belching or flatus, and
a sensation of bloating.
Inspect the skin for jaundice, bruises, and
spider angiomas, and assess skin turgor. Next,
inspect the abdomen for distention, auscultate
for bowel sounds and bruits, palpate for rigidity
and tenderness, and test for rebound tenderness. Palpate and percuss the liver for enlargement. Assess other body systems as
appropriate.
M
EDICAL CAUSES
◆ Adrenal insufficiency. Common GI findings
in this endocrine disorder include nausea, vomiting, anorexia, and diarrhea. Other findings include weakness; fatigue; weight loss; bronze
skin; hypotension; a weak, irregular pulse; vitiligo; and depression.
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◆ Anthrax (GI). Initial signs and symptoms in-
clude nausea, vomiting, loss of appetite, and
fever. Signs and symptoms may progress to abdominal pain, severe bloody diarrhea, and hematemesis.
◆ Appendicitis. With acute appendicitis, a
brief period of nausea may accompany onset
of abdominal pain. Pain typically begins as
vague epigastric or periumbilical discomfort
and rapidly progresses to severe stabbing pain
localized in the right lower quadrant (McBurney’s sign). Associated findings usually include abdominal rigidity and tenderness, cutaneous hyperalgesia, fever, constipation or
diarrhea, tachycardia, anorexia, moderate
malaise, and positive psoas (increased abdominal pain occurs when the examiner
places his hand above the patient’s right knee
and the patient flexes his right hip against resistance) and obturator signs (internal rotation
of the right leg with the leg flexed to 90 degrees at the hip and knee with a resulting
tightening of the internal obturator muscle
that causes abdominal discomfort).
◆ Cholecystitis (acute). With this disease, nau-
sea often follows severe right-upper-quadrant
pain that may radiate to the back or shoulders,
often following meals. Associated findings include mild vomiting, flatulence, abdominal tenderness and, possibly, rigidity and distention,
fever with chills, diaphoresis, and a positive
Murphy’s sign.
◆ Cholelithiasis. With this disease, nausea ac-
companies attacks of severe right-upper-quadrant
or epigastric pain after ingestion of fatty foods.
Other associated findings include vomiting, abdominal tenderness and guarding, flatulence,
belching, epigastric burning, tachycardia, and
restlessness. Occlusion of the common bile duct
may cause jaundice, clay-colored stools, fever,
and chills.
◆ Cirrhosis. Insidious early signs and symp-
toms of cirrhosis typically include nausea and
vomiting, anorexia, abdominal pain, and constipation or diarrhea. As the disease progresses,
jaundice and hepatomegaly may occur with abdominal distention, spider angiomas, palmar
erythema, severe pruritus, dry skin, fetor hepaticus, enlarged superficial abdominal veins, mental changes, and bilateral gynecomastia and testicular atrophy or menstrual irregularities.
◆ Diverticulitis. Besides nausea, diverticulitis
causes intermittent crampy abdominal pain,
constipation or diarrhea, low-grade fever, and
often a palpable, tender, firm, fixed mass.
◆ Ectopic pregnancy. Nausea, vomiting, vagi-
nal bleeding, and lower abdominal pain occur
in this potentially life-threatening disorder. Suspect ectopic pregnancy in a female of childbearing age with a 1- to 2-month history of amenorrhea.
◆ Electrolyte imbalances. Such disturbances
as hyponatremia or hypernatremia, hypokalemia, and hypercalcemia commonly cause
nausea and vomiting. Other effects include cardiac arrhythmias, tremors or seizures, anorexia,
malaise, and weakness.
◆ Escherichia coli O157:H7. Signs and
symptoms include nausea, watery or bloody
diarrhea, vomiting, fever, and abdominal
cramps. In children younger than age 5 and in
the elderly, hemolytic uremic syndrome may
develop in which red blood cells are destroyed, which may ultimately lead to acute
renal failure.
◆ Gastric cancer. This rare cancer may pro-
duce vague GI symptoms—mild nausea, anorexia, upper abdominal discomfort, and chronic
dyspepsia. Fatigue, weight loss, weakness, hematemesis, melena, and altered bowel habits
are also common.
◆ Gastritis. Nausea is common with this disor-
der, especially after ingestion of alcohol, aspirin,
spicy foods, or caffeine. Vomiting of mucus or
blood, epigastric pain, belching, fever, and
malaise may also occur.
◆ Gastroenteritis. Usually viral, this disorder
causes nausea, vomiting, diarrhea, and abdominal cramping. Fever, malaise, hyperactive bowel
sounds, abdominal pain and tenderness, and
possible dehydration and electrolyte imbalances
may also develop.
◆ Heart failure. This disorder may produce
nausea and vomiting, particularly with rightsided heart failure. Associated findings include
tachycardia, ventricular gallop, profound fatigue, dyspnea, crackles, peripheral edema,
jugular vein distention, ascites, nocturia, and diastolic hypertension.
◆ Hepatitis. Nausea is an insidious early symp-
tom of viral hepatitis. Vomiting, fatigue, myalgia
and arthralgia, headache, anorexia, photophobia, pharyngitis, cough, and fever also occur
early in the preicteric phase.
◆ Hyperemesis gravidarum. Unremitting nau-
sea and vomiting that persist beyond the first
trimester are characteristic of this pregnancy
disorder. Vomitus ranges from undigested food,
mucus, and bile early in the disorder to a coffeeground appearance in later stages. Associated
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findings include weight loss, signs of dehydration, headache, and delirium.
◆ Infection. Acute localized or systemic infec-
tion typically produces nausea. Other common
findings include fever, headache, fatigue, and
malaise.
◆ Inflammatory bowel disease. The most
common symptom is recurrent diarrhea with
blood, pus, and mucus. Nausea, vomiting, abdominal pain, and anorexia may also occur.
◆ Intestinal obstruction. Nausea commonly
occurs, especially with high small-intestinal obstruction. Vomiting may be bilious or fecal; abdominal pain is usually episodic and colicky but
can become severe and steady with strangulation. Constipation occurs early in large-intestinal
obstruction and later in small-intestinal obstruction; obstipation may signal complete obstruction. Bowel sounds are typically hyperactive in partial obstruction, and hypoactive or
absent in complete obstruction. Abdominal distention and tenderness occur, possibly with visible peristaltic waves and a palpable abdominal
mass.
◆ Irritable bowel syndrome. Nausea, dyspep-
sia, and abdominal distention may occur with
this syndrome especially during periods of increased stress. Other findings include lower abdominal pain and abdominal tenderness, which
is generally relieved by moving the bowels; diurnal diarrhea alternating with constipation or
normal bowel function; and small stools with
visible mucus and a feeling of incomplete evacuation.
◆ Labyrinthitis. Nausea and vomiting com-
monly occur with this acute inner ear inflammation. More significant findings include severe
vertigo, progressive hearing loss, nystagmus,
tinnitus and, possibly, otorrhea.
◆ Lactose intolerance. Depending on the indi-
vidual, signs and symptoms may include nausea, diarrhea, cramps, bloating, and gas, and
they occur after eating dairy products.
◆ Listeriosis. Signs and symptoms include
nausea, vomiting, diarrhea, fever, myalgias, and
abdominal pain. If the infection spreads to the
nervous system and causes meningitis, signs
and symptoms include fever, headache, nuchal
rigidity, and change in level of consciousness.
◆ Ménière’s disease. This disease causes sud-
den, brief, recurrent attacks of nausea, vomiting, vertigo, tinnitus, diaphoresis, and nystagmus. It also causes hearing loss and ear
fullness.
◆ Mesenteric artery ischemia. With this con-
dition, nausea and vomiting may accompany
severe cramping abdominal pain, especially after meals. Other findings include diarrhea or
constipation, abdominal tenderness and bloating, anorexia, weight loss, and abdominal
bruits.
◆ Mesenteric venous thrombosis. Insidious
or acute onset of nausea, vomiting, and abdominal pain occurs, with diarrhea or constipation,
abdominal distention, hematemesis, and
melena.
◆ Metabolic acidosis. This acid-base
imbalance may produce nausea and vomiting,
anorexia, diarrhea, Kussmaul’s respirations, and
decreased level of consciousness.
◆ Migraine headache. Nausea and vomiting
may occur in the prodromal stage, along with
photophobia, light flashes, increased sensitivity
to noise, light-headedness and, possibly, partial
vision loss and paresthesia of the lips, face, and
hands.
◆ Motion sickness. With this disorder, nausea
and vomiting are brought on by motion or
rhythmic movement. Headache, dizziness, fatigue, diaphoresis, hypersalivation, and dyspnea
may also occur.
◆ Myocardial infarction. Nausea and vomit-
ing may occur, but the cardinal symptom is severe substernal chest pain that may radiate to
the left arm, jaw, or neck. Dyspnea, pallor,
clammy skin, diaphoresis, altered blood pressure, and arrhythmias also occur.
◆ Norovirus infection. Acute gastroenteritis
from noroviruses commonly causes infected
individuals to experience nausea. Frequent accompanying symptoms include vomiting, diarrhea, and abdominal pain or cramping. Less
commonly, individuals may develop low-grade
fever, headache, chills, muscle aches, and
generalized tiredness. These viruses are carried in the stool or vomit of infected individuals, and are often spread through contaminated food or water. Duration of illness is brief,
with healthy individuals recovering in 24 to
60 hours.
◆ Pancreatitis (acute). Nausea, usually fol-
lowed by vomiting, is an early symptom of pancreatitis. Other common findings include steady,
severe pain in the epigastrium or left upper
quadrant that may radiate to the back; abdominal tenderness and rigidity; anorexia; diminished bowel sounds; and fever. Tachycardia,
restlessness, hypotension, skin mottling, and
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cold, sweaty extremities may occur in severe
cases.
◆ Peptic ulcer. With this disorder, nausea and
vomiting may follow attacks of sharp or gnawing, burning epigastric pain. Attacks typically
occur when the stomach is empty, or after ingestion of alcohol, caffeine, or aspirin; they’re
relieved by eating food or taking an antacid or
an antisecretory. Hematemesis or melena may
also occur.
◆ Peritonitis. Nausea and vomiting usually
accompany acute abdominal pain localized to
the area of inflammation. Other findings include high fever with chills; tachycardia; hypoactive or absent bowel sounds; abdominal
distention, rigidity, and tenderness (including
rebound tenderness); positive obturator sign
and obturator weakness; pale, cold skin; diaphoresis; hypotension; shallow respirations;
and hiccups.
◆ Preeclampsia. Nausea and vomiting com-
monly occur with this disorder of pregnancy,
along with rapid weight gain, epigastric pain,
oliguria, severe frontal headache, hyperreflexia,
and blurred or double vision. The classic diagnostic triad of signs include hypertension, proteinuria, and edema.
◆ Q Fever. Signs and symptoms include nau-
sea, vomiting, diarrhea, fever, chills, severe
headache, malaise, and chest pain. Fever may
last up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.
◆ Renal and urologic disorders. Cystitis,
pyelonephritis, calculi, uremia, and other disorders of the renal system can cause nausea. Related findings reflect the specific disorder.
◆ Rhabdomyolysis. Signs and symptoms in-
clude nausea, vomiting, muscle weakness or
pain, fever, malaise, and dark urine. Acute renal
failure is the most commonly reported complication of the disorder. It results from renal
structure obstruction and injury during the kidneys’ attempt to filter the myoglobin from the
bloodstream.
◆ Thyrotoxicosis. With this disorder, nausea
and vomiting may accompany the classic findings of severe anxiety, heat intolerance,
weight loss despite increased appetite, diaphoresis, diarrhea, tremor, tachycardia, and
palpitations. Other signs include exophthalmos, ventricular or atrial gallop, and an enlarged thyroid gland.
◆ Typhus. An abrupt onset of nausea, vomit-
ing, fever, and chills follows the initial symp-
toms of headache, myalgia, arthralgia, and
malaise.
O
THER CAUSES
◆ Drugs. Common nausea-producing drugs in-
clude antineoplastics, opiates, ferrous sulfate,
levodopa, oral potassium chloride replacements, estrogens, sulfasalazine, antibiotics,
quinidine, anesthetics, cardiac glycosides, theophylline (overdose), and nonsteroidal antiinflammatories.
HERB ALERT Herbal remedies, such as
ginkgo biloba and St. John’s wort, can pro-
duce adverse reactions, including nausea.
◆ Radiation and surgery. Radiation therapy
can cause nausea and vomiting. Postoperative
nausea and vomiting are common, especially
after abdominal surgery.
S
PECIAL CONSIDERATIONS
If your patient is experiencing severe nausea,
prepare him for blood tests to determine fluid
and electrolyte status, and acid-base balance.
Have him breathe deeply to ease his nausea;
keep his room air fresh and clean-smelling by
removing bedpans and emesis basins promptly
after use and by providing adequate ventilation.
Because he could easily aspirate vomitus when
in a supine position, elevate his head or position him on his side.
Because pain can precipitate or intensify
nausea, administer pain medications promptly, as needed. If possible, give medications by
injection or suppository to prevent exacerbating nausea. Be alert for abdominal distention
and hypoactive bowel sounds when you administer an antiemetic: These signs may indicate gastric retention. If you detect these, immediately insert a nasogastric tube, as
required.
Prepare the patient for such procedures as
computed tomography scan, ultrasound, endoscopy, and colonoscopy. Consult the nutritionist to determine the patient’s metabolic demands such as total or partial parenteral
nutrition.
P
EDIATRIC POINTERS
Nausea, commonly described as stomachache,
is one of the most common childhood complaints. Often the result of overeating, it can
also occur as part of diverse disorders, ranging
from acute infections to a conversion reaction
caused by fear.
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G
ERIATRIC POINTERS
Elderly patients have increased dental caries;
tooth loss; decreased salivary gland function,
which causes mouth dryness; reduced gastric
acid output and motility; and decreased senses
of taste and smell—any of which can contribute
to nonpathologic nausea.
test and compare bilateral muscle strength.
Check the sensation in his arms, and assess his
hand grasp and arm reflexes. Attempt to elicit
Brudzinski’s and Kernig’s signs if there is not a
history of neck trauma, and palpate the cervical
lymph nodes for enlargement. (See Neck pain:
Causes and associated findings, pages 480 to
483.)
Neck pain
Neck pain may originate from any neck structure, ranging from the meninges and cervical
vertebrae to its blood vessels, muscles, and
lymphatic tissue. This symptom can also be referred from other areas of the body. Its location,
onset, and pattern help determine its origin and
underlying causes. Neck pain usually results
from trauma and degenerative, congenital, inflammatory, metabolic, and neoplastic disorders.
EMERGENCY INTERVENTIONS If the
patient’s neck pain is due to trauma, first
ensure proper cervical spine immobilization,
preferably with a long backboard and a cervical
collar. Then take vital signs, and perform a
quick neurologic examination. If he shows signs
of respiratory distress, give oxygen. Intubation or
tracheostomy and mechanical ventilation may
be necessary. Ask the patient (or a family member, if the patient can’t answer) how the injury
occurred. Then examine the neck for abrasions,
swelling, lacerations, erythema, and ecchymoses.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient hasn’t sustained trauma, find out
the severity and onset of his neck pain. Where
specifically in the neck does he feel pain? Does
anything relieve or worsen the pain? Is there
any particular event that precipitates the pain?
Also, ask about the development of other
symptoms such as headaches. Next, focus on
the patient’s current and past illnesses and
injuries, diet, drug history, and family health
history.
Thoroughly inspect the patient’s neck, shoulders, and cervical spine for swelling, masses,
erythema, and ecchymoses. Assess active range
of motion in his neck by having him perform
flexion, extension, rotation, and lateral side
bending. Note the degree of pain produced by
these movements. Examine his posture, and
M
EDICAL CAUSES
◆ Ankylosing spondylitis. Intermittent, mod-
erate to severe neck pain and stiffness with severely restricted range of motion is characteristic of this disorder. Intermittent low back pain
and stiffness and arm pain are generally worse
in the morning or after periods of inactivity and
are usually relieved after exercise. Related findings also include low-grade fever, limited chest
expansion, malaise, anorexia, fatigue and, occasionally, iritis.
◆ Cervical extension injury. Anterior or pos-
terior neck pain may develop within hours or
days following a whiplash injury. Anterior pain
usually diminishes within several days, but
posterior pain persists and may even intensify.
Associated findings include tenderness,
swelling and nuchal rigidity, arm or back pain,
occipital headache, muscle spasms, visual
blurring, and unilateral miosis on the affected
side.
◆ Cervical fibrositis. This disorder may pro-
duce anterior neck pain that radiates to one or
both shoulders. Pain is intermittent and variable, often changing with weather patterns.
Other findings are nonspecific but commonly
include point tenderness over involved
muscles.
◆ Cervical spine fracture. Fracture at C1 to C4
can cause sudden death; survivors may experience severe neck pain that restricts all movement, intense occipital headache, quadriplegia,
deformity, and respiratory paralysis.
◆ Cervical spine infection (acute). This infec-
tion can cause neck pain that restricts motion.
Other findings include fever, possible deformity,
muscle spasms, local tenderness, dysphagia,
paresthesia, and muscle weakness.
◆ Cervical spine tumor. Metastatic tumors
typically produce persistent neck pain that increases with movement and isn’t relieved by
rest; primary tumors cause mild to severe pain
along a specific nerve root. Other findings depend on the lesions and may include paresthesia, arm and leg weakness that progresses to
NECK PAIN
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479
atrophy and paralysis, and bladder and bowel
incontinence.
◆ Cervical spondylosis. This degenerative
process produces posterior neck pain that restricts movement and is aggravated by it. Pain
may radiate down either arm and may accompany paresthesia, weakness, and stiffness.
◆ Cervical stenosis. This progressive disorder,
commonly asymptomatic, may cause nonspecific neck and arm pain, paresthesia, muscle
weakness or paralysis, and decreased range of
motion.
◆ Esophageal trauma. An esophageal mucos-
al tear or a pulsion diverticulum may produce
mild neck pain, chest pain, edema, hemoptysis,
and dysphagia.
◆ Herniated cervical disk. This disorder char-
acteristically causes variable neck pain that restricts movement and is aggravated by it. It also
causes referred pain along a specific dermatome, paresthesia and other sensory disturbances, and arm weakness.
◆ Hodgkin’s lymphoma. This disorder may
eventually result in generalized pain that may
affect the neck. Lymphadenopathy, the classic
sign, may accompany paresthesia, muscle
weakness, fever, fatigue, weight loss, malaise,
and hepatomegaly.
◆ Laryngeal cancer. Neck pain that radiates to
the ear develops late in this disorder. The patient may also develop dysphagia, dyspnea, hemoptysis, stridor, hoarseness, and cervical lymphadenopathy.
◆ Lymphadenitis. With this disorder, enlarged
and inflamed cervical lymph nodes cause acute
pain and tenderness. Fever, chills, and malaise
may also occur.
◆ Meningitis. Neck pain may accompany char-
acteristic nuchal rigidity. Related findings include fever, headache, photophobia, positive
Brudzinski’s and Kernig’s signs, and decreased
level of consciousness.
◆ Neck sprain. Minor sprains typically produce
pain, slight swelling, stiffness, and restricted
range of motion. Ligament rupture causes pain,
marked swelling, ecchymosis, muscle spasms,
and nuchal rigidity with head tilt.
◆ Osteoporosis. Neck pain is rare with this
disorder, which usually affects the thoracic or
lumbar vertebrae. Cervical vertebrae involvement produces tenderness and deformity.
◆ Paget’s disease. This slowly developing dis-
ease is commonly asymptomatic in its early
stages. As it progresses, cervical vertebrae de-
formity may produce severe, persistent neck
pain, along with paresthesia and arm weakness
or paralysis.
◆ Rheumatoid arthritis. This disorder usually
affects peripheral joints, but it can also involve
the cervical vertebrae. Acute inflammation may
cause moderate to severe pain that radiates
along a specific nerve root; increased warmth,
swelling, and tenderness in involved joints; stiffness, restricting range of motion; paresthesia
and muscle weakness; low-grade fever; anorexia; malaise; fatigue; and possible neck deformity. Some pain and stiffness remain after the
acute phase.
◆ Spinous process fracture. Fracture near the
cervicothoracic junction produces acute pain
radiating to the shoulders. Associated findings
include swelling, exquisite tenderness, restricted range of motion, muscle spasms, and deformity.
◆ Subarachnoid hemorrhage. This life-
threatening condition may cause moderate to
severe neck pain and rigidity, headache, and a
decreased level of consciousness. Kernig’s and
Brudzinski’s signs are present. The patient may
describe the headache as “the worst headache
of my life.”
◆ Thyroid trauma. Besides mild to moderate
neck pain, thyroid trauma may cause local
swelling and ecchymosis. If a hematoma forms,
it can cause dyspnea.
◆ Torticollis. With this neck deformity, severe
neck pain accompanies recurrent unilateral
stiffness and muscle spasms that produce a
characteristic head tilt.
◆ Tracheal trauma. Fracture of the tracheal
cartilage, a life-threatening condition, produces
moderate to severe neck pain and respiratory
difficulty.
Torn tracheal mucosa produces mild to moderate pain and may result in airway occlusion,
hemoptysis, hoarseness, and dysphagia.
S
PECIAL CONSIDERATIONS
Promote patient comfort by giving an anti-inflammatory and an analgesic, as needed. Prepare him for diagnostic tests, such as X-rays,
computed tomography scan, blood tests, and
cerebrospinal fluid analysis.
P
EDIATRIC POINTERS
The most common causes of neck pain in children are meningitis and trauma. A rare cause of
neck pain is congenital torticollis.
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SIGNS & SYMPTOMS
Neck pain: Causes and associated findings
Major associated signs and symptoms
Common
causes
Ankylosing
spondylitis
Cervical extension
injury
Cervical fibrositis
Cervical spine
fracture
Cervical spine
infection (acute)
Cervical spine
tumor
Cervical
spondylosis
Cervical stenosis
Esophageal trauma
Herniated cervical
disk
Hodgkin’s
lymphoma
Laryngeal cancer
Lymphadenitis
Meningitis
Neck sprain
Osteoporosis
Paget’s disease
Arm pain
Back pain
Brudzinski’s sign
Decreased level of
consciousness
Decreased range
of motion
Deformity
Dysphagia
Dyspnea
Ecchymoses
Fatigue
Fever
Headache
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Hemoptysis
Hoarseness
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