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Diseases » Hypotension » Causes
 

Causes of Hypotension

Contents
  1. Hypotension: Introduction
  2. List of Causes
  3. Drugs/substances (749 causes)
  4. Drug interaction (742 causes)
  5. Hidden causes
  6. Excerpts from book chapters
  7. Complication causes
  8. Causes of symptoms
  9. News
  10. Related cause information

List of causes of Hypotension

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Hypotension) that could possibly cause Hypotension includes:

More causes: see full list of causes for Low blood pressure

Causes of Hypotension (Diseases Database):

The follow list shows some of the possible medical causes of Hypotension that are listed by the Diseases Database:

Source: Diseases Database

Hypotension Causes: Book Excerpts

Hypotension as a complication of other conditions:

Other conditions that might have Hypotension as a complication may, potentially, be an underlying cause of Hypotension. Our database lists the following as having Hypotension as a complication of that condition:

Hypotension as a symptom:

Conditions listing Hypotension as a symptom may also be potential underlying causes of Hypotension. Our database lists the following as having Hypotension as a symptom of that condition:

Medications or substances causing Hypotension:

The following drugs, medications, substances or toxins are some of the possible causes of Hypotension as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

  • Urecholine
  • Duvoid
  • Myotonachol
  • Urabeth
  • Bethanechol Chloride
  • more drugs...»

See full list of 749 medications causing Hypotension


Drug interactions causing Hypotension:

When combined, certain drugs, medications, substances or toxins may react causing Hypotension as a symptom.

The list below is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

  • Prochlorperazine and propranolol reaction
  • Compazine and propranolol reaction
  • Compazine Spansule and propranolol reaction
  • Compro and propranolol reaction
  • Prazosin and alcohol interaction
  • more interactions...»

See full list of 742 drug interactions causing Hypotension

Medical news summaries relating to Hypotension:

The following medical news items are relevant to causes of Hypotension:

Related information on causes of Hypotension:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Hypotension may be found in:

Causes of Hypotension: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Hypotension.

Hypotension: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Orthostatic hypotension
    –Most common in elderly
    –May result in syncope or near-syncope upon standing
    –Decrease of more than 20 mmHg in systolic blood pressure, or a decrease of 10 mmHg in diastolic blood pressure within 2–5 minutes of standing
  • Hypotension secondary to medications is common in elderly patients (e.g., antihypertensives; vasodilators, including nitrates, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers; hypoglycemic agents; antidepressants; opiates; alcohol)
    • Volume depletion
      –Often due to hyperglycemia, dehydration, hemorrhage, occult bleeding, vomiting, diarrhea, or diuretic use
    • Autonomic failure
      –Absence of reflex-induced increase in heart rate as blood pressure is decreased
      –Often due to Parkinson's disease, cerebellar disorders, neuropathies, or Shy-Drager syndrome
    • Postprandial hypotension (within 75 minutes of eating)
      –Very common in elderly
    • Adrenal insufficiency
      –ACTH stimulation test shows inadequate increase in serum cortisol from baseline
  • Diabetic autonomic neuropathy
  • Shock
    –Cardiogenic shock
    –Septic shock
    –Neurogenic shock
    –Hemorrhagic shock
  • Anaphylaxis
  • Splenic rupture
  • Ectopic pregnancy
  • Hepatitis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Low Back Pain/Swelling: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Lumbosacral muscle strain
    –Most common etiology of low back pain
    –Most common cause of disability in adults <45 years old
    –Aggravated by movement, better with rest
  • Lumbar disc herniation
    –Especially of L4-L5 and L5-S1
    –Usually with unilateral radiation down the leg in a dermatomal pattern
    –Increased pain with sitting
    • Spinal stenosis
      –Back and bilateral buttock and thigh pain in older patients relieved by rest (pseudoclaudication)
      –Increased pain with standing
    • Sacral-iliac joint dysfunction
      –Especially in young, thin women or in pregnancy
      –Unilateral upper buttock pain, relieved with movement
    • Vertebral fracture
      –Often associated with trauma or osteoporosis
    • Spondylolisthesis
      –Especially in young athletes
    • Secondary gain (e.g., drug seeking, disability or liability issue)
    • Extraspinal causes (e.g., radiation from kidney stones)
    • Systemic causes (<1%)
      –Inflammation (e.g., ankylosing spondylitis): Morning stiffness, limited mobility
      –Infection: Osteomyelitis, abscess
      –Abdominal aortic aneurysm
      –Cancer (especially metastases from prostate, lung, colon, and breast or myeloma); constant, worsening pain, wakes up from sleep
      –Cauda equina syndrome
      –Paget's disease
    '>>

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Pulse pressure, narrowed: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Cardiac tamponade

With cardiac tamponade, a life-threatening disorder, pulse pressure narrows by 10 to 20 mm Hg. Paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds are classic. The patient may be anxious, restless, and cyanotic, with clammy skin and chest pain. He may exhibit dyspnea, tachypnea, a decreased LOC, and a weak, rapid pulse. A pericardial friction rub and hepatomegaly may also occur.

Heart failure

Narrowed pulse pressure occurs relatively late and may accompany tachypnea, palpitations, dependent edema, steady weight gain despite nausea and anorexia, chest tightness, slowed mental response, hypotension, diaphoresis, pallor, and oliguria. Assessment reveals a ventricular gallop, inspiratory crackles and, possibly, a tender, palpable liver. Later, dullness develops over the lung bases, and hemoptysis, cyanosis, marked hepatomegaly, and marked pitting edema may occur.

Shock

With anaphylactic shock, narrowed pulse pressure occurs late, preceded by a rapid, weak pulse that soon becomes uniformly absent. Within seconds or minutes after exposure to an allergen, the patient experiences hypotension, anxiety, restlessness, and feelings of doom, along with intense itching, a pounding headache and, possibly, urticaria. Other findings include dyspnea, stridor, and hoarseness; chest or throat tightness; skin flushing; nausea, abdominal cramps, and urinary incontinence; and seizures.

With cardiogenic shock, narrowed pulse pressure occurs relatively late. Typically, peripheral pulses are absent and central pulses are weak. A drop in systolic pressure to 30 mm Hg below baseline, or a sustained reading below 80 mm Hg not attributable to medication, produces poor tissue perfusion. Poor perfusion produces tachycardia; tachypnea; cold, pale, clammy skin; cyanosis; oliguria; restlessness; confusion; and obtundation.

With hypovolemic shock, narrowed pulse pressure occurs as a late sign. All peripheral pulses become first weak and then uniformly absent. Deepening shock leads to hypotension, urine output of less than 25 ml/hour, confusion, a decreased LOC and, possibly, hypothermia.

With septic shock, narrowed pulse pressure is a relatively late sign. All peripheral pulses become first weak and then uniformly absent. As shock progresses, the patient exhibits oliguria, thirst, anxiety, restlessness, confusion, and hypotension. Extremities become cool and cyanotic; the skin becomes cold and clammy. In time, he develops severe hypotension, persistent oliguria or anuria, respiratory failure, and coma.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pulse pressure, widened: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Aortic insufficiency

With acute aortic insufficiency, pulse pressure widens progressively as the valve deteriorates, and a bounding pulse and an atrial or a ventricular gallop develop. These signs may be accompanied by chest pain; palpitations; pallor; strong, abrupt carotid pulsations; pulsus bisferiens; and signs of heart failure, such as crackles, dyspnea, and jugular vein distention. Auscultation may reveal several murmurs, such as an early diastolic murmur (common) and an apical diastolic rumble (Austin Flint murmur).

Arteriosclerosis

With arteriosclerosis, reduced arterial compliance causes progressive widening of pulse pressure, which becomes permanent without treatment of the underlying disorder. This sign is preceded by moderate hypertension and accompanied by signs of vascular insufficiency, such as claudication, angina, and speech and vision disturbances.

Febrile disorder

A fever can cause widened pulse pressure. Accompanying symptoms vary depending on the specific disorder.

Increased ICP

Widening pulse pressure is an intermediate to late sign of increased ICP. Although a decreased LOC is the earliest and most sensitive indicator of this life-threatening condition, the onset and progression of widening pulse pressure also parallel rising ICP. (A gap of 50 mm Hg can signal a rapid deterioration in the patient’s condition.) Assessment reveals Cushing’s triad: bradycardia, hypertension, and respiratory pattern changes. Other findings include a headache, vomiting, and impaired or unequal motor movement. The patient may also exhibit vision disturbances, such as blurring or photophobia, and pupillary changes.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pulse, absent or weak: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Aortic aneurysm (dissecting)

When a dissecting aneurysm affects circulation to the innominate, left common carotid, subclavian, or femoral artery, it causes weak or absent arterial pulses distal to the affected area. Absent or diminished pulses occur in 50% of patients with proximal dissection and usually involve the brachiocephalic vessels. Pulse deficits are much less common in patients with distal dissection and tend to involve the left subclavian and femoral arteries. Tearing pain usually develops suddenly in the chest and neck and may radiate to the upper and lower back and abdomen. Other findings include syncope, loss of consciousness, weakness or transient paralysis of the legs or arms, the diastolic murmur of aortic insufficiency, systemic hypotension, and mottled skin below the waist.

Aortic arch syndrome (Takayasu’s arteritis)

Aortic arch syndrome produces weak or abruptly absent carotid pulses and unequal or absent radial pulses. These signs are usually preceded by malaise, night sweats, pallor, nausea, anorexia, weight loss, arthralgia, and Raynaud’s phenomenon. Other findings include neck, shoulder, and chest pain; paresthesia; intermittent claudication; bruits; vision disturbances; dizziness; and syncope. If the carotid artery is involved, diplopia and transient blindness may occur.

Aortic bifurcation occlusion (acute)

Aortic bifurcation occlusion is a rare disorder that produces abrupt absence of all leg pulses. The patient reports moderate to severe pain in the legs and, less commonly, in the abdomen, lumbosacral area, or perineum. Also, his legs are cold, pale, numb, and flaccid.

Aortic stenosis

With aortic stenosis, the carotid pulse is sustained but weak. Dyspnea (especially on exertion or paroxysmal nocturnal), chest pain, and syncope dominate the clinical picture. The patient commonly has an atrial gallop. Other findings include a harsh systolic ejection murmur, crackles, palpitations, fatigue, and narrowed pulse pressure.

Arrhythmias

Cardiac arrhythmias may produce generalized weak pulses accompanied by cool, clammy skin. Other findings reflect the arrhythmia’s severity and may include hypotension, chest pain, dyspnea, dizziness, and a decreased level of consciousness (LOC).

Arterial occlusion

With acute occlusion, arterial pulses distal to the obstruction are unilaterally weak and then absent. The affected limb is cool, pale, and cyanotic, with an increased capillary refill time, and the patient complains of moderate to severe pain and paresthesia. A line of color and temperature demarcation develops at the level of obstruction. Varying degrees of limb paralysis may also occur, along with intense intermittent claudication. With chronic occlusion, occurring with disorders such as arteriosclerosis and Buerger’s disease, pulses in the affected limb weaken gradually.

Cardiac tamponade

Life-threatening cardiac tamponade causes a weak, rapid pulse accompanied by these classic findings: paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds. Narrowed pulse pressure, pericardial friction rub, and hepatomegaly may also occur. The patient may appear anxious, restless, and cyanotic and may have chest pain, clammy skin, dyspnea, and tachypnea.

Coarctation of the aorta

Findings of coarctation of the aorta include bounding pulses in the arms and neck, with decreased pulsations and systolic pulse pressure in the lower extremities.

Peripheral vascular disease

Peripheral vascular disease causes a weakening and loss of peripheral pulses. The patient complains of aching pain distal to the occlusion that worsens with exercise and abates with rest. The skin feels cool and shows decreased hair growth. Impotence may occur in male patients with occlusion in the descending aorta or femoral areas.

Pulmonary embolism

Pulmonary embolism causes a generalized weak, rapid pulse. It may also cause an abrupt onset of chest pain, tachycardia, dyspnea, apprehension, syncope, diaphoresis, and cyanosis. Acute respiratory findings include tachypnea, dyspnea, decreased breath sounds, crackles, a pleural friction rub, and a cough — possibly with blood-tinged sputum.

Shock

With anaphylactic shock, pulses become rapid and weak and then uniformly absent within seconds or minutes after exposure to an allergen. This is preceded by hypotension, anxiety, restlessness, feelings of doom, intense itching, a pounding headache and, possibly, urticaria.

With cardiogenic shock, peripheral pulses are absent and central pulses are weak, depending on the degree of vascular collapse. Pulse pressure is narrow. A drop in systolic blood pressure to 30 mm Hg below baseline, or a sustained reading below 80 mm Hg, produces poor tissue perfusion. Resulting signs include cold, pale, clammy skin; tachycardia; rapid, shallow respirations; oliguria; restlessness; confusion; and obtundation.

With hypovolemic shock, all pulses in the extremities become weak and then uniformly absent, depending on the severity of hypovolemia. As shock progresses, remaining pulses become thready and more rapid. Early signs of cardiogenic shock include restlessness, thirst, tachypnea, and cool, pale skin. Late signs include hypotension with narrowing pulse pressure, clammy skin, a drop in urine output to less than
25 ml/hour, confusion, a decreased LOC and, possibly, hypothermia.

With septic shock, all pulses in the extremities first become weak. Depending on the degree of vascular collapse, pulses may then become uniformly absent. Shock is heralded by chills, a sudden fever and, possibly, nausea, vomiting, and diarrhea. Typically, the patient experiences tachycardia, tachypnea, and flushed, warm, and dry skin. As shock progresses, he develops thirst, hypotension, anxiety, restlessness, and confusion. Then pulse pressure narrows and the skin becomes cold, clammy, and cyanotic. The patient experiences severe hypotension, oliguria or anuria, respiratory failure, and coma.

Thoracic outlet syndrome

A patient with thoracic outlet syndrome may develop gradual or abrupt weakness or loss of the pulses in the arms, depending on how quickly vessels in the neck compress. These pulse changes commonly occur after the patient works with his hands above his shoulders, lifts a weight, or abducts his arm. Paresthesia and pain occur along the ulnar distribution of the arm and disappear as soon as the patient returns his arm to a neutral position. The patient may also have asymmetrical blood pressure and cool, pale skin.

Other causes

Treatments

Localized absent pulse may occur distal to arteriovenous shunts for dialysis.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pulsus paradoxus: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Cardiac tamponade

Pulsus paradoxus commonly occurs with cardiac tamponade, but it may be difficult to detect if intrapericardial pressure rises abruptly and profound hypotension occurs. With severe tamponade, assessment also reveals these classic findings: hypotension, diminished or muffled heart sounds, and jugular vein distention. Related findings include chest pain, a pericardial friction rub, narrowed pulse pressure, anxiety, restlessness, clammy skin, and hepatomegaly. Characteristic respiratory signs and symptoms include dyspnea, tachypnea, and cyanosis; the patient typically sits up and leans forward to facilitate breathing.

If cardiac tamponade develops gradually, pulsus paradoxus may be accompanied by weakness, anorexia, and weight loss. The patient may also report chest pain, but he won’t have muffled heart sounds or severe hypotension.

Chronic obstructive pulmonary disease (COPD)

The wide fluctuations in intrathoracic pressure that characterize COPD produce pulsus paradoxus and possibly tachycardia. Other findings vary, but may include dyspnea, tachypnea, wheezing, a productive or nonproductive cough, accessory muscle use, barrel chest, and clubbing. The patient may show labored, pursed-lip breathing after exertion or even at rest. He typically sits up and leans forward to facilitate breathing. Auscultation reveals decreased breath sounds, rhonchi, and crackles. Weight loss, cyanosis, and edema may occur.

Pericarditis (chronic constrictive)

Pulsus paradoxus can occur in up to 50% of patients with pericarditis. Other findings include a pericardial friction rub, chest pain, exertional dyspnea, orthopnea, hepatomegaly, and ascites. Patients also exhibit peripheral edema and Kussmaul’s sign — jugular vein distention that becomes more prominent on inspiration.

Pulmonary embolism (massive)

Decreased left ventricular filling and stroke volume in massive pulmonary embolism produce pulsus paradoxus as well as syncope and severe apprehension, dyspnea, tachypnea, and pleuritic chest pain. The patient appears cyanotic, with jugular vein distention. He may succumb to circulatory collapse, with hypotension and a weak, rapid pulse. Pulmonary infarction may produce hemoptysis along with decreased breath sounds and a pleural friction rub over the affected area.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Orthostatic hypotension [Postural hypotension]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Adrenal insufficiency

Adrenal insufficiency typically begins insidiously, with progressively severe signs and symptoms. Orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation — bronze coloring of the skin — which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, a decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing and cravings for salty food.

Alcoholism

Chronic alcoholism can lead to the development of peripheral neuropathy, which can present as orthostatic hypotension. Impotence is also a major issue in these patients. Other symptoms include numbness, tingling, nausea, vomiting, changes in bowel habits, and bizarre behavior.

Amyloidosis

Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and a cough.

Hyperaldosteronism

Hyperaldosteronism typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, a headache, paresthesia and, possibly, tetany with positive Trousseau’s and Chvostek’s signs. The patient may also exhibit vision disturbances, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.

Hyponatremia

In hyponatremia, orthostatic hypotension is typically accompanied by a headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and a decreased LOC. Cyanosis, a thready pulse and, eventually, vasomotor collapse may occur in a severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and the use of thiazide diuretics.

Hypovolemia

Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.

Other causes

Drugs

Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or depressing the sympathetic nervous system. These drugs include antihypertensives (especially guanethidine monosulfate and the initial dosage of prazosin hydrochloride), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium tosylate, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.

Treatments

Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Blood pressure decrease [Hypotension]: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Acute adrenal insufficiency. Orthostatic hypotension is characteristic with acute adrenal insufficiency, accompanied by fatigue, weakness, nausea, vomiting, abdominal discomfort, weight loss, fever, and tachycardia. The patient may also have hyperpigmentation of fingers, nails, nipples, scars, and body folds; pale, cool, clammy skin; restlessness; decreased urine output; tachypnea; and coma.

❑ Alcohol toxicity. Low blood pressure occurs infrequently; more commonly, alcohol toxicity produces distinct alcohol breath odor, tachycardia, bradypnea, hypothermia, a decreased LOC, seizures, a staggering gait, nausea, vomiting, diuresis, and slow, stertorous breathing.

❑ Anaphylactic shock. Following exposure to an allergen, such as penicillin or insect venom, a dramatic fall in blood pressure and narrowed pulse pressure signal anaphylactic reaction. Initially, anaphylactic shock causes anxiety, restlessness, a feeling of doom, intense itching (especially of the hands and feet), and pounding headache. Later, it may also produce weakness, sweating, nasal congestion, coughing, difficulty breathing, nausea, abdominal cramps, involuntary defecation, seizures, flushing, change or loss of voice due to laryngeal edema, urinary incontinence, and tachycardia.

❑ Anthrax (inhalation). Anthrax is an acute infectious disease that's caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in the cutaneous, inhalation, or GI form.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

❑ Cardiac arrhythmias. With an arrhythmia, blood pressure may fluctuate between normal and low readings. Dizziness, chest pain, difficulty breathing, light-headedness, weakness, fatigue, and palpitations may also occur. Auscultation typically reveals an irregular rhythm and a pulse rate greater than 100 beats/minute or less than 60 beats/minute.

❑ Cardiac contusion. With cardiac contusion, low blood pressure occurs along with tachycardia and, at times, anginal pain and dyspnea.

❑ Cardiac tamponade. An accentuated fall in systolic pressure (more than 10 mm Hg) during inspiration, known as paradoxical pulse, is characteristic in patients with cardiac tamponade. This disorder also causes restlessness, cyanosis, tachycardia, jugular vein distention, muffled heart sounds, dyspnea, and Kussmaul's sign (increased venous distention with inspiration).

❑ Cardiogenic shock. A fall in systolic pressure to less than 80 mm Hg or to 30 mm Hg less than the patient's baseline because of decreased cardiac contractility is characteristic in patients with cardiogenic shock. Accompanying low blood pressure are tachycardia, narrowed pulse pressure, diminished Korotkoff sounds, peripheral cyanosis, and pale, cool, clammy skin. Cardiogenic shock also causes restlessness and anxiety, which may progress to disorientation and confusion. Associated signs and symptoms include angina, dyspnea, jugular vein distention, oliguria, ventricular gallop, tachypnea, and a weak, rapid pulse.

❑ Cholera. This acute infection, caused by the bacterium Vibrio cholerae, may be mild with uncomplicated diarrhea or severe and life-threatening. Cholera is spread by ingesting contaminated water or food, especially shellfish. Signs include abrupt watery diarrhea and vomiting. Severe fluid and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

❑ Diabetic ketoacidosis. Hypovolemia triggered by osmotic diuresis in hyperglycemia is responsible for the low blood pressure associated with diabetic ketoacidosis, which is usually present in patients with type 1 diabetes mellitus. It also commonly produces polydipsia, polyuria, polyphagia, dehydration, weight loss, abdominal pain, nausea, vomiting, breath with fruity odor, Kussmaul's respirations, tachycardia, seizures, confusion, and stupor that may progress to coma.

❑ Heart failure. With heart failure, blood pressure may fluctuate between normal and low readings. However, a precipitous drop in blood pressure may signal cardiogenic shock. Other signs and symptoms of heart failure include exertional dyspnea, dyspnea of abrupt or gradual onset, paroxysmal nocturnal dyspnea or difficulty breathing in the supine position (orthopnea), fatigue, weight gain, pallor or cyanosis, sweating, and anxiety. Auscultation reveals ventricular gallop, tachycardia, bilateral crackles, and tachypnea. Dependent edema, jugular vein distention, increased capillary refill time, and hepatomegaly may also occur.

❑ Hyperosmolar hyperglycemic nonketotic syndrome (HHNS). HHNS, which is common in the patient with type 2 diabetes mellitus, decreases blood pressure — at times dramatically — if he loses significant fluid from diuresis due to severe hyperglycemia and hyperosmolarity. It also produces dry mouth, poor skin turgor, tachycardia, confusion progressing to coma and, occasionally, generalized tonic-clonic seizure.

❑ Hypovolemic shock. A fall in systolic pressure to less than 80 mm Hg or 30 mm Hg less than the patient's baseline, secondary to acute blood loss or dehydration, is characteristic in hypovolemic shock. Accompanying it are diminished Korotkoff sounds, a narrowed pulse pressure, and a rapid, weak, and irregular pulse. Peripheral vasoconstriction causes cyanosis of the extremities and pale, cool, clammy skin. Other signs and symptoms include oliguria, confusion, disorientation, restlessness, and anxiety.

❑ Hypoxemia. Initially, blood pressure may be normal or slightly elevated, but as hypoxemia becomes more pronounced, blood pressure drops. The patient may also display tachycardia, tachypnea, dyspnea, and confusion and may progress from stupor to coma.

❑ Myocardial infarction (MI). With MI, a life-threatening disorder, blood pressure may be low or high. However, a precipitous drop in blood pressure may signal cardiogenic shock. Associated signs and symptoms include chest pain that may radiate to the jaw, shoulder, arm, or epigastrium; dyspnea; anxiety; nausea or vomiting; sweating; and cool, pale, or cyanotic skin. Auscultation may reveal an atrial gallop, a murmur and, occasionally, an irregular pulse.

❑ Neurogenic shock. The result of sympathetic denervation due to cervical injury or anesthesia, neurogenic shock produces low blood pressure and bradycardia. However, the patient's skin remains warm and dry because of cutaneous vasodilation and sweat gland denervation. Depending on the cause of shock, there may also be motor weakness of the limbs or diaphragm.

❑ Pulmonary embolism. Pulmonary embolism causes sudden, sharp chest pain and dyspnea accompanied by a cough and, occasionally, a low-grade fever. Low blood pressure occurs with a narrowed pulse pressure and diminished Korotkoff sounds. Associated signs include tachycardia, tachypnea, a paradoxical pulse, jugular vein distention, and hemoptysis.

❑ Septicshock. Initially, septic shock produces fever and chills. Low blood pressure, tachycardia, and tachypnea may also develop early, but the patient's skin remains warm. Later, low blood pressure becomes increasingly severe — less than 80 mm Hg or 30 mm Hg less than the patient's baseline — and is accompanied by narrowed pulse pressure. Other late signs and symptoms include pale skin, cyanotic extremities, apprehension, thirst, oliguria, and coma.

❑ Vasovagal syncope.Vasovagal syncope is the transient loss or near-loss of consciousness that's characterized by low blood pressure, pallor, cold sweats, nausea, palpitations or slowed heart rate, and weakness following stressful, painful, or claustrophobic experiences.

Other causes

❑ Diagnostic tests.Diagnostic tests include the gastric acid stimulation test using histamine and X-ray studies using contrast media. The latter may trigger an allergic reaction, which causes low blood pressure.

❑ Drugs. Calcium channel blockers, diuretics, vasodilators, alpha- and beta-adrenergic blockers, general anesthetics, opioid analgesics, monoamine oxidase inhibitors, anxiolytics (such as benzodiazepines), tranquilizers, and most I.V. antiarrhythmics (especially bretylium tosylate) can cause low blood pressure.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Low birth weight: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

This section lists some fetal and placental causes of low birth weight as well as the associated signs and symptoms pres-ent in the neonate at birth.

Chromosomal aberrations

Abnormalities in the number, size, or configuration of chromosomes can cause low birth weight and possibly multiple congenital anomalies in a premature or SGA neonate

For example, a neonate with trisomy 21 (Down syndrome) may be SGA and have prominent epicanthal folds, a flat-bridged nose, a protruding tongue, palmar simian creases, muscular hypotonia, and an umbilical hernia.

Cytomegalovirus infection

Although low birth weight in cytomegalovirus infection is usually associated with premature birth, the neonate may be SGA

Assessment at birth may reveal these classic signs: petechiae and ecchymoses, jaundice, and hepatosplenomegaly, which increases for several days. The neonate may also have a high fever, lymphadenopathy, tachypnea, and dyspnea, along with prolonged bleeding at puncture sites.

Placental dysfunction

Low birth weight and a wasted appearance occur in an SGA neonate

He may be symmetrically short or may appear relatively long for his low weight. Additional findings reflect the underlying cause. For example, if maternal hyperparathyroidism caused placental dysfunction, the neonate may exhibit muscle jerking and twitching, carpopedal spasm, ankle clonus, vomiting, tachycardia, and tachypnea.

Rubella (congenital)

Usually, the low-birth-weight neonate with this congenital rubellais born at term but is SGA

A characteristic “blueberry muffin” rash accompanies cataracts, purpuric lesions, hepatosplenomegaly, and a large anterior fontanel

Abnormal heart sounds, if present, vary with the type of associated congenital heart defect.

Varicella (congenital)

Low birth weight is accompanied by cataracts and skin vesicles.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Pulse pressure, narrowed: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Aortic stenosis

Narrowed pulse pressure occurs late in significant stenosis. This disorder also produces an atrial or ventricular gallop; chest pain; a harsh, systolic ejection murmur; angina; dyspnea; paroxysmal nocturnal dyspnea; and syncope. Crackles, palpitations, fatigue, and diminished carotid pulses may also occur.

Cardiac tamponade

With this life-threatening disorder, pulse pressure narrows by 10 to 20 mm Hg. Paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds are classic. The patient may be anxious, restless, and cyanotic, with clammy skin and chest pain. He may exhibit dyspnea, tachypnea, decreased LOC, and a weak, rapid pulse. Pericardial friction rub and hepatomegaly may also occur.

Heart failure

Narrowed pulse pressure occurs relatively late and may accompany tachypnea, palpitations, dependent edema, steady weight gain despite nausea and anorexia, chest tightness, slowed mental response, hypotension, diaphoresis, pallor, and oliguria. Assessment reveals a ventricular gallop, inspiratory crackles and, possibly, a tender, palpable liver. Later, dullness develops over the lung bases, and hemoptysis, cyanosis, marked hepatomegaly, and marked pitting edema may occur.

Shock

With anaphylactic shock, narrowed pulse pressure occurs late, preceded by a rapid, weak pulse that soon becomes uniformly absent. Within seconds or minutes after exposure to an allergen, the patient experiences hypotension, anxiety, restlessness, and feelings of doom, along with intense itching, a pounding headache and, possibly, urticaria. Other findings include dyspnea, stridor, and hoarseness; chest or throat tightness; skin flushing; nausea, abdominal cramps, and urinary incontinence; and seizures.

With cardiogenic shock, narrowed pulse pressure occurs relatively late. Typically, peripheral pulses are absent and central pulses are weak. A drop in systolic pressure to 30 mm Hg belowbaseline, or a sustained reading below 80 mm Hg not attributable to medication, produces poor tissue perfusion. Poor perfusion produces tachycardia; tachypnea; cold, pale, clammy skin; cyanosis; oliguria; restlessness; confusion; and obtundation.

With hypovolemic shock, narrowed pulse pressure occurs as a late sign. All peripheral pulses become first weak and then uniformly absent. Deepening shock leads to hypotension, urine output of less than 25 ml/hour, confusion, decreased LOC and, possibly, hypothermia.

With septic shock, narrowed pulse pressure is a relatively late sign. All peripheral pulses become first weak and then uniformly absent. As shock progresses, the patient exhibits oliguria, thirst, anxiety, restlessness, confusion, and hypotension. Extremities become cool and cyanotic; the skin becomes cold and clammy. In time, he develops severe hypotension, persistent oliguria or anuria, respiratory failure, and coma.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pulse pressure, widened: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Aortic insufficiency

With acute aortic insufficiency, pulse pressure widens progressively as the valve deteriorates, and a bounding pulse and an atrial gallop or ventricular gallop develop. These signs may be accompanied by chest pain; palpitations; pallor; strong, abrupt carotid pulsations; pulsus bisferiens; and signs of heart failure, such as crackles, dyspnea, and jugular vein distention. Auscultation may reveal several murmurs, such as an early diastolic murmur (common) and an apical diastolic rumble (Austin Flint murmur).

Arteriosclerosis

With this disorder, reduced arterial compliance causes progressive widening of pulse pressure, which becomes permanent without treatment of the underlying disorder. This sign is preceded by moderate hypertension and accompanied by signs of vascular insufficiency, such as claudication, angina, and speech and vision disturbances.

Febrile disorders

Fever can cause widened pulse pressure. Accompanying symptoms vary depending on the specific disorder.

Increased intracranial pressure

Widening pulse pressure is an intermediate to late sign of increased ICP. Although decreased LOC is the earliest and most sensitive indicator of this life-threatening condition, the onset and progression of widening pulse pressure also parallel rising ICP. (Even a gap of only 50 mm Hg can signal a rapid deterioration in the patient’s condition.) Assessment reveals Cushing’s triad: bradycardia, hypertension, and respiratory pattern changes. Other findings include headache, vomiting, and impaired or unequal motor movement. The patient may also exhibit vision disturbances, such as blurring or photophobia, and pupillary changes.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pulse, absent or weak: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Aortic aneurysm (dissecting)

When a dissecting aneurysm affects circulation to the innominate, left common carotid, subclavian, or femoral artery, it causes weak or absent arterial pulses distal to the affected area. Absent or diminished pulses occur in 50% of patients with proximal dissection and usually involve the brachiocephalic vessels. Pulse deficits are much less common in patients with distal dissection and tend to involve the left subclavian and femoral arteries. Tearing pain usually develops suddenly in the chest and neck and may radiate to the upper and lower back and abdomen. Other findings include syncope, loss of consciousness, weakness or transient paralysis of the legs or arms, the diastolic murmur of aortic insufficiency, systemic hypotension, and mottled skin below the waist.

Aortic arch syndrome (Takayasu’s arteritis)

This syndrome produces weak or abruptly absent carotid pulses and unequal or absent radial pulses. These signs are usually preceded by malaise, night sweats, pallor, nausea, anorexia, weight loss, arthralgia, and Raynaud’s phenomenon. Other findings include neck, shoulder, and chest pain; paresthesia; intermittent claudication; bruits; vision disturbances; dizziness; and syncope. If the carotid artery is involved, diplopia and transient blindness may occur.

Aortic bifurcation occlusion (acute)

This rare disorder produces abrupt absence of all leg pulses. The patient reports moderate to severe pain in the legs and, less commonly, in the abdomen, lumbosacral area, or perineum. Also, his legs are cold, pale, numb, and flaccid.

Aortic stenosis

With this disorder, the carotid pulse is sustained but weak. Dyspnea (especially on exertion or paroxysmal nocturnal), chest pain, and syncope dominate the clinical picture. The patient commonly has an atrial gallop. Other findings include a harsh systolic ejection murmur, crackles, palpitations, fatigue, and narrowed pulse pressure.

Arrhythmias

Cardiac arrhythmias may produce generalized weak pulses accompanied by cool, clammy skin. Other findings reflect the arrhythmia’s severity and may include hypotension, chest pain, dyspnea, dizziness, and decreased level of consciousness.

Arterial occlusion

With acute occlusion, arterial pulses distal to the obstruction are unilaterally weak and then absent. The affected limb is cool, pale, and cyanotic, with increased capillary refill time, and the patient complains of moderate to severe pain and paresthesia. A line of color and temperature demarcation develops at the level of obstruction. Varying degrees of limb paralysis may also occur, along with intense intermittent claudication. With chronic occlusion, occurring with disorders such as arteriosclerosis and Buerger’s disease, pulses in the affected limb weaken gradually.

Cardiac tamponade

Life-threatening cardiac tamponade causes a weak, rapid pulse accompanied by these classic findings: paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds. Narrowed pulse pressure, pericardial friction rub, and hepatomegaly may also occur. The patient may appear anxious, restless, and cyanotic and may have chest pain, clammy skin, dyspnea, and tachypnea.

Coarctation of the aorta

Findings of this disorder include bounding pulses in the arms and neck, with decreased pulsations and systolic pulse pressure in the lower extremities.

Peripheral vascular disease

This disorder causes a weakening and loss of peripheral pulses. The patient complains of aching pain distal to the occlusion that worsens with exercise and abates with rest. The skin feels cool and shows decreased hair growth. Impotence may occur in male patients with occlusion in the descending aorta or femoral areas.

Pulmonary embolism

This disorder causes a generalized weak, rapid pulse. It may also cause abrupt onset of chest pain, tachycardia, dyspnea, apprehension, syncope, diaphoresis, and cyanosis. Acute respiratory findings include tachypnea, dyspnea, decreased breath sounds, crackles, a pleural friction rub, and a cough—possibly with blood-tinged sputum.

Shock

With anaphylactic shock, pulses become rapid and weak and then uniformly absent within seconds or minutes after exposure to an allergen. This is preceded by hypotension, anxiety, restlessness, feelings of doom, intense itching, a pounding headache and, possibly, urticaria.

With cardiogenic shock, peripheral pulses are absent and central pulses are weak, depending on the degree of vascular collapse. Pulse pressure is narrow. A drop in systolic blood pressure to 30 mm Hg below baseline, or a sustained reading below 80 mm Hg, produces poor tissue perfusion. Resulting signs include cold, pale, clammy skin; tachycardia; rapid, shallow respirations; oliguria; restlessness; confusion; and obtundation.

With hypovolemic shock, all pulses in the extremities become weak and then uniformly absent, depending on the severity of hypovolemia. As shock progresses, remaining pulses become thready and more rapid. Early signs of cardiogenic shock include restlessness, thirst, tachypnea, and cool, pale skin. Late signs include hypotension with narrowing pulse pressure, clammy skin, a drop in urine output to less than 25 ml/hour, confusion, decreased level of consciousness and, possibly, hypothermia.

With septic shock, all pulses in the extremities first become weak. Depending on the degree of vascular collapse, pulses may then become uniformly absent. Shock is heralded by chills, sudden fever and, possibly, nausea, vomiting, and diarrhea. Typically, the patient experiences tachycardia, tachypnea, and flushed, warm, and dry skin. As shock progresses, he develops thirst, hypotension, anxiety, restlessness, and confusion. Then pulse pressure narrows and the skin becomes cold, clammy, and cyanotic. The patient experiences severe hypotension, oliguria or anuria, respiratory failure, and coma.

Thoracic outlet syndrome

A patient with this syndrome may develop gradual or abrupt weakness or loss of the pulses in the arms, depending on how quickly vessels in the neck compress. These pulse changes commonly occur after the patient works with his hands above his shoulders, lifts a weight, or abducts his arm. Paresthesia and pain occur along the ulnar distribution of the arm and disappear as soon as the patient returns his arm to a neutral position. The patient may also have asymmetrical blood pressure and cool, pale skin.

Other causes

Treatments

Localized absent pulse may occur distal to arteriovenous shuntsfor dialysis.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Pulsus paradoxus: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Cardiac tamponade

Pulsus paradoxus commonly occurs with this disorder, but it may be difficult to detect if intrapericardial pressure rises abruptly and profound hypotension occurs. With severe tamponade, assessment also reveals these classic findings: hypotension, diminished or muffled heart sounds, and jugular vein distention. Related findings include chest pain, pericardial friction rub, narrowed pulse pressure, anxiety, restlessness, clammy skin, and hepatomegaly. Characteristic respiratory signs and symptoms include dyspnea, tachypnea, and cyanosis; the patient typically sits up and leans forward to facilitate breathing.

If cardiac tamponade develops gradually, pulsus paradoxus may be accompanied by weakness, anorexia, and weight loss. The patient may also report chest pain, but he won’t have muffled heart sounds or severe hypotension.

Chronic obstructive pulmonary disease (COPD)

The wide fluctuations in intrathoracic pressure that characterize this disorder produce pulsus paradoxus and possibly tachycardia. Other findings vary but may include dyspnea, tachypnea, wheezing, productive or nonproductive cough, accessory muscle use, barrel chest, and clubbing. The patient may show labored, pursed-lip breathing after exertion or even at rest. He typically sits up and leans forward to facilitate breathing. Auscultation reveals decreased breath sounds, rhonchi, and crackles. Weight loss, cyanosis, and edema may occur.

Pericarditis (chronic constrictive)

Pulsus paradoxus can occur in up to 50% of patients with this disorder. Other findings include pericardial friction rub, chest pain, exertional dyspnea, orthopnea, hepatomegaly, and ascites. The patient also exhibits peripheral edema and Kussmaul’s sign—jugular vein distention that becomes more prominent on inspiration.

Pulmonary embolism (massive)

Decreased left ventricular filling and stroke volume in massive pulmonary embolism produce pulsus paradoxus, as well as syncope and severe apprehension, dyspnea, tachypnea, and pleuritic chest pain. The patient appears cyanotic, with jugular vein distention. He may succumb to circulatory collapse, with hypotension and a weak, rapid pulse. Pulmonary infarction may produce hemoptysis along with decreased breath sounds and a pleural friction rub over the affected area.

Right ventricular infarction

This infarction may produce pulsus paradoxus and elevated jugular venous or central venous pressure. Other findings are similar to those of myocardial infarction.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Orthostatic hypotension [Postural hypotension]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Adrenal insufficiency

This disorder typically begins insidiously, with progressively severe signs and symptoms. Orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation—bronze coloring of the skin—which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing, and cravings for salty food.

Alcoholism

Chronic alcoholism can lead to the development of peripheral neuropathy, which can present as orthostatic hypotension. Impotence is also a major issue in these patients. Other symptoms include numbness, tingling, nausea, vomiting, changes in bowel habits, and bizarre behavior.

Amyloidosis

Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and cough.

Diabetic autonomic neuropathy

Here, orthostatic hypotension may be accompanied by syncope, dysphagia, constipation or diarrhea, painless bladder distention with overflow incontinence, impotence, and retrograde ejaculation.

Hyperaldosteronism

This disorder typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, headache, paresthesia and, possibly, tetany with positive Trousseau’s and Chvostek’s signs. The patient may also exhibit visual disturbance, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.

Hyponatremia

In this disorder, orthostatic hypotension is typically accompanied by headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and decreased LOC. Cyanosis, thready pulse, and eventually vasomotor collapse may occur in severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and use of thiazide diuretics.

Hypovolemia

Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.

Pheochromocytoma

Although this disorder may produce orthostatic hypotension, its cardinal sign is paroxysmal or sustained hypertension. Typically, the patient is pale or flushed and diaphoretic, and his extreme anxiety makes him appear panicky. Associated signs and symptoms include tachycardia, palpitations, chest and abdominal pain, paresthesia, tremors, nausea and vomiting, low-grade fever, insomnia, and headache.

Shy-Drager syndrome

This neurodegenerative disorder is characterized by an insidious onset of multiple autonomic failure, manifested by orthostatic hypotension, urinary and fecal incontinence, decreased sweating, and impotence. This syndrome is most common in young and middle-age adults.

Other causes

Drugs

Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or depressing the sympathetic nervous system. These drugs include antihypertensives (especially the initial dosage of prazosin hydrochloride), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium tosylate, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.

Treatments

Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Blood pressure decrease [Hypotension]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Adrenal insufficiency (acute)

Orthostatic hypotension is characteristic in acute adrenal insufficiency and is accompanied by fatigue, weakness, nausea, vomiting, abdominal discomfort, weight loss, fever, and tachycardia. The patient may also have hyperpigmentation of fingers, nails, nipples, scars, and body folds; pale, cool, clammy skin; restlessness; decreased urine output; tachypnea; and coma.

Alcohol toxicity

Low blood pressure occurs infrequently in alcohol toxicity; more common signs and symptoms include a distinct alcohol breath odor, tachycardia, bradypnea, hypothermia, decreased LOC, seizures, staggering gait, nausea, vomiting, diuresis, and slow, stertorous breathing.

Anaphylactic shock

Following exposure to an allergen, such as penicillin or insect venom, a dramatic fall in blood pressure and narrowed pulse pressure signal this severe allergic reaction. Initially, anaphylactic shock causes anxiety, restlessness, a feeling of doom, intense itching (especially of the hands and feet), and a pounding headache. Later, it may also produce weakness, sweating, nasal congestion, coughing, difficulty breathing, nausea, abdominal cramps, involuntary defecation, seizures, flushing, urinary incontinence, tachycardia, and change or loss of voice due to laryngeal edema.

Anthrax, inhalation

Anthrax is an acute infectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.

Cardiac arrhythmias

In an arrhythmia, blood pressure may fluctuate between normal and low readings. Dizziness, chest pain, difficulty breathing, light-headedness, weakness, fatigue, and palpitations may also occur. Auscultation typically reveals an irregular rhythm and a pulse rate greater than 100 beats/minute or less than 60 beats/minute.

Cardiac contusion

In a cardiac contusion, low blood pressure occurs along with tachycardia and, at times, anginal pain and dyspnea.

Cardiac tamponade

An accentuated fall in systolic pressure (more than 10 mm Hg) during inspiration, known as paradoxical pulse, is characteristic in patients with cardiac tamponade. This disorder also causes restlessness, cyanosis, tachycardia, jugular vein distention, muffled heart sounds, dyspnea, and Kussmaul’s sign (increased venous distention with inspiration).

Cardiogenic shock

A fall in systolic pressure to less than 80 mm Hg, or to 30 mm Hg less than the patient’s baseline, because of decreased cardiac contractility is characteristic in patients with this disorder. Accompanying low blood pressure are tachycardia, narrowed pulse pressure, diminished Korotkoff sounds, peripheral cyanosis, and pale, cool, clammy skin. Cardiogenic shock also causes restlessness and anxiety, which may progress to disorientation and confusion. Associated signs and symptoms include angina, dyspnea, jugular vein distention, oliguria, ventricular gallop, tachypnea, and weak, rapid pulse.

Cholera

Cholera is an acute infection caused by the bacterium Vibrio cholerae that may be mild with uncomplicated diarrhea or severe and life-threatening. Cholera is spread by ingestion of contaminated water or food, especially shellfish. Signs include abrupt watery diarrhea and vomiting. Severe water and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Diabetic ketoacidosis

Hypovolemia triggered by osmotic diuresis in hyperglycemia is responsible for the low blood pressure associated with diabetic ketoacidosis, which is usually present in patients with type 1 diabetes mellitus. It also commonly produces polydipsia, polyuria, polyphagia, dehydration, weight loss, abdominal pain, nausea, vomiting, breath with fruity odor, Kussmaul’s respirations, tachycardia, seizures, confusion, and stupor that may progress to coma.

Heart failure

In heart failure, blood pressure may fluctuate between normal and low readings, but a precipitous drop in blood pressure may signal cardiogenic shock. Other signs and symptoms of heart failure include exertional dyspnea, dyspnea of abrupt or gradual onset, paroxysmal nocturnal dyspnea or difficulty breathing in the supine position (orthopnea), fatigue, weight gain, pallor or cyanosis, sweating, and anxiety. Auscultation
reveals ventricular gallop, tachycardia, bilateral crackles, and tachypnea. Dependent edema, jugular vein distention, increased capillary refill time, and hepatomegaly may also occur.

Hyperosmolar hyperglycemic nonketotic syndrome (HHNS)

HHNS, which is common in persons with type 2 diabetes mellitus, decreases blood pressure—at times dramatically, if the patient loses significant fluid from diuresis due to severe hyperglycemia and hyperosmolarity. It also produces dry mouth, poor skin turgor, tachycardia, confusion progressing to coma and, occasionally, generalized tonic-clonic seizures.

Hypovolemic shock

A fall in systolic pressure to less than 80 mm Hg, or 30 mm Hg less than the patient’s baseline, secondary to acute blood loss or dehydration is characteristic in patients with hypovolemic shock. Accompanying it are diminished Korotkoff sounds, narrowed pulse pressure, and rapid, weak, and irregular pulse. Peripheral vasoconstriction causes cyanosis of the extremities and pale, cool, clammy skin. Other signs and symptoms include oliguria, confusion, disorientation, restlessness, and anxiety.

Hypoxemia

Initially, blood pressure may be normal or slightly elevated, but as hypoxemia becomes more pronounced blood pressure drops. The patient may also display tachycardia, tachypnea, dyspnea, confusion, and stupor that may progress to coma.

Myocardial infarction

In this life-threatening disorder, blood pressure may be low or high. However, a precipitous drop in blood pressure may signal cardiogenic shock. Associated signs and symptoms include chest pain that may radiate to the jaw, shoulder, arm, or epigastrium; dyspnea; anxiety; nausea or vomiting; sweating; and cool, pale, or cyanotic skin. Auscultation may reveal an atrial gallop, a murmur and, occasionally, an irregular pulse.

Neurogenic shock

The result of sympathetic denervation due to cervical injury or anesthesia, neurogenic shock produces low blood pressure and bradycardia. However, the patient’s skin remains warm and dry because of cutaneous vasodilation and sweat gland denervation. Depending on the cause of shock, motor weakness of the limbs or diaphragm may also occur.

Pulmonary embolism

Pulmonary embolism causes sudden, sharp chest pain and dyspnea accompanied by cough and, occasionally, low-grade fever. Low blood pressure occurs with narrowed pulse pressure and diminished Korotkoff sounds. Associated signs include tachycardia, tachypnea, paradoxical pulse, jugular vein distention, and hemoptysis.

Septic Shock

Initially, septic shock produces fever and chills. Low blood pressure, tachycardia, and tachypnea may also develop early, but the patient’s skin remains warm. Later, low blood pressure becomes increasingly severe—with systolic pressure less than 80 mm Hg, or 30 mm Hg less than the baseline—and is accompanied by narrowed pulse pressure. Other late signs and symptoms include pale skin, cyanotic extremities, apprehension, thirst, oliguria, and coma.

Vasovagal syncope

Vasovagal syncope is a transient loss or near-loss of consciousness that’s characterized by low blood pressure, pallor, cold sweats, nausea, palpitations or bradycardia, and weakness following stressful, painful, or claustrophobic experiences.

Other causes

Diagnostic tests

These include the gastric acid stimulation test using histamine and X-ray studies using contrast media. The latter may trigger an allergic reaction, which causes low blood pressure.

Drugs

Calcium channel blockers, diuretics, vasodilators, alpha- and beta-adrenergic blockers, general anesthetics, opioid analgesics, monoamine oxidase inhibitors, anxiolytics (such as benzodiazepines), tranquilizers, and most I.V. antiarrhythmics (especially bretylium tosylate) can cause low blood pressure.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Low birth weight: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

This section lists some fetal and placental causes of low birth weight as well as the associated signs and symptoms present in the neonate at birth.

Chromosomal aberrations

Abnormalities in the number, size, or configuration of chromosomes can cause low birth weight and possibly multiple congenital anomalies in a premature or SGA neonate. For example, a neonate with trisomy 21 (Down syndrome) may be SGA and have prominent epicanthal folds, a flat-bridged nose, a protruding tongue, palmar simian creases, muscular hypotonia, and an umbilical hernia.

Cytomegalovirus infection

Although low birth weight in this disorder is usually associated with premature birth, some neonates may be SGA. Assessment at birth may reveal these classic signs: petechiae and ecchymoses, jaundice, and hepatosplenomegaly, which increases for several days. The neonate may also have a high fever, lymphadenopathy, tachypnea, and dyspnea, along with prolonged bleeding at puncture sites.

Placental dysfunction

Low birth weight and a wasted appearance occur in an SGA neonate. The neonate may be symmetrically short or may appear relatively long for his low weight. Additional findings reflect the underlying cause. For example, if maternal hyperparathyroidism caused placental dysfunction, the neonate may exhibit muscle jerking and twitching, carpopedal spasm, ankle clonus, vomiting, tachycardia, and tachypnea.

Rubella (congenital)

Usually, the low-birth-weight neonate with this disease is born at term but is SGA. A characteristic “blueberry muffin” rash accompanies cataracts, purpuric lesions, hepatosplenomegaly, and a large anterior fontanel. Abnormal heart sounds, if present, vary with the type of associated congenital heart defect.

Toxoplasmosis (congenital)

The low-birth-weight neonate may be either premature or SGA and may have hydrocephalus or microcephalus. Associated findings include fever, seizures, lymphadenopathy, hepatosplenomegaly, jaundice, and rash. Other defects, which may occur months or years later, include strabismus, blindness, epilepsy, and mental retardation.

Varicella (congenital)

Low birth weight is accompanied by cataracts and skin vesicles.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Orthostatic Hypotension: Differential Overview
(Field Guide to Bedside Diagnosis)

Dysautonomia

❑ Diabetes

❑ Drugs

❑ Pernicious anemia

❑ Amyloidosis

❑ Guillain-Barré syndrome

❑ Wernicke syndrome

Other

❑ Dehydration

❑ Prolonged standing

❑ Hemorrhage

❑ Thermodilation

❑ Vasovagal response

❑ Pregnancy

❑ Addison disease

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Source: Field Guide to Bedside Diagnosis, 2007

Low Back Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Musculoligamentous strain

❑ Lumbar disc herniation

❑ Osteoarthritis

❑ Compression fracture

❑ Pyelonephritis

❑ Secondary gain

❑ Scoliosis

❑ Spondylolisthesis

❑ Metastatic cancer

❑ Spinal stenosis

❑ Transverse process fracture

❑ Pancreatic cancer

❑ Ankylosing spondylitis

❑ Sacroiliitis

❑ Aortic dissection

❑ Cauda equina syndrome

❑ Vertebral osteomyelitis

❑ Epidural abscess

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Source: Field Guide to Bedside Diagnosis, 2007

Pulse pressure, widened: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Aortic insufficiency

With acute aortic insufficiency, pulse pressure widens progressively as the valve deteriorates, and a bounding pulse and an atrial or a ventricular gallop develop. These signs may be accompanied by chest pain, palpitations, pallor, pulsus bisferiens, and strong, abrupt carotid pulsations. Other signs of heart failure, such as crackles, dyspnea, and jugular vein distention, may also be present. Auscultation may reveal several murmurs, such as an early diastolic murmur (common) and an apical diastolic rumble (Austin Flint murmur).

Arteriosclerosis

With arteriosclerosis, reduced arterial compliance causes progressive widening pulse pressure, which becomes permanent without treatment of the underlying disorder. This sign is preceded by moderate hypertension and is accompanied by signs of vascular insufficiency, such as claudication, angina, and speech and vision disturbances.

Febrile disorders

Fever can cause widened pulse pressure. Accompanying symptoms vary depending on the specific disorder.

Increased ICP

Widening pulse pressure is an intermediate to late sign of increased ICP. Although a decreased LOC is the earliest and most sensitive indicator of this life-threatening condition, the onset and progression of widening pulse pressure also parallel rising ICP. (Even a gap of only 50 mm Hg can signal a rapid deterioration in the patient’s condition.) Assessment reveals Cushing’s triad: bradycardia, hypertension, and respiratory pattern changes. Other findings include headache, vomiting, and impaired or unequal motor movement. The patient may also exhibit vision disturbances, such as blurring or photophobia, and pupillary changes.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Hypotension, orthostatic: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Adrenal insufficiency

Adrenal insufficiency typically begins insidiously, with progressively severe signs and symptoms. Orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation — bronze coloring of the skin — which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing, and cravings for salty food.

Alcoholism

Chronic alcoholism can lead to the development of peripheral neuropathy, which can present as orthostatic hypotension. Impotence is also a major issue in these patients. Other symptoms include numbness, tingling, nausea, vomiting, changes in bowel habits, and bizarre behavior.

Amyloidosis

Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and cough.

Diabetic autonomic neuropathy

Here, orthostatic hypotension may be accompanied by syncope, dysphagia, constipation or diarrhea, painless bladder distention with overflow incontinence, impotence, and retrograde ejaculation.

Hyperaldosteronism

Hyperaldosteronism typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, headache, paresthesia and, possibly, tetany with positive Trousseau’s and Chvostek’s signs. The patient may also exhibit vision disturbance, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.

Hyponatremia

In hyponatremia, orthostatic hypotension is typically accompanied by headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and decreased LOC. Cyanosis, thready pulse, and eventually vasomotor collapse may occur in severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and use of thiazide diuretics.

Hypovolemia

Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.

Pheochromocytoma

Although pheochromocytoma may produce orthostatic hypotension, its cardinal sign is paroxysmal or sustained hypertension. Typically, the patient is pale or flushed and diaphoretic, and his extreme anxiety makes him appear panicky. Associated signs and symptoms include tachycardia, palpitations, chest and abdominal pain, paresthesia, tremors, nausea and vomiting, low-grade fever, insomnia, and headache.

Shy-Drager syndrome

Shy-Drager syndrome is a neurodegenerative disorder that’s characterized by an insidious onset of multiple autonomic failure, manifested by orthostatic hypotension, urinary and fecal incontinence, decreased sweating, and impotence. This syndrome is most common in young and middle-aged adults.

Other causes

Drugs

Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or depressing the sympathetic nervous system. These drugs include antihypertensives (especially guanethidine monosulfate and the initial dosage of prazosin hydrochloride), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium tosylate, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.

Medical treatments

Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Pulsus paradoxus [Paradoxical pulse]: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Cardiac tamponade

Pulsus paradoxus commonly occurs with cardiac tamponade, but it may be difficult to detect if intrapericardial pressure rises abruptly and profound hypotension occurs. With severe tamponade, assessment also reveals these classic findings: hypotension, diminished or muffled heart sounds, and jugular vein distention. Related findings include chest pain, pericardial friction rub, narrowed pulse pressure, anxiety, restlessness, clammy skin, and hepatomegaly. Characteristic respiratory signs and symptoms include dyspnea, tachypnea, and cyanosis; the patient typically sits up and leans forward to facilitate breathing.

If cardiac tamponade develops gradually, pulsus paradoxus may be accompanied by weakness, anorexia, and weight loss. The patient may also report chest pain, but he won’t have muffled heart sounds or severe hypotension.

Chronic obstructive pulmonary disease (COPD)

The wide fluctuations in intrathoracic pressure that characterize COPD produce pulsus paradoxus and possibly tachycardia. Other findings vary but may include dyspnea, tachypnea, wheezing, productive or nonproductive cough, accessory muscle use, barrel chest, and clubbing. The patient may show labored, pursed-lip breathing after exertion or even at rest. He typically sits up and leans forward to facilitate breathing. Auscultation reveals decreased breath sounds, rhonchi, and crackles. Weight loss, cyanosis, and edema may occur.

Pericarditis (chronic constrictive)

Pulsus paradoxus can occur in up to 50% of patients with chronic constrictive pericarditis. Other findings include pericardial friction rub, chest pain, exertional dyspnea, orthopnea, hepatomegaly, and ascites. Patients also exhibit peripheral edema and Kussmaul’s sign — jugular vein distention that becomes more prominent on inspiration.

Pulmonary embolism (massive)

Decreased left ventricular filling and stroke volume in massive pulmonary embolism produce pulsus paradoxus as well as syncope and severe apprehension, dyspnea, tachypnea, and pleuritic chest pain. The patient appears cyanotic, with jugular vein distention. He may succumb to circulatory collapse, with hypotension and a weak, rapid pulse. Pulmonary infarction may produce hemoptysis along with decreased breath sounds and a pleural friction rub over the affected area.

Right ventricular infarction

Infarction may produce pulsus paradoxus and elevated jugular venous or central venous pressure. Other findings are similar to those of myocardial infarction.

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Pulse pressure, narrowed: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Aortic stenosis

Narrowed pulse pressure occurs late in significant stenosis. Aortic stenosis also produces an atrial or ventricular gallop; chest pain; a harsh, systolic ejection murmur; angina; dyspnea; paroxysmal nocturnal dyspnea; and syncope. Crackles, palpitations, fatigue, and diminished carotid pulses may also occur.

Cardiac tamponade

With cardiac tamponade, a life-threatening disorder, pulse pressure narrows by 10 to 20 mm Hg. Paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds are classic. The patient may be anxious, restless, and cyanotic, with clammy skin and chest pain. He may exhibit dyspnea, tachypnea, decreased LOC, and a weak, rapid pulse. Pericardial friction rub and hepatomegaly may also occur.

Heart failure

Narrowed pulse pressure occurs relatively late in heart failure and may accompany tachypnea, palpitations, dependent edema, steady weight gain despite nausea and anorexia, chest tightness, slowed mental response, hypotension, diaphoresis, pallor, and oliguria. Assessment reveals a ventricular gallop, inspiratory crackles and, possibly, a tender, palpable liver. Later, dullness develops over the lung bases, and hemoptysis, cyanosis, marked hepatomegaly, and marked pitting edema may occur.

Shock

With anaphylactic shock, narrowed pulse pressure occurs late, preceded by a rapid, weak pulse that soon becomes uniformly absent. Within seconds or minutes after exposure to an allergen, the patient experiences hypotension, anxiety, restlessness, and feelings of doom, along with intense itching, a pounding headache and, possibly, urticaria. Other findings include dyspnea, stridor, and hoarseness; chest or throat tightness; skin flushing; nausea, abdominal cramps, and urinary incontinence; and seizures.

With cardiogenic shock, narrowed pulse pressure occurs relatively late. Typically, peripheral pulses are absent and central pulses are weak. A drop in systolic pressure to 30 mm Hg belowbaseline, or a sustained reading below 80 mm Hg not attributable to medication, produces poor tissue perfusion. Poor perfusion produces tachycardia, tachypnea, cyanosis, oliguria, restlessness, confusion, obtundation, and cold, pale, clammy skin.

With hypovolemic shock, narrowed pulse pressure occurs as a late sign. All peripheral pulses become first weak and then uniformly absent. Deepening shock leads to hypotension, urine output of less than 25 ml/hour, confusion, decreased LOC and, possibly, hypothermia.

With septic shock, narrowed pulse pressure is a relatively late sign. All peripheral pulses become first weak and then uniformly absent. As shock progresses, the patient exhibits oliguria, thirst, anxiety, restlessness, confusion, and hypotension. Extremities become cool and cyanotic; the skin becomes cold and clammy. In time, he develops severe hypotension, persistent oliguria or anuria, respiratory failure, and coma.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Pulse pressure, widened: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Aortic insufficiency

With acute aortic insufficiency, pulse pressure widens progressively as the valve deteriorates, and a bounding pulse and an atrial gallop or ventricular gallop develop. These signs may be accompanied by chest pain; palpitations; pallor; strong, abrupt carotid pulsations; pulsus bisferiens; and signs of heart failure, such as crackles, dyspnea, and jugular vein distention. Auscultation may reveal several murmurs, such as an early diastolic murmur (common) and an apical diastolic rumble (Austin Flint murmur).

Arteriosclerosis

With arteriosclerosis, pulse pressure progressively widens. This sign is preceded by moderate hypertension and is accompanied by signs of vascular insufficiency, such as claudication, angina, and speech and vision disturbances.

Febrile disorders

Fever can cause widened pulse pressure. Accompanying symptoms vary depending on the specific disorder but may include fatigue, chills, malaise, anorexia, tachycardia, tachypnea, and diaphoresis.

Increased intracranial pressure

Widening pulse pressure is an intermediate to late sign of increased ICP. Although decreased LOC is the earliest and most sensitive indicator of this life-threatening condition, the onset and progression of widening pulse pressure also parallel rising ICP. (Even a gap of only 50 mm Hg can signal a rapid deterioration in the patient’s condition.) Assessment reveals Cushing’s triad: bradycardia, hypertension, and respiratory pattern changes. Other findings include headache, vomiting, and impaired or unequal motor movement. The patient may also exhibit vision disturbances, such as blurring or photophobia, and pupillary changes.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Pulse, absent or weak: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Aortic aneurysm (dissecting)

When a dissecting aneurysm affects circulation to the innominate, left common carotid, subclavian, or femoral artery, it causes weak or absent arterial pulses distal to the affected area. Absent or diminished pulses occur in 50% of patients with proximal dissection and usually involve the brachiocephalic vessels. Pulse deficits are much less common in patients with distal dissection and tend to involve the left subclavian and femoral arteries. Tearing pain usually develops suddenly in the chest and neck and may radiate to the upper and lower back and abdomen. Other findings include syncope, loss of consciousness, weakness or transient paralysis of the legs or arms, the diastolic murmur of aortic insufficiency, systemic hypotension, and mottled skin below the waist.

Aortic stenosis

With aortic stenosis, the carotid pulse is sustained but weak. Dyspnea (especially paroxysmal dyspnea or dyspnea on exertion), chest pain, and syncope dominate the clinical picture. The patient commonly has an atrial gallop. Other findings include a harsh systolic ejection murmur, crackles, palpitations, fatigue, and narrowed pulse pressure.

Arterial occlusion

With acute occlusion, arterial pulses distal to the obstruction are unilaterally weak and then absent. The affected limb is cool, pale, and cyanotic, with increased capillary refill time, and the patient complains of moderate to severe pain and paresthesia. A line of color and temperature demarcation develops at the level of obstruction. Varying degrees of limb paralysis may also occur, along with intense intermittent claudication. With chronic occlusion, occurring with such disorders as arteriosclerosis and Buerger’s disease, pulses in the affected limb weaken gradually.

Cardiac arrhythmias

Cardiac arrhythmias may produce generalized weak pulses accompanied by cool, clammy skin. Other findings reflect the arrhythmia’s severity and may include hypotension, chest pain, dyspnea, dizziness, and decreased level of consciousness (LOC).

Cardiac tamponade

Life-threatening cardiac tamponade causes a weak, rapid pulse accompanied by these classic findings: paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds. Narrowed pulse pressure, pericardial friction rub, and hepatomegaly may also occur. The patient may appear anxious, restless, and cyanotic and may have chest pain, clammy skin, dyspnea, and tachypnea.

Coarctation of the aorta

Findings of this disorder include bounding pulses in the arms and neck, with decreased pulsations and systolic pulse pressure in the lower extremities. Auscultation may reveal a systolic ejection click at the base and apex of the heart and, occasionally, over the carotid arteries that’s often accompanied by a systolic ejection murmur at the base.

Peripheral vascular disease

Peripheral vascular disease causes a weakening and loss of peripheral pulses. The patient complains of aching pain distal to the occlusion that worsens with exercise and abates with rest. The skin feels cool and shows decreased hair growth. Impotence may occur in male patients with occlusion in the descending aorta or femoral areas.

Pulmonary embolism

A pulmonary embolism causes a generalized weak, rapid pulse. It may also cause abrupt onset of chest pain, tachycardia, dyspnea, apprehension, syncope, diaphoresis, and cyanosis. Acute respiratory findings include tachypnea, dyspnea, decreased breath sounds, crackles, a pleural friction rub, and a cough — possibly with blood-tinged sputum.

Shock

With anaphylactic shock, pulses become rapid and weak and then uniformly absent within seconds or minutes after exposure to an allergen. This is preceded by hypotension, anxiety, restlessness, feelings of doom, intense itching, a pounding headache and, possibly, urticaria.

With cardiogenic shock, peripheral pulses are absent and central pulses are weak, depending on the degree of vascular collapse. Pulse pressure is narrow. Other signs include cold, pale, clammy skin; hypotension; tachycardia; rapid, shallow respirations; oliguria; restlessness; confusion; and obtundation.

With hypovolemic shock, all peripheral pulses become weak and then uniformly absent, depending on the severity of hypovolemia. As shock progresses, remaining pulses become thready and more rapid. Early signs of hypovolemic shock include restlessness, thirst, tachypnea, and cool, pale skin. Late signs include hypotension with narrowing pulse pressure, clammy skin, a drop in urine output to less than 25 ml/hour, confusion, decreased LOC and, possibly, hypothermia.

With septic shock, all pulses in the extremities first become weak. Depending on the degree of vascular collapse, pulses may then become uniformly absent. Shock is heralded by chills, sudden fever and, possibly, nausea, vomiting, and diarrhea. Typically, the patient experiences tachycardia, tachypnea, and flushed, warm, and dry skin. As shock progresses, he develops thirst, hypotension, anxiety, restlessness, and confusion. Then pulse pressure narrows, and the skin becomes cold, clammy, and cyanotic. The patient experiences severe hypotension, oliguria or anuria, respiratory failure, and coma.

Thoracic outlet syndrome

In thoracic outlet syndrome, the patient may develop gradual or abrupt weakness or loss of the pulses in the arms, depending on how quickly vessels in the neck compress. These pulse changes commonly occur after the patient works with his hands above his shoulders, lifts a weight, or abducts his arm. Paresthesia and pain occur along the ulnar distribution of the arm and disappear as soon as the patient returns his arm to a neutral position. The patient may also have asymmetrical blood pressure and cool, pale skin.

Other causes

Treatments

Localized absent pulse may occur distal to arteriovenous shuntsfor dialysis.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Pulsus paradoxus: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Cardiac tamponade

Pulsus paradoxus commonly occurs with cardiac tamponade, but it may be difficult to detect if intrapericardial pressure rises abruptly and profound hypotension occurs. With severe tamponade, assessment also reveals these classic findings: hypotension, diminished or muffled heart sounds, and jugular vein distention. Related findings include chest pain, pericardial friction rub, narrowed pulse pressure, anxiety, restlessness, clammy skin, and hepatomegaly. Characteristic respiratory signs and symptoms include dyspnea, tachypnea, and cyanosis; the patient typically sits up and leans forward to facilitate breathing.

If cardiac tamponade develops gradually, pulsus paradoxus may be accompanied by weakness, anorexia, and weight loss. The patient may also report chest pain, but he won’t have muffled heart sounds or severe hypotension.

Chronic obstructive pulmonary disease

The wide fluctuations in intrathoracic pressure that characterize chronic obstructive pulmonary disease (COPD) produce pulsus paradoxus and possibly tachycardia. Other findings vary but may include dyspnea, tachypnea, wheezing, productive or nonproductive cough, accessory muscle use, barrel chest, and clubbing. The patient may show labored, pursed-lip breathing after exertion or even at rest. Auscultation reveals decreased breath sounds, rhonchi, and crackles. Weight loss, cyanosis, and edema may occur.

Pericarditis (chronic constrictive)

Pulsus paradoxus can occur in up to 50% of patients with chronic constrictive pericarditis. Other findings include pericardial friction rub, chest pain, exertional dyspnea, orthopnea, hepatomegaly, and ascites. The patient also exhibits peripheral edema and Kussmaul’s sign — jugular vein distention that becomes more prominent on inspiration.

Pulmonary embolism (massive)

Decreased left ventricular filling and stroke volume in massive pulmonary embolism produce pulsus paradoxus as well as syncope and severe apprehension, dyspnea, tachypnea, and pleuritic chest pain. The patient appears cyanotic, with jugular vein distention. He may succumb to circulatory collapse, with hypotension and a weak, rapid pulse. Pulmonary infarction may produce hemoptysis along with decreased breath sounds and a pleural friction rub over the affected area.

Right ventricular infarction

Right ventricular infarction may produce pulsus paradoxus and elevated jugular venous or central venous pressure. Other findings are similar to those of myocardial infarction. Signs of right-sided heart failure may occur, such as distended neck veins, hepatomegaly, and peripheral edema.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Orthostatic hypotension: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Adrenal insufficiency

In adrenal insufficiency, orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation — bronze coloring of the skin — which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing, and cravings for salty food.

Amyloidosis

Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and cough.

Diabetic autonomic neuropathy

Orthostatic hypotension may be accompanied by syncope, dysphagia, constipation or diarrhea, painless bladder distention with overflow incontinence, impotence, and retrograde ejaculation.

Hyperaldosteronism

Hyperaldosteronism typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, headache, paresthesia and, possibly, tetany with positive Trousseau’s and Chvostek’s signs. The patient may also exhibit vision disturbance, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.

Hyponatremia

In hyponatremia, orthostatic hypotension is typically accompanied by headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and decreased LOC. Cyanosis, thready pulse, and eventually vasomotor collapse may occur in severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and use of thiazide diuretics.

Hypovolemia

Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.

Other causes

Drugs

Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or by depressing the sympathetic nervous system. These drugs include antihypertensives (especially guanethidine and the initial dosage of prazosin), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.

Treatments

Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Pulse pressure, narrowed: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Cardiac tamponade.In cardiac tamponade, a life-threatening disorder, pulse pressure narrows by 10 to 20 mm Hg. Paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds are classic. The patient may be anxious, restless, and cyanotic, with clammy skin and chest pain. He may exhibit dyspnea, tachypnea, decreased LOC, and a weak, rapid pulse. A pericardial friction rub and hepatomegaly may also occur.

Heart failure.Narrowed pulse pressure occurs relatively late with heart failure and may accompany tachypnea, palpitations, dependent edema, steady weight gain despite nausea and anorexia, chest tightness, slowed mental response, hypotension, diaphoresis, pallor, and oliguria. Assessment reveals a ventricular gallop, inspiratory crackles and, possibly, a tender, palpable liver. Later, dullness develops over the lung bases, and hemoptysis, cyanosis, marked hepatomegaly, and marked pitting edema may occur.

Shock.With anaphylactic shock, narrowed pulse pressure occurs late, preceded by a rapid, weak pulse that soon becomes uniformly absent. Within seconds or minutes after exposure to an allergen, the patient experiences hypotension, anxiety, restlessness, and feelings of doom, along with intense itching, a pounding headache and, possibly, urticaria. Other findings include dyspnea, stridor, and hoarseness; chest or throat tightness; skin flushing; nausea, abdominal cramps, and urinary incontinence; and seizures.

With cardiogenic shock, narrowed pulse pressure occurs relatively late. Typically, peripheral pulses are absent and central pulses are weak. A drop in systolic pressure to 30 mm Hg below baseline, or a sustained reading below 80 mm Hg not attributable to medication, produces poor tissue perfusion. Poor perfusion produces tachycardia; tachypnea; cold, pale, clammy skin; cyanosis; oliguria; restlessness; confusion; and obtundation.

With hypovolemic shock, narrowed pulse pressure occurs as a late sign. All peripheral pulses become first weak and then uniformly absent. Deepening shock leads to hypotension, urine output of less than 25 ml/hour, confusion, decreased LOC and, possibly, hypothermia.

With septic shock, narrowed pulse pressure is a relatively late sign. All peripheral pulses become first weak and then uniformly absent. As shock progresses, the patient exhibits oliguria, thirst, anxiety, restlessness, confusion, and hypotension. Extremities become cool and cyanotic; the skin becomes cold and clammy. In time, he develops severe hypotension, persistent oliguria or anuria, respiratory failure, and coma.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Pulse pressure, widened: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Aortic insufficiency.With acute aortic insufficiency, pulse pressure widens progressively as the valve deteriorates, and a bounding pulse and an atrial or a ventricular gallop develop. These signs may be accompanied by chest pain; palpitations; pallor; strong, abrupt carotid pulsations; pulsus bisferiens; and signs of heart failure, such as crackles, dyspnea, and jugular vein distention. Auscultation may reveal several murmurs, such as an early diastolic murmur (common) and an apical diastolic rumble (Austin Flint murmur).

Arteriosclerosis.With arteriosclerosis, reduced arterial compliance causes progressive widening of pulse pressure, which becomes permanent without treatment of the underlying disorder. This sign is preceded by moderate hypertension and accompanied by signs of vascular insufficiency, such as claudication and angina.

Febrile disorder.Fever can cause widened pulse pressure. Accompanying symptoms vary depending on the specific disorder causing the fever.

Increased ICP.Widening pulse pressure is an intermediate to late sign of increased ICP. Although decreased LOC is the earliest and most sensitive indicator of this life-threatening condition, the onset and progression of widening pulse pressure also parallel rising ICP. (A gap of 50 mm Hg can signal a rapid deterioration in the patient's condition.) Assessment reveals Cushing's triad: bradycardia, hypertension, and respiratory pattern changes. Other findings include headache, vomiting, and impaired or unequal motor movement. The patient may also exhibit vision disturbances, such as blurring or photophobia, and pupillary changes.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Pulse, absent or weak: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Aortic aneurysm (dissecting).When a dissecting aneurysm affects circulation to the innominate, left common carotid, subclavian, or femoral artery, it causes weak or absent arterial pulses distal to the affected area. Absent or diminished pulses occur in 50% of patients with proximal dissection and usually involve the brachiocephalic vessels. Pulse deficits are much less common in patients with distal dissection and tend to involve the left subclavian and femoral arteries. Tearing pain usually develops suddenly in the chest and neck and may radiate to the upper and lower back and abdomen. Other findings include syncope, loss of consciousness, weakness or transient paralysis of the legs or arms, the diastolic murmur of aortic insufficiency, systemic hypotension, and mottled skin below the waist.

Aortic arch syndrome (Takayasu's arteritis).Aortic arch syndrome produces weak or abruptly absent carotid pulses and unequal or absent radial pulses. These signs are usually preceded by malaise, night sweats, pallor, nausea, anorexia, weight loss, arthralgia, and Raynaud's phenomenon. Other findings include neck, shoulder, and chest pain; paresthesia; intermittent claudication; bruits; vision disturbances; dizziness; and syncope. If the carotid artery is involved, diplopia and transient blindness may occur.

Aortic bifurcation occlusion (acute).Aortic bifurcation occlusionproduces abrupt absence of all leg pulses. The patient reports moderate to severe pain in the legs and, less commonly, in the abdomen, lumbosacral area, or perineum. Also, his legs are cold, pale, numb, and flaccid.

Aortic stenosis.With aortic stenosis, the carotid pulse is sustained but weak. Dyspnea (especially on exertion or paroxysmal nocturnal), chest pain, and syncope dominate the clinical picture. The patient commonly has an atrial gallop. Other findings include a harsh systolic ejection murmur, crackles, palpitations, fatigue, and narrowed pulse pressure.

Arrhythmias.Cardiac arrhythmias may produce generalized weak pulses accompanied by cool, clammy skin. Other findings reflect the arrhythmia's severity and may include hypotension, chest pain, dyspnea, dizziness, and decreased level of consciousness (LOC).

Arterial occlusion.Withacute occlusion, arterial pulses distal to the obstruction are unilaterally weak and then absent. The affected limb is cool, pale, and cyanotic, with an increased capillary refill time, and the patient complains of moderate to severe pain and paresthesia. A line of color and temperature demarcation develops at the level of obstruction. Varying degrees of limb paralysis may also occur, along with intense intermittent claudication. With chronic occlusion, occurring with disorders such as arteriosclerosis and Buerger's disease, pulses in the affected limb weaken gradually.

Cardiac tamponade.Life-threatening cardiac tamponade causes a weak, rapid pulse accompanied by these classic findings: paradoxical pulse, jugular vein distention, hypotension, and muffled heart sounds. Narrowed pulse pressure, pericardial friction rub, and hepatomegaly may also occur. The patient may appear anxious, restless, and cyanotic and may have chest pain, clammy skin, dyspnea, and tachypnea.

Coarctation of the aorta.Findings of coarctation of the aorta include bounding pulses in the arms and neck, with decreased pulsations and systolic pulse pressure in the lower extremities.

Peripheral vascular disease.Peripheral vascular disease causes a weakening and loss of peripheral pulses. The patient complains of aching pain distal to the occlusion that worsens with exercise and abates with rest. The skin feels cool and shows decreased hair growth. Impotence may occur in male patients with occlusion in the descending aorta or femoral areas.

Pulmonary embolism.Pulmonary embolism causes a generalized weak, rapid pulse. It may also cause an abrupt onset of chest pain, tachycardia, dyspnea, apprehension, syncope, diaphoresis, and cyanosis. Acute respiratory findings include tachypnea, dyspnea, decreased breath sounds, crackles, a pleural friction rub, and a cough—possibly with blood-tinged sputum.

Shock.With anaphylactic shock, pulses become rapid and weak and then uniformly absent within seconds or minutes after exposure to an allergen. This is preceded by hypotension, anxiety, restlessness, feelings of doom, intense itching, a pounding headache and, possibly, urticaria.

With cardiogenic shock, peripheral pulses are absent and central pulses are weak, depending on the degree of vascular collapse. Pulse pressure is narrow. A drop in systolic blood pressure to 30 mm Hg below baseline, or a sustained reading below 80 mm Hg, produces poor tissue perfusion. Resulting signs include cold, pale, clammy skin; tachycardia; rapid, shallow respirations; oliguria; restlessness; confusion; and obtundation.

With hypovolemic shock, all pulses in the extremities become weak and then uniformly absent, depending on the severity of hypovolemia. As shock progresses, remaining pulses become thready and more rapid. Early signs of hypovolemic shock include restlessness, thirst, tachypnea, and cool, pale skin. Late signs include hypotension with narrowing pulse pressure, clammy skin, a drop in urine output to less than 25 ml/hour, confusion, decreased LOC and, possibly, hypothermia.

With septic shock, all pulses in the extremities first become weak. Depending on the degree of vascular collapse, pulses may then become uniformly absent. Shock is heralded by chills, a sudden fever and, possibly, nausea, vomiting, and diarrhea. Typically, the patient experiences tachycardia, tachypnea, and flushed, warm, and dry skin. As shock progresses, he develops thirst, hypotension, anxiety, restlessness, and confusion. Then pulse pressure narrows and the skin becomes cold, clammy, and cyanotic. The patient experiences severe hypotension, oliguria or anuria, respiratory failure, and coma.

Thoracic outlet syndrome.A patient with thoracic outletsyndrome may develop gradual or abrupt weakness or loss of the pulses in the arms, depending on how quickly vessels in the neck compress. These pulse changes commonly occur after the patient works with his hands above his shoulders, lifts a weight, or abducts his arm. Paresthesia and pain occur along the ulnar distribution of the arm and disappear as soon as the patient returns his arm to a neutral position. The patient may also have asymmetrical blood pressure and cool, pale skin.

Other causes

Treatments.Localized absent pulse may occur distal to arteriovenous shunts for dialysis or following orthopedic injury or repair.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Pulsus paradoxus: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Cardiac tamponade.Pulsus paradoxus commonly occurs with cardiac tamponade, but it may be difficult to detect if intrapericardial pressure rises abruptly and profound hypotension occurs. With severe tamponade, assessment also reveals these classic findings: hypotension, diminished or muffled heart sounds, and jugular vein distention. Related findings include chest pain, a pericardial friction rub, narrowed pulse pressure, anxiety, restlessness, clammy skin, and hepatomegaly. Characteristic respiratory signs and symptoms include dyspnea, tachypnea, and cyanosis; the patient typically sits up and leans forward to facilitate breathing.

If cardiac tamponade develops gradually, pulsus paradoxus may be accompanied by weakness, anorexia, and weight loss. The patient may also report chest pain, but he won't have muffled heart sounds or severe hypotension.

Chronic obstructive pulmonary disease (COPD).The wide fluctuations in intrathoracic pressure that characterize COPD produce pulsus paradoxus and possibly tachycardia. Other findings vary, but may include dyspnea, tachypnea, wheezing, a productive or nonproductive cough, accessory muscle use, barrel chest, and clubbing. The patient may show labored, pursed-lip breathing after exertion or even at rest. He typically sits up and leans forward to facilitate breathing. Auscultation reveals decreased breath sounds, rhonchi, and crackles. Weight loss, cyanosis, and edema may occur.

Pericarditis (chronic constrictive).Pulsus paradoxus can occur in up to 50% of patients with pericarditis. Other findings include a pericardial friction rub, chest pain, exertional dyspnea, orthopnea, hepatomegaly, and ascites. Patients also exhibit peripheral edema and Kussmaul's sign—jugular vein distention that becomes more prominent on inspiration.

Pulmonary embolism (massive).Decreased left ventricular filling and stroke volume with massive pulmonary embolism produce pulsus paradoxus as well as syncope and severe apprehension, dyspnea, tachypnea, and pleuritic chest pain. The patient appears cyanotic, with jugular vein distention. He may succumb to circulatory collapse, with hypotension and a weak, rapid pulse. Pulmonary infarction may produce hemoptysis along with decreased breath sounds and a pleural friction rub over the affected area.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Orthostatic hypotension [Postural hypotension]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Adrenal insufficiency.Adrenal insufficiency typically begins insidiously, with progressively severe signs and symptoms. Orthostatic hypotension may be accompanied by fatigue, muscle weakness, poor coordination, anorexia, nausea and vomiting, fasting hypoglycemia, weight loss, abdominal pain, irritability, and a weak, irregular pulse. Another common feature is hyperpigmentation—bronze coloring of the skin—which is especially prominent on the face, lips, gums, tongue, buccal mucosa, elbows, palms, knuckles, waist, and knees. Diarrhea, constipation, a decreased libido, amenorrhea, and syncope may also occur along with enhanced taste, smell, and hearing and cravings for salty food.

Alcoholism.Chronic alcoholism can lead to the development of peripheral neuropathy, which can present as orthostatic hypotension. Impotence is also a major issue in these patients. Other symptoms include numbness, tingling, nausea, vomiting, changes in bowel habits, and bizarre behavior.

Amyloidosis.Orthostatic hypotension is commonly associated with amyloid infiltration of the autonomic nerves. Associated signs and symptoms vary widely and include angina, tachycardia, dyspnea, orthopnea, fatigue, and cough.

Hyperaldosteronism.Hyperaldosteronism typically produces orthostatic hypotension with sustained elevated blood pressure. Most other clinical effects of hyperaldosteronism result from hypokalemia, which increases neuromuscular irritability and produces muscle weakness, intermittent flaccid paralysis, fatigue, headache, paresthesia and, possibly, tetany with positive Trousseau's and Chvostek's signs. The patient may also exhibit vision disturbances, nocturia, polydipsia, and personality changes. Diabetes mellitus is a common finding.

Hyponatremia.With hyponatremia, orthostatic hypotension is typically accompanied by headache, profound thirst, tachycardia, nausea and vomiting, abdominal cramps, muscle twitching and weakness, fatigue, oliguria or anuria, cold clammy skin, poor skin turgor, irritability, seizures, and decreased LOC. Cyanosis, a thready pulse and, eventually, vasomotor collapse may occur with a severe sodium deficit. Common causes include adrenal insufficiency, hypothyroidism, syndrome of inappropriate antidiuretic hormone secretion, and the use of thiazide diuretics.

Hypovolemia.Mild to moderate hypovolemia may cause orthostatic hypotension associated with apathy, fatigue, muscle weakness, anorexia, nausea, and profound thirst. The patient may also develop dizziness, oliguria, sunken eyeballs, poor skin turgor, and dry mucous membranes.

Other causes

Drugs.Certain drugs may cause orthostatic hypotension by reducing circulating blood volume, causing blood vessel dilation, or depressing the sympathetic nervous system. These drugs include antihypertensives (especially guanethidine monosulfate and the initial dosage of prazosin hydrochloride), tricyclic antidepressants, phenothiazines, levodopa, nitrates, monoamine oxidase inhibitors, morphine, bretylium tosylate, and spinal anesthesia. Large doses of diuretics can also cause orthostatic hypotension.

Treatments.Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Blood pressure, decreased [Hypotension]: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Acute adrenal insufficiency.Orthostatic hypotension is characteristic with acute adrenal insufficiency, accompanied by fatigue, weakness, nausea, vomiting, abdominal discomfort, weight loss, fever, and tachycardia. The patient may also have hyperpigmentation of fingers, nails, nipples, scars, and body folds; pale, cool, clammy skin; restlessness; decreased urine output; tachypnea; and coma.

Anaphylactic shock.Following exposure to an allergen, such as penicillin or insect venom, a dramatic fall in blood pressure and narrowed pulse pressure signal anaphylactic reaction. Initially, anaphylactic shock causes anxiety, restlessness, a feeling of doom, intense itching (especially of the hands and feet), and pounding headache. Later, it may also produce weakness, sweating, nasal congestion, coughing, difficulty breathing, nausea, abdominal cramps, involuntary defecation, seizures, flushing, change or loss of voice due to laryngeal edema, urinary incontinence, and tachycardia.

Anthrax (inhalation).Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Cardiac arrhythmias.With an arrhythmia, blood pressure may fluctuate between normal and low readings. Dizziness, chest pain, difficulty breathing, light-headedness, weakness, fatigue, and palpitations may also occur. Auscultation typically reveals an irregular rhythm and a pulse rate greater than 100 beats/ minute or less than 60 beats/minute. A life-threatening arrhythmia may cause absence of a pulse and no palpable blood pressure and requires emergency resuscitation measures.

Cardiac contusion.With cardiac contusion, low blood pressure occurs along with tachycardia and, at times, anginal pain and dyspnea.

Cardiac tamponade.An accentuated fall in systolic pressure (more than 10 mm Hg) during inspiration, known as paradoxical pulse, is characteristic in patients with cardiac tamponade. This disorder also causes restlessness, cyanosis, tachycardia, jugular vein distention, muffled heart sounds, dyspnea, and Kussmaul's sign (increased venous distention with inspiration).

Cardiogenic shock.A fall in systolic pressure to less than 80 mm Hg or to 30 mm Hg less than the patient's baseline because of decreased cardiac contractility is characteristic in patients with cardiogenic shock. Accompanying low blood pressure are tachycardia, narrowed pulse pressure, diminished Korotkoff sounds, peripheral cyanosis, and pale, cool, clammy skin. Cardiogenic shock also causes restlessness and anxiety, which may progress to disorientation and confusion. Associated signs and symptoms include angina, dyspnea, jugular vein distention, oliguria, ventricular gallop, tachypnea, and a weak, rapid pulse.

Cholera.Cholera may be mild and with uncomplicated diarrhea or severe and life-threatening. Signs include abrupt watery diarrhea and vomiting. Severe fluid and electrolyte loss leads to thirst, weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.

Diabetic ketoacidosis.Hypovolemia triggered by osmotic diuresis in hyperglycemia is responsible for the low blood pressure associated with diabetic ketoacidosis, which is usually present in patients with type 1 diabetes mellitus. It commonly produces polydipsia, polyuria, polyphagia, dehydration, weight loss, abdominal pain, nausea, vomiting, breath with fruity odor, Kussmaul's respirations, tachycardia, seizures, confusion, and stupor that may progress to coma.

Heart failure.With heart failure, blood pressure may fluctuate between normal and low readings. A precipitous drop in blood pressure may signal cardiogenic shock. Other signs and symptoms of heart failure include exertional dyspnea, dyspnea of abrupt or gradual onset, paroxysmal nocturnal dyspnea or difficulty breathing in the supine position (orthopnea), fatigue, weight gain, pallor or cyanosis, sweating, and anxiety. Auscultation reveals ventricular gallop, tachycardia, bilateral crackles, and tachypnea. Dependent edema, jugular vein distention, increased capillary refill time, and hepatomegaly may also occur.

Hyperosmolar hyperglycemic
nonketotic syndrome (HHNS).HHNS, which is common in the patient with type 2 diabetes mellitus, decreases blood pressure—at times dramatically—if he loses significant fluid from diuresis due to severe hyperglycemia and hyperosmolarity. It also produces dry mouth, poor skin turgor, tachycardia, confusion progressing to coma and, occasionally, generalized tonic-clonic seizure.

Hypovolemic shock.A fall in systolic pressure to less than 80 mm Hg or 30 mm Hg less than the patient's baseline, secondary to acute blood loss or dehydration, is characteristic in hypovolemic shock. Accompanying it are diminished Korotkoff sounds, a narrowed pulse pressure, and a rapid, weak, and irregular pulse. Peripheral vasoconstriction causes cyanosis of the extremities and pale, cool, clammy skin. Other signs and symptoms include oliguria, confusion, disorientation, restlessness, and anxiety.

Hypoxemia.Initially, blood pressure may be normal or slightly elevated, but as hypoxemia becomes more pronounced, blood pressure drops. The patient may display tachycardia, tachypnea, dyspnea, and confusion and may progress from stupor to coma.

Myocardial infarction (MI).With MI, a life-threatening disorder, blood pressure may be low or high. A precipitous drop in blood pressure may signal cardiogenic shock. Associated signs and symptoms include chest pain that may radiate to the jaw, shoulder, arm, or epigastrium; dyspnea; anxiety; nausea or vomiting; sweating; and cool, pale, or cyanotic skin. Auscultation may reveal an atrial gallop, a murmur and, occasionally, an irregular pulse.

Neurogenic shock.The result of sympathetic denervation due to cervical injury or anesthesia, neurogenic shock produces low blood pressure and bradycardia. The patient's skin remains warm and dry because of cutaneous vasodilation and sweat gland denervation. Depending on the cause of shock, there may also be motor weakness of the limbs or diaphragm.

Pulmonary embolism.Pulmonary embolism causes sudden, sharp chest pain and dyspnea accompanied by a cough and, occasionally, a low-grade fever. Low blood pressure occurs with a narrowed pulse pressure and diminished Korotkoff sounds. Associated signs include tachycardia, tachypnea, a paradoxical pulse, jugular vein distention, and hemoptysis.

Septic shock.Initially, septic shock produces fever and chills. Low blood pressure, tachycardia, and tachypnea may also develop early, but the patient's skin remains warm. Low blood pressure becomes increasingly severe—less than 80 mm Hg or 30 mm Hg less than the patient's baseline—and is accompanied by narrowed pulse pressure. Other late signs and symptoms include pale skin, cyanotic extremities, apprehension, thirst, oliguria, and coma.

Vasovagal syncope.Vasovagal syncope is the transient loss or near-loss of consciousness that's characterized by low blood pressure, pallor, cold sweats, nausea, palpitations or slowed heart rate, and weakness following stressful, painful, or claustrophobic experiences.

Other causes

Diagnostic tests.Diagnostic tests include the gastric acid stimulation test using histamine and X-ray studies using contrast media. The latter may trigger an allergic reaction, which causes low blood pressure.

Drugs.Calcium channel blockers, diuretics, vasodilators, alpha- and beta-adrenergic blockers, general anesthetics, opioid analgesics, monoamine oxidase inhibitors, anxiolytics (such as benzodiazepines), tranquilizers, and most I.V. antiarrhythmics (especially bretylium tosylate) can cause low blood pressure.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Low birth weight: Medical causes
(Nursing: Interpreting Signs and Symptoms)

This section lists some fetal and placental causes of low birth weight as well as the associated signs and symptoms present in the neonate at birth.

Chromosomal aberrations.Abnormalities in the number, size, or configuration of chromosomes can cause low birth weight and possibly multiple congenital anomalies in a premature or SGA neonate. For example, a neonate with trisomy 21 (Down syndrome) may be SGA and have prominent epicanthal folds, a flat-bridged nose, a protruding tongue, palmar simian creases, muscular hypotonia, and an umbilical hernia.

Cytomegalovirus infection.Although low birth weight in cytomegalovirus infection is usually associated with premature birth, the neonate may be SGA. Assessment at birth may reveal these classic signs: petechiae and ecchymoses, jaundice, and hepatosplenomegaly, which increases for several days. The neonate may also have a high fever, lymphadenopathy, tachypnea, and dyspnea, along with prolonged bleeding at puncture sites.

Placental dysfunction.With placental dysfunction, low birth weight and a wasted appearance occur in an SGA neonate. He may be symmetrically short or may appear relatively long for his low weight. Additional findings reflect the underlying cause. For example, if maternal hyperparathyroidism caused placental dysfunction, the neonate may exhibit muscle jerking and twitching, carpopedal spasm, ankle clonus, vomiting, tachycardia, and tachypnea.

Rubella (congenital).Usually, the low-birth-weight neonate with congenital rubella is born at term but is SGA. A characteristic “blueberry muffin” rash accompanies cataracts, purpuric lesions, hepatosplenomegaly, and a large anterior fontanel. Abnormal heart sounds, if present, vary with the type of associated congenital heart defect.

Varicella (congenital).With congenital varicella, low birth weight is accompanied by cataracts and skin vesicles.

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Source: Nursing: Interpreting Signs and Symptoms, 2007


 » Next page: Risk Factors for Hypotension

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