Causes of Emotional stress
Emotional stress Causes: Book Excerpts
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Anxiety:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Generalized anxiety disorder
–Excessive worry associated with at least three symptoms, including restlessness or edgy feeling, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
–The most common anxiety disorder in primary care
- Panic disorder
–Recurrent, unpredictable panic attacks with intense apprehension, fear or terror, and somatic symptoms (e.g., tachycardia)
–May present with or without agoraphobia
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Depression: Anxiety often presents in a mixed state with depression
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Medications (e.g., bronchodilators, steroids, antidepressants, antihypertensives)
-
Substance use, including drugs (e.g., alcohol, caffeine, cocaine, cannabis)
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Obsessive-compulsive disorder
–Obsessions are persistent ideas, images, or impulses that generate anxiety
–Compulsions are intentional repetitive behaviors or mental acts aimed at reducing the distress of obsessions
- Anxiety disorder due to a general medical condition
–Cardiovascular etiologies include MI, angina, arrhythmias, CAD, CHF, MVP
–Respiratory etiologies include asthma, COPD, and pulmonary embolism
–Endocrine etiologies include hyper- or hypothyroidism, hypoglycemia, and Cushing's syndrome
–Neurological etiologies include Parkinson's disease and epilepsy
–Cancer
-
Pheochromocytoma: Adrenal tumor that usually presents with hypertension and increased heart rate and sometimes with fright reaction of sweating, headache, and pale facial appearance
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Parkinson's disease: Presents with tremor at rest, usually in one hand (as opposed to the more generalized essential tremor in anxiety)
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Post-traumatic or acute stress disorder
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Social anxiety disorder
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Specific phobia
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Bipolar disorder (especially manic stage)
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Agitation:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
❑ Alcohol withdrawal syndrome. Mild to severe agitation occurs in alcohol withdrawal syndrome, along with hyperactivity, tremors, and anxiety. With delirium, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and a depressed mood. The patient’s pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac exhaustion, and shock can occur.
❑ Anxiety. Anxiety produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.
❑ Dementia. Mild to severe agitation can result from many common syndromes, such as Alzheimer’s and Huntington’s diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.
❑ Drug withdrawal syndrome. Mild to severe agitation occurs in drug withdrawal syndrome. Related findings vary with the drug, but include anxiety, abdominal cramps, diaphoresis, and anorexia. With opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.
❑ Hepatic encephalopathy. Agitation occurs only with fulminating encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.
❑ Hypersensitivity reaction. Moderate to severe agitation appears, possibly as the first sign of a reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.
With anaphylactic shock, a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.
❑ Hypoxemia. Beginning as restlessness, agitation rapidly worsens. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.
❑ Increased intracranial pressure (ICP). Agitation usually precedes other early signs and symptoms, such as head-ache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; a decreased LOC; seizures; and motor changes such as decerebrate or decorticate posture.
❑ Post-head trauma syndrome. Shortly after, or even years after injury, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.
❑ Vitamin B6 deficiency. Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.
Other causes
❑ Drugs. Mild to moderate agitation, which is commonly dose related, develops as an adverse reaction to central nervous system stimulants — especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics, such as ephedrine; caffeine; and theophylline.
❑ Radiographic contrast media. Reaction to the contrast medium injected during various diagnostic tests produces moderate to severe agitation along with other signs of hypersensitivity.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Anxiety:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
❑ Acute respiratory distress syndrome. Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.
❑ Anaphylactic shock. Acute anxiety usually signals the onset of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, a barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.
❑ Angina pectoris. Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.
❑ Asthma. With allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, a productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.
❑ Autonomic hyperreflexia. The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.
❑ Cardiogenic shock. Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; a weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.
❑ Chronic obstructive pulmonary disease (COPD). Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.
❑ Heart failure. With heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.
❑ Hyperthyroidism. Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.
❑ Mitral valve prolapse. Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an apical systolic murmur.
❑ Mood disorder. Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. With the depressive form, chronic anxiety occurs with varying severity. Associated findings include dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. With the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.
❑ Myocardial infarction (MI). With MI, a life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. It can be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.
❑ Obsessive-compulsive disorder. Chronic anxiety occurs with obsessive-compulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational, but is unable to control them. Anxiety builds if he can’t perform these acts and diminishes after he does.
❑ Pheochromocytoma. Acute, severe anxiety accompanies pheochromocytoma’s cardinal sign: persistent or paroxysmal hypertension. Common associated signs and symptoms include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, a severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.
❑ Phobias. With phobias, chronic anxiety occurs along with a persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational, but can’t suppress it.
❑ Pneumonia. Acute anxiety may occur with pneumonia because of hypoxemia. Other findings include a productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.
❑ Pneumothorax. Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It’s accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.
❑ Postconcussion syndrome. Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated signs and symptoms include irritability, insomnia, dizziness, and a mild headache. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension.
❑ Posttraumatic stress disorder. Posttraumatic stress disorder occurs in the patient who has experienced an extreme traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.
❑ Pulmonary edema. With pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and a thready pulse. The patient’s skin may be cool, clammy, and cyanotic.
❑ Pulmonary embolism. With pulmonary embolism, acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and a low-grade fever.
❑ Rabies. Anxiety signals the beginning of the acute phase of rabies, a rare disorder, which is commonly accompanied by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.
❑ Somatoform disorder. Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally, but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.
Other causes
❑ Drugs. Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Confusion:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Brain tumor.
In the early stages of a brain tumor, confusion is usually mild and difficult to detect. As the tumor impinges on cerebral structures, however, confusion worsens and the patient may exhibit personality changes, bizarre behavior, sensory and motor deficits, visual field deficits, and aphasia.
Cerebrovascular disorders.
Cerebrovascular disorders produce confusion due to tissue hypoxia and ischemia. Confusion may be insidious and fleeting, as in a transient ischemic attack, or acute and permanent, as in a stroke.
Decreased cerebral perfusion.
Mild confusion is an early symptom of decreased cerebral perfusion. Associated findings usually include hypotension, tachycardia or bradycardia, an irregular pulse, ventricular gallop, edema, and cyanosis.
Fluid and electrolyte imbalance.
The extent of imbalance determines the severity of the patient's confusion. Typically, he'll show signs of dehydration, such as lassitude, poor skin turgor, dry skin and mucous membranes, and oliguria. He may also develop hypotension and a low-grade fever.
Head trauma.
Concussion, contusion, and brain hemorrhage may produce confusion at the time of injury, shortly afterward, or months or even years afterward. The patient may be delirious, with periodic loss of consciousness. Vomiting, a severe headache, pupillary changes, and sensory and motor deficits are also common.
Heatstroke.
Heatstroke causes pronounced confusion that gradually worsens as the patient's body temperature rises. Initially, he may be irritable and dizzy; later, he may become delirious, have seizures, and lose consciousness.
Hypothermia.
Confusion may be an early sign of hypothermia. Typically, the patient displays slurred speech, cold and pale skin, hyperactive deep tendon reflexes, a rapid pulse, and decreased blood pressure and respirations. As his body temperature continues to drop, his confusion progresses to stupor and coma, his muscles become rigid, and his respiratory rate decreases.
Hypoxemia.
Acute pulmonary disorders that result in hypoxemia produce confusion that can range from mild disorientation to delirium. Chronic pulmonary disorders produce persistent confusion.
Infection.
Severe generalized infection, such as sepsis, typically produces delirium. Central nervous system (CNS) infections, such as meningitis, cause varying degrees of confusion along with a headache and nuchal rigidity.
Metabolic encephalopathy.
Hyperglycemia and hypoglycemia can produce sudden confusion. A patient with hypoglycemia may also experience transient delirium and seizures. Uremic and hepatic encephalopathies produce gradual confusion that may progress to seizures and coma. Usually, the patient also experiences tremors and restlessness.
Nutritional deficiencies.
Inadequate dietary intake of thiamine, niacin, or vitamin B12 produces insidious, progressive confusion and possible mental deterioration.
Seizure disorders.
Mild to moderate confusion may immediately follow any type of seizure. The confusion usually disappears within several hours.
Other causes
Alcohol.
Intoxication causes confusion and stupor, and alcohol withdrawal may cause delirium and seizures.
Drugs.
Large doses of CNS depressants produce confusion that can persist for several days after the drug is discontinued. Opioid and barbiturate withdrawal also causes acute confusion, possibly with delirium. Other drugs that commonly cause confusion include lidocaine, a cardiac glycoside, indomethacin, cycloserine, chloroquine, atropine, and cimetidine.
HERB ALERT:Herbal remedies, such as St. John's wort, can cause confusion, especially when taken in conjunction with an antidepressant or other serotonergic drug.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Depression:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
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 disorderssuch as cancer.
Psychiatric disorders
Affective disordersare 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 disordersand 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.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Fontanel depression:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Dehydration
With mild dehydration (5% weight loss), the anterior fontanel appears slightly depressed. The infant has pale, dry skin and mucous membranes; decreased urine output; a normal or slightly elevated pulse rate; and, possibly, irritability
Moderate dehydration (10% weight loss) causes slightly more pronounced fontanel depression, along with gray skin with poor turgor, dry mucous membranes, decreased tears, and decreased urine output. The infant has normal or decreased blood pressure, an increased pulse rate and, possibly, lethargy.
Severe dehydration (15%or greater weight loss) may result in a markedly sunken fontanel, along with extremely poor skin turgor, parched mucous membranes, marked oliguria or anuria, lethargy, and signs of shock, such as a rapid, thready pulse; very low blood pressure; and obtundation.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Generalized anxiety disorder:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Theorists share a common premise: Conflict, whether intrapsychic, sociopersonal, or interpersonal, promotes an anxiety state.
Generalized anxiety disorder has a 1-year prevalence range from 3% to 8%. It’s more common in women than in men, and half of all cases begin in childhood or adolescence.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Major depression:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
The multiple causes of depression aren’t completely understood. Current research suggests possible genetic, familial, biochemical, physical, psychological, and social causes. Psychological causes (the focus of many nursing interventions) may include feelings of helplessness and vulnerability, anger, hopelessness and pessimism, and low self-esteem. They may be related to abnormal character and behavior patterns and troubled personal relationships. In many cases, the history identifies a specific personal loss or severe stressor that probably interacts with the person’s predisposition to provoke major depression.
Depression may be secondary to a specific medical condition — for example, metabolic disturbances, such as hypoxia and hypercalcemia; endocrine disorders, such as diabetes and Cushing’s syndrome; neurologic diseases, such as Parkinson’s and Alzheimer’s diseases; cancer (especially of the pancreas); viral and bacterial infections, such as influenza and pneumonia; cardiovascular disorders, such as heart failure; pulmonary disorders, such as chronic obstructive lung disease; musculoskeletal disorders, such as degenerative arthritis; GI disorders, such as irritable bowel syndrome; genitourinary problems, such as incontinence; collagen vascular diseases, such as lupus; and anemias.
Drugs prescribed for medical and psychiatric conditions as well as many commonly abused substances can also cause depression. Examples include antihypertensives, psychotropics, opioid and nonopioid analgesics, antiparkinsonian drugs, numerous cardiovascular medications, oral antidiabetics, antimicrobials, steroids, chemotherapeutic agents, cimetidine, and alcohol. Depression occurs in up to 18 million Americans, affecting all racial, ethnic, and socioeconomic groups. It affects both sexes, but is more common in women.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Agitation:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Affective disturbances
Agitation may occur in either the depressive or manic phase of affective disturbances and in personality disorders, such as borderline and antisocial personality disorders. The hallmark of the depressive form is depressed mood upon awakening, which eases during the day. Chronic anxiety may be mild or severe. Psychomotor agitation may be characterized by an inability to sit still, hand-wringing, pacing, and irritability. Other findings in the manic state may include decreased sleep, pressured speech, and grandiosity.
Alcohol withdrawal syndrome
Mild to severe agitation occurs with hyperactivity, tremors, and anxiety. In delirium tremens, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and depressed mood. Pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac arrhythmias, and shock can occur.
Anxiety
Anxiety is a common symptom that produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings may include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.
Chronic renal failure
Moderate to severe agitation occurs in chronic renal failure, which is marked by confusion and memory loss. The agitation is accompanied by diverse signs and symptoms, such as nausea, vomiting, anorexia, mouth ulcers, ammonia breath odor, GI bleeding, pallor, edema, dry skin, and uremic frost.
Dementia
Mild to severe agitation can result from many common dementia syndromes, such as Alzheimer’s and Huntington’s diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.
Drug withdrawal syndrome
Findings vary with the drug but include mild to severe agitation, anxiety, abdominal cramps, diaphoresis, and anorexia. In opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.
Hepatic encephalopathy
Agitation occurs only in fulminating encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.
Hypersensitivity reaction
Moderate to severe agitation may be the first sign of a hypersensitivity reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.
In anaphylactic shock, a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.
Hypoxemia
Beginning as restlessness, agitation rapidly worsens in hypoxemia. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.
Increased intracranial pressure (ICP)
Agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; decreased LOC; seizures; and motor changes, such as decerebrate or decorticate posture.
Organic brain syndrome
In organic brain syndrome, agitation is manifested as hyperactivity, emotional lability, confusion, and memory loss. Slurred or incoherent speech and paranoid behavior may also occur.
Post–head trauma syndrome
Shortly—or even years—after injury, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Fatigue, wandering behavior, and poor judgment are other findings.
Vitamin B6 Deficiency
Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.
Other causes
Drugs
Mild to moderate agitation, which is commonly dose related, is an adverse effect of central nervous system stimulants—especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics such as ephedrine; caffeine; and theophylline.
Radiographic contrast media
Injection of a contrast medium during various diagnostic tests may produce moderate to severe agitation along with other signs of hypersensitivity.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Anxiety:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Acute respiratory distress syndrome
Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.
Anaphylactic shock
Acute anxiety is usually the first sign of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.
Angina pectoris
Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.
Asthma
In allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.
Autonomic hyperreflexia
The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by a severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.
Cardiogenic shock
Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.
Chronic obstructive pulmonary disease (COPD)
Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.
Heart failure
In heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.
Hyperthyroidism
Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, diaphoresis, an enlarged thyroid, and diarrhea. Exophthalmos also may occur.
Hyperventilation syndrome
Hyperventilation syndrome produces acute anxiety, pallor, circumoral and peripheral paresthesia and, occasionally, carpopedal spasms.
Hypochondriasis
Mild to moderate chronic anxiety occurs in hypochondriasis. The patient focuses more on the belief that he has a specific serious disease rather than on the actual symptoms. Difficulty swallowing, back pain, light-headedness, and upset stomach are common complaints. The patient tends to “physician hop” and isn’t reassured by favorable physical examinations and laboratory test results.
Hypoglycemia
Anxiety resulting from hypoglycemia is usually mild to moderate and associated with hunger, mild headache, palpitations, blurred vision, weakness, and diaphoresis.
Mitral valve prolapse
Panic may occur in patients with this valvular disorder, also known as click-murmur syndrome because its hallmark is a midsystolic click, followed by an apical systolic murmur. Mitral valve prolapse also may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain.
Mood disorder
Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. In the depressive form, chronic anxiety of varying severity occurs along with dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. In the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.
Myocardial infarction (MI)
In this life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. MI may be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.
Obsessive-compulsive disorder
Chronic anxiety occurs in obsessive-compulsive disorder, which is marked by recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational but is unable to control them. Anxiety builds if he can’t perform these acts and diminishes after he does.
Pheochromocytoma
Acute, severe anxiety accompanies pheochromocytoma’s cardinal sign: persistent or paroxysmal hypertension. Other common findings include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.
Phobias
In phobias, chronic anxiety accompanies persistent fear of an object, an activity, or a situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational but can’t suppress it.
Pneumonia
Acute anxiety may occur in pneumonia because of hypoxemia. Other findings include productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.
Pneumothorax
Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It’s accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.
Postconcussion syndrome
Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension. Associated signs and symptoms include irritability, insomnia, dizziness, and mild headache.
Posttraumatic stress disorder
Posttraumatic stress disorder occurs in patients who have experienced an extremely traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.
Pulmonary edema
In pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and thready pulse. The patient’s skin may be cool, clammy, and cyanotic.
Pulmonary embolism
Acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and low-grade fever.
Rabies
Anxiety signals the beginning of the acute phase of rabies. This rare disorder is characterized by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.
Somatoform disorder
Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.
Other causes
Drugs
Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Confusion:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Brain tumor
In the early stages of a brain tumor, confusion is usually mild and difficult to detect. As the tumor impinges on cerebral structures, however, confusion worsens and the patient may exhibit personality changes, bizarre behavior, sensory and motor deficits, visual field deficits, and aphasia.
Cerebrovascular disorders
These disorders produce confusion due to tissue hypoxia and ischemia. Confusion may be insidious and fleeting, as in a transient ischemic attack, or acute and permanent, as in a stroke.
Decreased cerebral perfusion
Mild confusion is an early symptom of decreased cerebral perfusion. Associated findings usually include hypotension, tachycardia or bradycardia, irregular pulse, ventricular gallop, edema, and cyanosis.
Fluid and electrolyte imbalance
The extent of the imbalance determines the severity of the patient’s confusion. Typically, he’ll show signs of dehydration, such as lassitude, poor skin turgor, dry skin and mucous membranes, and oliguria. He may also develop hypotension and a low-grade fever.
Head trauma
Concussion, contusion, and brain hemorrhage may produce confusion at the time of injury, shortly afterward, or months or even years afterward. The patient may be delirious, with periodic loss of consciousness. Vomiting, severe headache, pupillary changes, and sensory and motor deficits are also common.
Heatstroke
This disorder causes pronounced confusion that gradually worsens as body temperature rises. Initially, the patient may be irritable and dizzy; later, he may become delirious, have seizures, and lose consciousness.
Hypothermia
Confusion may be an early sign of this disorder. Typically, the patient displays slurred speech, cold and pale skin, hyperactive deep tendon reflexes, rapid pulse, and decreased blood pressure and respiratory rate. As his body temperature continues to drop, his confusion progresses to stupor and coma, his muscles become rigid, and his respiratory rate decreases.
Hypoxemia
Acute pulmonary disorders that result in hypoxemia produce confusion that can range from mild disorientation to delirium. Chronic pulmonary disorders produce persistent confusion.
Infection
A severe generalized infection, such as sepsis, commonly produces delirium. Central nervous system (CNS) infections, such as meningitis, cause varying degrees of confusion along with headache and nuchal rigidity.
Metabolic encephalopathy
Both hyperglycemia and hypoglycemia can produce sudden confusion. A patient with hypoglycemia may also experience transient delirium and seizures. Uremic and hepatic encephalopathies produce gradual confusion that may progress to seizures and coma. Usually, the patient also experiences tremors and restlessness.
Nutritional deficiencies
Inadequate dietary intake of thiamine, niacin, or vitamin B12 produces insidious, progressive confusion and possibly mental deterioration.
Seizure disorders
Mild to moderate confusion may immediately follow any type of seizure. The confusion usually disappears within several hours.
Thyroid hormone disorders
Hyperthyroidism produces mild to moderate confusion along with nervousness, inability to concentrate, weight loss, flushed skin, and tachycardia. Hypothyroidism produces mild, insidious confusion and memory loss; weight gain; bradycardia; and fatigue.
Other causes
Alcohol
Intoxication causes confusion and stupor, and alcohol withdrawal may cause delirium and seizures.
Drugs
Large doses of CNS depressants produce confusion that can persist for several days after the drug is discontinued. Opioid and barbiturate withdrawal also causes acute confusion, possibly with delirium. Other drugs that commonly cause confusion include lidocaine, cardiac glycosides, indomethacin, cycloserine, chloroquine, atropine, and cimetidine.
Heavy metal poisoning
Chronic ingestion or inhalation of heavy metals (such as lead, arsenic, mercury, and manganese) eventually produces confusion and, typically, weakness and drowsiness. The patient may also experience headache, vomiting, seizures, tremors, gait disturbances, and mental deterioration.
Herb Alert
Herbal medicines, such as St. John’s wort, can cause confusion, especially when taken in conjunction with an antidepressant or another serotonergic drug.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Depression:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
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 with high doses), methyldopa, and clonidine; beta-adrenergic blockers such as propranolol; levodopa; indomethacin; cycloserine; corticosteroids; and hormonal contraceptives.
Postpartum period
Although its cause hasn’t been determined, postpartum depression occurs in about 1 in every 2,000 to 3,000 women who have given birth. Symptoms range from mild postpartum blues to an intense, suicidal, depressive psychosis.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Fontanel depression:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Dehydration
In mild dehydration (5% weight loss), the anterior fontanel appears slightly depressed. Other findings include pale, dry skin and mucous membranes; decreased urine output; a normal or slightly elevated pulse rate; and possibly irritability.
Moderate dehydration (10% weight loss) causes slightly more pronounced fontanel depression along with gray skin with poor turgor, dry mucous membranes, decreased tears, and decreased urine output. The infant has normal or decreased blood pressure and an increased pulse rate; he may also be lethargic.
Severe dehydration (15% or greater weight loss) may result in a markedly sunken fontanel along with extremely poor skin turgor, parched mucous membranes, marked oliguria or anuria, lethargy, and signs of shock, such as rapid, thready pulse, very low blood pressure, and obtundation.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Anxiety:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Situational/characterologic
❑ Post-traumatic stress disorder
❑ Drugs/withdrawal
❑ Generalized anxiety disorder
❑ Panic disorder
❑ Phobia
❑ Agitated depression
❑ Hypoglycemia
❑ Hyperthyroidism
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Source: Field Guide to Bedside Diagnosis, 2007
Depression:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Dysthymia
❑ Major depression
❑ Adjustment disorder with depressed mood
❑ Seasonal affective disorder
❑ Bipolar disorder
❑ Drug-induced
❑ Grief
❑ Thyroid disease
❑ Dementia
❑ Stroke
❑ Paraneoplastic
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Source: Field Guide to Bedside Diagnosis, 2007
Anxiety disorder, generalized:
Causes
(Handbook of Diseases)
Etiology is thought to involve the y-aminobutyric acid (GABA) A receptor–chloride ion channel complex. Benzodiazepines bind two separate GABA-A receptor sites: Type I has broad anatomic distribution, and type II is concentrated in the hippocampus, striatum, and neocortex. Serotonin (5-hydroxytryptamine [5-HT]) also appears to have a role in anxiety. Theorists share a common premise: Con-flict — whether intrapsychic, sociopersonal, or interpersonal — promotes an anxiety state.
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Source: Handbook of Diseases, 2003
Depression, major:
Causes
(Handbook of Diseases)
The multiple causes of depression aren’t completely understood. Current research suggests possible genetic, familial, biochemical, physical, psychological, and social causes.
Psychological factors
Such causes may include feelings of helplessness and vulnerability, anger, hopelessness and pessimism, and low self-esteem; they may be related to abnormal character and behavior patterns and troubled personal relationships.
In many patients, the history identifies a specific personal loss or severe stressor that probably interacts with the person’s predisposition to provoke major depression.
Medical conditions
Depression may be secondary to a specific medical condition — for example, metabolic disturbances, such as hypoxia and hypercalcemia; endocrine disorders, such as diabetes and Cushing’s disease; neurologic diseases, such as Parkinson’s and Alzheimer’s disease; and cancer, especially of the pancreas.
Other medical conditions that may underlie depression include viral and bacterial infections, such as influenza and pneumonia; cardiovascular disorders such as heart failure; pulmonary disorders such as chronic obstructive pulmonary disease; musculoskeletal disorders such as degenerative arthritis; GI disorders such as irritable bowel syndrome; genitourinary problems such as incontinence; collagen vascular diseases such as lupus; and anemias.
Drugs
Drugs prescribed for medical and psychiatric conditions as well as many commonly abused substances, can also cause depression. Examples include antihypertensives, psychotropics, narcotic and nonnarcotic analgesics, antiparkinsonian drugs, numerous cardiovascular medications, oral antidiabetics, antimicrobials, steroids, chemotherapeutic agents, cimetidine, and alcohol.
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Source: Handbook of Diseases, 2003
Agitation:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Affectivedisturbance
Agitation may occur in depressed and manic phases of affectivedisturbance and in personality disorders, such as borderline and antisocial personality disorders. In its depressive form, chronic anxiety occurs with varying severity. The hallmark is depressed mood upon awakening, which eases during the day. Psychomotor agitation may be characterized by an inability to sit still, hand-wringing, pacing, and irritability. Other findings in manic states may include decreased sleep, pressured speech, and grandiosity.
Alcohol withdrawal syndrome
With alcohol withdrawal syndrome, mild to severe agitation occurs. It may be accompanied by hyperactivity, tremors, and anxiety. With delirium tremens, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and depressed mood. Pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac exhaustion, and shock can occur.
Anxiety
Anxiety produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.
Chronic renal failure
Moderate to severe agitation occurs with chronic renal failure, marked especially by confusion and memory loss. The agitation is accompanied by diverse signs and symptoms, such as nausea, vomiting, anorexia, mouth ulcers, ammonia breath odor, GI bleeding, pallor, edema, dry skin, and uremic frost.
Dementia
Mild to severe agitation related to dementia can result from many common syndromes, such as Alzheimer’s and Huntington’s diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.
Drug withdrawal syndrome
In drug withdrawal syndrome, mild to severe agitation occurs. Related findings vary with the drug but include anxiety, abdominal cramps, diaphoresis, and anorexia. With narcotic or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.
Hepatic encephalopathy
Agitation occurs with fulminating hepatic encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus (musty, sweet breath odor), asterixis, and hyperreflexia. Lethargy, aberrant behavior, and apraxia may also occur.
Hypersensitivity reaction
Moderate to severe agitation may be the first sign of a hypersensitivity reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.
With anaphylactic shock, a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, skin that’s warm and moist, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.
Hypoxemia
Beginning as restlessness, agitation rapidly worsens with hypoxemia. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.
Increased intracranial pressure
With increased intracranial pressure (ICP), agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; decreased LOC; seizures; and motor changes, such as decerebrate or decorticate posture.
Organic brain syndrome
With organic brain syndrome, agitation is manifested as hyperactivity, emotional lability, confusion, and memory loss. Slurred or incoherent speech and paranoid behavior may also occur.
Post–head trauma syndrome
Shortly after — or even years after — head trauma, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.
Vitamin B6 deficiency
With vitamin B6 deficiency, agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.
Other causes
Drugs
Mild to moderate agitation, which is commonly dose related, develops as an adverse reaction to central nervous system stimulants — especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics such as ephedrine; caffeine; and theophylline.
Radiographic contrast media
Reaction to the contrast medium injected during various diagnostic tests produces moderate to severe agitation along with other signs of hypersensitivity.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Anxiety:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Acute respiratory distress syndrome
With acute respiratory distress syndrome (ARDS), acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.
Anaphylactic shock
Acute anxiety usually signals the onset of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.
Angina pectoris
Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.
Asthma
During allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.
Autonomic hyperreflexia
The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.
Cardiogenic shock
With cardiogenic shock, acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.
Chronic obstructive pulmonary disease
Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize chronic obstructive pulmonary disease (COPD). Other signs and symptoms include barrel chest, pursed-lip breathing, and finger clubbing (late in the disease).
Heart failure
Acute anxiety is commonly the first symptom of inadequate oxygenation in a patient with heart failure. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.
Hyperthyroidism
Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.
Hyperventilation syndrome
Hyperventilation syndrome produces acute anxiety, pallor, circumoral and peripheral paresthesia and, occasionally, carpopedal spasms. Other signs and symptoms include chest pain, tachycardia, belching, flatus, and dizziness.
Hypochondriasis
Mild to moderate chronic anxiety occurs with hypochondriasis. The patient focuses more on the belief that he has a specific serious disease than on the actual symptoms. Difficulty swallowing, back pain, light-headedness, and upset stomach are common complaints. The patient tends to “physician hop” and isn’t reassured by favorable physical examinations and laboratory test results.
Hypoglycemia
Anxiety resulting from hypoglycemia is usually mild to moderate and associated with hunger, mild headache, palpitations, blurred vision, weakness, and diaphoresis. Other signs and symptoms include nervousness, dizziness, and tingling and numbness around the mouth.
Mitral valve prolapse
Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder also may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an apical systolic murmur.
Mood disorder
Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. With the depressive form, chronic anxiety occurs with varying severity. Associated findings include dysphoria; anger; insomnia or hypersomnia; decreased libido, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. With the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.
Myocardial infarction
With myocardial infarction, a life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. It can be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.
Obsessive-compulsive disorder
Chronic anxiety occurs with obsessive-compulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational but can’t control them. Anxiety builds if he can’t perform these acts and diminishes after he does.
Pheochromocytoma
Acute, severe anxiety accompanies the cardinal sign of pheochromocytoma: persistent or paroxysmal hypertension. Common associated signs and symptoms include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.
Phobias
With phobias, chronic anxiety occurs along with persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational but can’t suppress it.
Postconcussion syndrome
Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated signs and symptoms include irritability, insomnia, dizziness, and mild headache. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension.
Posttraumatic stress disorder
Posttraumatic stress disorder occurs in patients who have experienced an extreme traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.
Pulmonary edema
With pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and thready pulse. The patient’s skin may be cool, clammy, and cyanotic.
Pulmonary embolism
Hypoxia resulting from a pulmonary embolus may lead to acute anxiety and restlessness. The patient may also experience dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and low-grade fever.
Somatoform disorder
Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of a somatoform disorder.
Other causes
Drugs
Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Confusion:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Brain tumor
In the early stages of a brain tumor, confusion is usually mild and difficult to detect. As the tumor impinges on cerebral structures, however, confusion worsens and the patient may exhibit personality changes, bizarre behavior, sensory and motor deficits, visual field deficits, and aphasia.
Decreased cerebral perfusion
Mild confusion is an early symptom of decreased cerebral perfusion. Confusion may be insidious and fleeting, as in a transient ischemic attack, or acute and permanent, as in stroke. Associated findings usually include hypotension, tachycardia or bradycardia, irregular pulse, ventricular gallop, edema, and cyanosis.
Fluid and electrolyte imbalance
A fluid and electrolyte imbalance can cause confusion. The extent of imbalance determines the severity of the patient’s confusion. Typically, he’ll show signs of dehydration, such as lassitude, poor skin turgor, dry skin and mucous membranes, and oliguria. He may also develop hypotension and a low-grade fever.
Head trauma
Such head trauma as concussions, contusions, and brain hemorrhages may produce confusion at the time of injury, shortly afterward, or months or even years afterward. The patient may be delirious, with periodic loss of consciousness. Vomiting, severe headache, pupillary changes, and sensory and motor deficits are also common.
Heatstroke
Heatstroke causes pronounced confusion that gradually worsens as body temperature rises. Initially, the patient may be irritable and dizzy; later, he may become delirious, have seizures, and lose consciousness.
Heavy metal poisoning
Chronic ingestion or inhalation of heavy metals (such as lead, arsenic, mercury, and manganese) eventually produces confusion and, typically, weakness and drowsiness. The patient may also experience headache, vomiting, seizures, tremors, gait disturbances, and mental deterioration.
Hypothermia
Confusion may be an early sign of hypothermia. Typically, the patient displays slurred speech, cold and pale skin, hyperactive deep tendon reflexes, rapid pulse, and decreased blood pressure and respirations. As his body temperature continues to drop, his confusion progresses to stupor and coma, his muscles develop rigidity, and his respiratory rate decreases.
Hypoxemia
Acute pulmonary disorders that result in hypoxemia produce confusion that can range from mild disorientation to delirium. In advanced stages, chronic pulmonary disorders produce persistent confusion as well as severe dyspnea, disability, cor pulmonale, and severe respiratory failure.
Infection
Severe generalized infection, such as sepsis, commonly produces delirium. Central nervous system (CNS) infections such as meningitis cause varying degrees of confusion along with headache and nuchal rigidity.
Metabolic encephalopathy
Both hyperglycemia and hypoglycemia can produce sudden confusion. A patient with hypoglycemia may also experience transient delirium and seizures. Uremic and hepatic encephalopathies produce gradual confusion that may progress to seizures and coma. Usually, the patient also experiences tremors and restlessness.
Nutritional deficiencies
Inadequate dietary intake of thiamine, niacin, or vitamin B12, which causes nutritional deficiencies, produces insidious, progressive confusion and possible mental deterioration. Associated CNS abnormalities may become severe enough to induce hallucinations and paranoia.
Seizure disorders
Mild to moderate confusion may immediately follow any type of seizure. The confusion usually disappears within several hours. The patient may have difficulty talking and may fall into deep sleep after the seizures.
Thyroid hormone disorders
Hyperthyroidism produces mild to moderate confusion along with nervousness, inability to concentrate, weight loss, flushed skin, and tachycardia. Hypothyroidism produces mild, insidious confusion and memory loss; weight gain; bradycardia; and fatigue.
Other causes
Alcohol
Intoxication causes confusion and stupor, and alcohol withdrawal may cause delirium and seizures.
Drugs
Large doses of CNS depressants produce confusion that can persist for several days after the drug is discontinued. Opioid and barbiturate withdrawal also causes acute confusion, possibly with delirium. Other drugs that commonly cause confusion include lidocaine, digoxin, indomethacin, cycloserine, chloroquine, atropine, and cimetidine.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Agitation:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Alcohol withdrawal syndrome.Mild to severe agitation occurs in alcohol withdrawal syndrome, along with hyperactivity, tremors, and anxiety. With delirium, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and a depressed mood. The patient's pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac exhaustion, and shock can occur.
Anxiety.Anxiety produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.
Dementia.Mild to severe agitation can result from many common syndromes, such as Alzheimer's and Huntington's diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.
Drug withdrawal syndrome.Mild to severe agitation occurs in drug withdrawal syndrome. Related findings vary with the drug, but include anxiety, abdominal cramps, diaphoresis, and anorexia. With opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.
Hepatic encephalopathy.Agitation occurs only with fulminating hepatic encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.
Hypersensitivity reaction.Moderate to severe agitation appears, possibly as the first sign of a reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.
With anaphylactic shock,a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.
Hypoxemia.Beginning as restlessness, agitation rapidly worsens. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.
Increased intracranial pressure (ICP).Agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; a decreased LOC; seizures; and motor changes such as decerebrate or decorticate posture.
Post-head trauma syndrome.Shortly after, or even years after a head injury, mild to severe agitation may develop, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.
Vitamin B6 deficiency.Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.
Other causes
Drugs.Mild to moderate agitation, which is commonly dose related, develops as an adverse reaction to central nervous system stimulants—especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics, such as ephedrine; caffeine; and theophylline.
Radiographic contrast media.Reaction to the contrast medium injected during various diagnostic tests produces moderate to severe agitation along with other signs of hypersensitivity.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Anxiety:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Acute respiratory distress syndrome (ARDS).Acute anxiety occurs with ARDS along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, rhonchi, and decreased pulse oximetry.
Anaphylactic shock.Acute anxiety usually signals the onset of anaphylacticshock. It's accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, a barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.
Angina pectoris.Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.
Asthma.With allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, a productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, decreased pulse oximetry, tachycardia, and diaphoresis.
Autonomic hyperreflexia.The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.
Cardiogenic shock.Acute anxiety in cardiogenic shock is accompanied by cool, pale, clammy skin; tachycardia; a weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.
Chronic obstructive pulmonary
disease (COPD).Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.
Generalized anxiety disorder.Anxiety may be the patient's chief complaint in this type of anxiety disorder. It's characterized by excessive, unrealistic worry lasting 6 months or more. Associated findings include trembling, insomnia, GI disturbances, dizziness, irritability, and muscle aches.
Heart failure.With heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, cyanosis, and decreased pulse oximetry.
Hyperthyroidism.Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.
Mitral valve prolapse.Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an apical systolic murmur.
Myocardial infarction (MI).With MI, a life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. It can be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.
Obsessive-compulsive disorder.Chronic anxiety occurs with obsessive-compulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational, but is unable to control them. Anxiety builds if he can't perform these acts and diminishes after he does.
Pheochromocytoma.Acute, severe anxiety accompanies pheochromocytoma's cardinal sign: persistent or paroxysmal hypertension. Common associated signs and symptoms include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, a severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.
Phobias.With phobias, chronic anxiety occurs along with a persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational, but can't suppress it.
Pneumonia.Acute anxiety may occur with pneumonia because of hypoxemia. Other findings include a productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.
Pneumothorax.Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It's accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.
Postconcussion syndrome.Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated signs and symptoms include irritability, insomnia, dizziness, and a mild headache. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension.
Posttraumatic stress disorder.Posttraumatic stress disorder produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient may relive the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.
Pulmonary edema.With pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, decreased pulse oximetry, ventricular gallop, hypotension, and a thready pulse. The patient's skin may be cool, clammy, and cyanotic.
Pulmonary embolism.With pulmonary embolism, acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and a low-grade fever.
Rabies.Anxiety signals the beginning of the acute phase of rabies, a rare disorder, which is commonly accompanied by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.
Somatoform disorder.Somatoform disorder is characterized by anxiety and multiple somatic complaints that can't be explained physiologically. The symptoms aren't produced intentionally, but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.
Other causes
Drugs.Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Confusion:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Brain tumor.In the early stages of a brain tumor, confusion is usually mild and difficult to detect. As the tumor impinges on cerebral structures, however, confusion worsens and the patient may exhibit personality changes, bizarre behavior, sensory and motor deficits, visual field deficits, and aphasia.
Cerebrovascular disorders.Cerebrovascular disorders produce confusion due to tissue hypoxia and ischemia. Confusion may be insidious and fleeting, as in a transient ischemic attack, or acute and permanent, as in a stroke.
Decreased cerebral perfusion.Mild confusion is an early symptom of decreased cerebral perfusion. Associated findings usually include hypotension, tachycardia or bradycardia, an irregular pulse, ventricular gallop, edema, and cyanosis.
Fluid and electrolyte imbalance.The extent and type of fluid and electrolyte imbalance determines the severity of the patient's confusion. Typically, he'll show signs of dehydration, such as lassitude, poor skin turgor, dry skin and mucous membranes, and oliguria. He may also develop hypotension and a low-grade fever.
Head trauma.Concussion, contusion, and brain hemorrhage may produce confusion at the time of injury, shortly afterward, or months or even years afterward. The patient may be delirious, with periodic loss of consciousness. Vomiting, a severe headache, pupillary changes, and sensory and motor deficits are also common.
Heatstroke.Heatstroke causes pronounced confusion that gradually worsens as the patient's body temperature rises. Initially, he may be irritable and dizzy; later, he may become delirious, have seizures, and lose consciousness.
Hypothermia.Confusion may be an early sign of hypothermia. Typically, the patient displays slurred speech, cold and pale skin, hyperactive deep tendon reflexes, a rapid pulse, and decreased blood pressure and respirations. As his body temperature continues to drop, his confusion progresses to stupor and coma, his muscles become rigid, and his respiratory rate decreases.
Hypoxemia.Acute pulmonary disorders that result in hypoxemia produce confusion that can range from mild disorientation to delirium. Chronic pulmonary disorders produce persistent confusion.
Infection.Severe generalized infection, such as sepsis, typically produces delirium. Central nervous system (CNS) infections, such as meningitis, cause varying degrees of confusion along with a headache and nuchal rigidity.
Metabolic encephalopathy.Hyperglycemia and hypoglycemia can produce sudden confusion. A patient with hypoglycemia may also experience transient delirium and seizures. Uremic and hepatic encephalopathies produce gradual confusion that may progress to seizures and coma. Usually, the patient also experiences tremors and restlessness.
Nutritional deficiencies.Inadequate dietary intake of thiamine, niacin, or vitamin B12 produces insidious, progressive confusion and possible mental deterioration.
Seizure disorder.Mild to moderate confusion may immediately follow any type of seizure. The confusion usually disappears within several hours.
Other causes
Alcohol.Intoxication causes confusion and stupor, and alcohol withdrawal may cause delirium and seizures.
Drugs.Large doses of CNS depressants produce confusion that can persist for several days after the drug is discontinued. Opioid and barbiturate withdrawal also causes acute confusion, possibly with delirium. Other drugs that commonly cause confusion include lidocaine, a cardiac glycoside, indomethacin, cycloserine, chloroquine, atropine, cimetidine, and sleeping aids.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Fontanel depression:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Dehydration.With mild dehydration (5% weight loss), the anterior fontanel appears slightly depressed. The infant has pale, dry skin and mucous membranes; decreased urine output; a normal or slightly elevated pulse rate; and, possibly, irritability.
Moderate dehydration (10% weight loss) causes slightly more pronounced fontanel depression, along with gray skin with poor turgor, dry mucous membranes, decreased tears, and decreased urine output. The infant has normal or decreased blood pressure, an increased pulse rate and, possibly, lethargy.
Severe dehydration (15% or greater weight loss) may result in a markedly sunken fontanel, along with extremely poor skin turgor, parched mucous membranes, marked oliguria or anuria, lethargy, and signs of shock, such as a rapid, thready pulse; very low blood pressure; and obtundation.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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