Additional Information
Book Details
Abstract
Presented in a useful handbook style, Top 60 Signs for Nurses: Quick reference guide for best practice care outlines the evidence base and clinical value of each clinical sign to assist with interpretation.
Each of the signs is related back to the mechanism of action along with clearly documented research to demonstrate the evidence base associated with this sign.
- Signs are ordered alphabetically within each chapter outlining a specific body system
- Extensive reference lists of up-to-date literature strengthen the authority of the content
- Clinical Pearls highlight the main signs which students and graduate nurses should look out for to help them identify conditions with which the patients present
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | cover | ||
| Inside Front Cover | ifc1 | ||
| Top 60 signs for nurses | i | ||
| Copyright Page | iv | ||
| Table Of Contents | v | ||
| Acknowledgements | vi | ||
| Preface | vi | ||
| 60 signs reviewers list | vii | ||
| Reviewers | viii | ||
| Abbreviations | x | ||
| 1 Respiratory Signs | 1 | ||
| Accessory muscle breathing | 2 | ||
| Description | 3 | ||
| Condition/s associated with | 3 | ||
| Mechanism/s | 3 | ||
| Sign value | 4 | ||
| Agonal respiration | 5 | ||
| Description | 5 | ||
| Condition/s associated with | 5 | ||
| Mechanism/s | 5 | ||
| Sign value | 5 | ||
| Apnoea | 6 | ||
| Description | 6 | ||
| Condition/s associated with | 6 | ||
| Central sleep apnoea (CSA) | 6 | ||
| Obstructive sleep apnoea (OSA) | 6 | ||
| Mechanism/s | 6 | ||
| Central sleep apnoea | 6 | ||
| Obstructive sleep apnoea | 8 | ||
| Sign value | 8 | ||
| Asymmetrical chest expansion | 9 | ||
| Description | 9 | ||
| Condition/s associated with | 9 | ||
| More common | 9 | ||
| Less common | 10 | ||
| Mechanism/s | 10 | ||
| Pneumonia, pleural effusions | 10 | ||
| Foreign body | 10 | ||
| Flail segment | 10 | ||
| Kyphoscoliosis | 11 | ||
| Unilateral diaphragm paralysis | 11 | ||
| Sign value | 11 | ||
| Barrel chest | 12 | ||
| Description | 13 | ||
| Condition/s associated with | 13 | ||
| Mechanism/s | 13 | ||
| Bradypnoea | 14 | ||
| Description | 14 | ||
| Condition/s associated with | 14 | ||
| More common | 14 | ||
| Less common | 14 | ||
| Mechanism/s | 14 | ||
| Sign value | 14 | ||
| Breath sounds: vesicular or normal | 15 | ||
| Description | 15 | ||
| Condition/s associated with | 15 | ||
| Mechanisms | 15 | ||
| Sign value | 15 | ||
| Breath sounds: bronchial | 16 | ||
| Description | 16 | ||
| Condition/s associated with | 16 | ||
| Mechanism/s | 16 | ||
| Atelectasis/collapse mechanism/s | 16 | ||
| Sign value | 16 | ||
| Breath sounds: reduced or diminished | 17 | ||
| Description | 17 | ||
| Condition/s associated with: | 17 | ||
| Mechanism/s | 17 | ||
| Emphysema/chronic obstructive pulmonary disease mechanism/s | 18 | ||
| Low flow states | 18 | ||
| Low transmission states | 18 | ||
| Sign value | 19 | ||
| Crackles (rales) | 22 | ||
| Description | 22 | ||
| Inspiratory crackles | 22 | ||
| Expiratory crackles | 22 | ||
| Condition/s associated with | 22 | ||
| Mechanism/s | 22 | ||
| Bronchiectactic crackle mechanism/s | 23 | ||
| COPD crackle mechanism/s | 23 | ||
| Pneumonia crackle mechanism/s | 23 | ||
| Sign value | 24 | ||
| Dyspnoea | 25 | ||
| Description | 25 | ||
| Condition/s associated with | 25 | ||
| General mechanism/s | 25 | ||
| Common pathways | 25 | ||
| Mechanical loading, respiratory effort and ‘corollary discharge’ | 25 | ||
| Chemoreceptors | 25 | ||
| Mechanoreceptors | 27 | ||
| Neuroventilatory dissociation | 27 | ||
| Deconditioning | 27 | ||
| COPD | 27 | ||
| Anaemia | 28 | ||
| Heart failure | 28 | ||
| Asthma | 28 | ||
| Neuromuscular disorders | 28 | ||
| Pulmonary hypertension | 28 | ||
| Primary pulmonary hypertension mechanism/s | 29 | ||
| Sign value | 29 | ||
| Grunting | 31 | ||
| Description | 31 | ||
| Condition/s associated with | 31 | ||
| More common | 31 | ||
| Less common | 31 | ||
| Mechanism/s | 31 | ||
| Sign value | 31 | ||
| Haemoptysis | 32 | ||
| Description | 32 | ||
| Condition/s associated with | 32 | ||
| More common | 32 | ||
| Less common | 32 | ||
| Mechanism/s | 32 | ||
| Cancer | 32 | ||
| Pulmonary venous hypertension | 32 | ||
| Infection | 32 | ||
| Sign value | 32 | ||
| Hyperventilation | 33 | ||
| Description | 33 | ||
| Condition/s associated with | 33 | ||
| Mechanism/s | 34 | ||
| Psychogenic | 34 | ||
| Organic causes | 34 | ||
| Respiratory disease | 34 | ||
| Pulmonary embolism | 34 | ||
| CNS disorders | 34 | ||
| Hepatic disease | 34 | ||
| Physiological causes | 35 | ||
| Metabolic acidosis | 35 | ||
| Pregnancy | 35 | ||
| Intercostal recession | 36 | ||
| Description | 36 | ||
| Condition/s associated with | 36 | ||
| Common | 36 | ||
| Mechanism/s | 36 | ||
| Sign value | 36 | ||
| Kussmaul’s breathing | 37 | ||
| Description | 37 | ||
| Condition/s associated with | 37 | ||
| More common | 37 | ||
| Less common | 37 | ||
| Mechanism/s | 38 | ||
| Sign value | 38 | ||
| Orthopnoea | 39 | ||
| Description | 39 | ||
| Condition/s associated with | 39 | ||
| Congestive heart failure mechanism/s | 40 | ||
| Bilateral diaphragm paralysis mechanism/s | 41 | ||
| COPD mechanism/s | 41 | ||
| Sign value | 42 | ||
| Percussion | 43 | ||
| Topographic percussion theory | 43 | ||
| Cage resonance theory | 43 | ||
| Percussion: dullness | 44 | ||
| Description | 44 | ||
| Condition/s associated with | 44 | ||
| Mechanism/s | 44 | ||
| Sign value | 44 | ||
| Percussion: resonance/hyper-resonance | 45 | ||
| Description | 45 | ||
| Condition/s associated with | 45 | ||
| Mechanism/s | 45 | ||
| Sign value | 45 | ||
| Platypnoea/orthodeoxia | 46 | ||
| Description | 46 | ||
| Condition/s associated with | 46 | ||
| General mechanism/s | 46 | ||
| Intracardiac shunts (e.g. patent foramen ovale) | 47 | ||
| Pneumonectomy | 48 | ||
| Pulmonary arteriovenous shunts | 48 | ||
| Hepatic | 48 | ||
| Pulmonary ventilation/perfusion (V/Q) mismatching | 49 | ||
| Sign value | 49 | ||
| Pursed-lip breathing (PLB) | 50 | ||
| Description | 50 | ||
| Condition/s associated with | 50 | ||
| Mechanism/s | 50 | ||
| Sign value | 50 | ||
| Sputum | 51 | ||
| Description | 51 | ||
| Condition/s associated with | 51 | ||
| Mechanism/s | 51 | ||
| Sign value | 51 | ||
| Stridor | 53 | ||
| Description | 53 | ||
| Condition/s associated with | 53 | ||
| More common | 53 | ||
| Less common | 53 | ||
| Mechanism/s | 53 | ||
| Characteristics of stridor | 53 | ||
| Sign value | 54 | ||
| Tachypnoea | 55 | ||
| Description | 55 | ||
| Condition/s associated with | 55 | ||
| Mechanism/s | 55 | ||
| Sign value | 56 | ||
| Tracheal tug | 57 | ||
| Description | 57 | ||
| Condition/s associated with | 57 | ||
| Most common | 57 | ||
| Less common | 57 | ||
| Mechanism/s | 57 | ||
| Tracheal tug – Campbell’s sign | 57 | ||
| Tracheal tug – Oliver’s sign | 57 | ||
| Sign value | 57 | ||
| Trepopnoea | 58 | ||
| Description | 58 | ||
| Condition/s associated with | 58 | ||
| Mechanism/s | 58 | ||
| Unilateral lung disease | 58 | ||
| Congestive heart failure | 58 | ||
| Lung tumour | 58 | ||
| Sign value | 58 | ||
| Vocal fremitus/tactile fremitus | 59 | ||
| Description | 59 | ||
| Condition/s associated with | 59 | ||
| Mechanism/s | 59 | ||
| Sign value | 59 | ||
| Vocal resonance | 60 | ||
| Description | 60 | ||
| Condition/s associated with | 60 | ||
| Mechanism/s | 60 | ||
| Sign value | 61 | ||
| Wheeze | 62 | ||
| Description | 62 | ||
| Condition/s associated with | 62 | ||
| Mechanism/s | 62 | ||
| Sign value | 62 | ||
| References | 64 | ||
| 2 Cardiovascular Signs | 70 | ||
| Apex beat (also cardiac impulse) | 71 | ||
| Description | 71 | ||
| Arterial pulse | 72 | ||
| Bradycardia | 76 | ||
| Description | 76 | ||
| Condition/s associated with | 76 | ||
| More common | 76 | ||
| Less common | 76 | ||
| Mechanism/s | 76 | ||
| Myocardial infarction | 76 | ||
| Cellular hypoxia | 76 | ||
| Sinus node disease | 77 | ||
| Heart block | 77 | ||
| Electrolyte imbalances | 77 | ||
| Haemochromatosis | 77 | ||
| Drugs | 77 | ||
| Sign value | 77 | ||
| Capillary return decreased/delayed | 78 | ||
| Description | 78 | ||
| Condition/s associated with | 78 | ||
| Mechanism/s | 78 | ||
| Dehydration mechanism/s | 78 | ||
| Decreased peripheral perfusion mechanism/s | 78 | ||
| Shocked state mechanism/s | 79 | ||
| Sign value | 79 | ||
| Cheyne–Stokes breathing | 80 | ||
| Description | 81 | ||
| Condition/s associated with | 81 | ||
| More common | 81 | ||
| Less common | 81 | ||
| Mechanism/s | 82 | ||
| Mechanism/s in congestive heart failure | 82 | ||
| Sign value | 82 | ||
| Clubbing | 83 | ||
| Description | 83 | ||
| Condition/s associated with | 83 | ||
| Mechanism/s | 83 | ||
| Sign value | 85 | ||
| Crackles (also rales) | 86 | ||
| Description | 86 | ||
| Condition/s associated with | 86 | ||
| More common | 86 | ||
| Mechanism/s | 86 | ||
| Heart failure | 86 | ||
| Other | 86 | ||
| Sign value | 86 | ||
| Cyanosis | 87 | ||
| Jugular venous pressure (JVP) | 88 | ||
| Peripheral oedema | 90 | ||
| Definition | 90 | ||
| Condition/s associated with | 90 | ||
| More common | 90 | ||
| Less common | 90 | ||
| Mechanism/s | 90 | ||
| Mechanism in heart failure | 91 | ||
| Liver disease | 92 | ||
| Nephrotic syndrome | 93 | ||
| Sign value | 94 | ||
| Skin turgor: decreased | 95 | ||
| Description | 95 | ||
| Condition/s associated with | 95 | ||
| Mechanism/s | 95 | ||
| Ehlers–Danlos syndrome mechanism | 96 | ||
| Sign value | 96 | ||
| Tachycardia (sinus) | 97 | ||
| Description | 97 | ||
| Condition/s associated with | 97 | ||
| More common | 97 | ||
| Less common | 97 | ||
| Mechanism/s | 97 | ||
| Mechanism in hyperthyroidism | 97 | ||
| Sign value | 98 | ||
| References | 99 | ||
| 3 Haematological and Oncological Signs | 101 | ||
| Ecchymoses, purpura and petechiae | 102 | ||
| Description | 102 | ||
| General mechanism/s | 103 | ||
| Thrombocytopenia | 103 | ||
| Vasculitis | 104 | ||
| Cushing’s | 104 | ||
| Mechanism of colour changes | 104 | ||
| Sign value | 104 | ||
| Lymphadenopathy | 105 | ||
| Description | 105 | ||
| Condition/s associated with | 105 | ||
| General mechanism/s | 105 | ||
| Malignancy | 105 | ||
| Infectious causes | 105 | ||
| Autoimmune | 107 | ||
| Sign value | 107 | ||
| Painful versus painless nodes | 109 | ||
| References | 110 | ||
| 4 Neurological Signs | 111 | ||
| Gag reflex | 113 | ||
| Description | 114 | ||
| Condition/s associated with | 114 | ||
| Common | 114 | ||
| Less common | 114 | ||
| Mechanism/s | 114 | ||
| Normal variant | 114 | ||
| Generalised CNS depression | 114 | ||
| Glossopharyngeal nerve lesion | 114 | ||
| Vagus nerve lesion | 115 | ||
| Lateral medullary syndrome (Wallenberg’s syndrome) | 115 | ||
| Sign value | 115 | ||
| Photophobia | 116 | ||
| Description | 116 | ||
| Condition/s associated with | 116 | ||
| Common | 116 | ||
| Less common | 116 | ||
| Mechanism/s | 116 | ||
| Inflammation of the meninges | 117 | ||
| Migraine | 117 | ||
| Corneal injury | 117 | ||
| Anterior uveitis | 117 | ||
| Sign value | 117 | ||
| Pinpoint pupils | 118 | ||
| Description | 119 | ||
| Condition/s associated with | 119 | ||
| Common | 119 | ||
| Less common | 119 | ||
| Mechanism/s | 119 | ||
| Opioid effect | 119 | ||
| Pontine haemorrhage | 119 | ||
| Cholinergic toxicity | 119 | ||
| α-2 agonist effect | 120 | ||
| Cerebral herniation with pontine compression | 120 | ||
| Beta-blocker effect | 120 | ||
| Senile miosis in normal ageing | 120 | ||
| Sign value | 120 | ||
| References | 123 | ||
| 5 Gastroenterological Signs | 124 | ||
| Ascites | 125 | ||
| Description | 125 | ||
| Condition/s associated with | 125 | ||
| Mechanism/s | 125 | ||
| Peripheral arterial vasodilatation theory | 125 | ||
| Liver disease | 126 | ||
| Congestive heart failure, Budd–Chiari syndrome | 128 | ||
| Nephrotic syndrome | 128 | ||
| Myxoedema mechanism/s | 130 | ||
| Exudative ascites | 130 | ||
| Chylous ascites | 130 | ||
| Nephrogenic – haemodialysis | 130 | ||
| Ascites clinical signs | 130 | ||
| Sign value | 130 | ||
| Bowel sounds: absent | 134 | ||
| Description | 134 | ||
| Condition/s associated with | 134 | ||
| More common | 134 | ||
| Less common | 134 | ||
| General mechanism/s | 134 | ||
| Bowel obstruction | 134 | ||
| Infection | 134 | ||
| Postoperative ileus | 134 | ||
| Hypokalaemia | 135 | ||
| Pseudo-obstruction | 135 | ||
| Bowel sounds: hyperactive (borborygmus) | 136 | ||
| Description | 136 | ||
| Condition/s associated with: | 136 | ||
| More common | 136 | ||
| Less common | 136 | ||
| Mechanism/s | 136 | ||
| Coffee ground vomiting/bloody vomitus/haematemesis | 137 | ||
| Description | 137 | ||
| Condition/s associated with | 137 | ||
| More common | 137 | ||
| Less common | 137 | ||
| General mechanism/s | 137 | ||
| Peptic ulcer disease | 137 | ||
| Mallory–Weiss tear | 137 | ||
| Oesophageal varices | 138 | ||
| Sign value | 138 | ||
| Guarding | 139 | ||
| Description | 139 | ||
| Condition/s associated with | 139 | ||
| Mechanism/s | 139 | ||
| Sign value | 139 | ||
| Haematuria | 140 | ||
| Description | 140 | ||
| Condition/s associated with | 140 | ||
| Common | 140 | ||
| Less common | 140 | ||
| Mechanism/s | 140 | ||
| Sign value | 140 | ||
| Jaundice | 142 | ||
| Description | 142 | ||
| Condition/s associated with | 142 | ||
| Mechanism/s | 142 | ||
| Pre-hepatic | 143 | ||
| Intrahepatic | 143 | ||
| Drug-induced liver injury | 143 | ||
| Post-hepatic | 146 | ||
| Sign value | 146 | ||
| Melaena | 147 | ||
| Description | 147 | ||
| Condition/s associated with | 147 | ||
| More common | 147 | ||
| Less common | 147 | ||
| Mechanism/s | 147 | ||
| Sign value | 147 | ||
| Oliguria/anuria | 148 | ||
| Description | 148 | ||
| Condition/s associated with | 148 | ||
| Mechanisms/s | 148 | ||
| Pre-renal | 148 | ||
| Renal | 149 | ||
| Post-renal | 149 | ||
| Sign value | 149 | ||
| References | 150 | ||
| 6 Endocrinological Signs | 152 | ||
| Bruising | 153 | ||
| Description | 153 | ||
| Condition/s associated with | 153 | ||
| Mechanism/s | 153 | ||
| Cushing’s syndrome | 153 | ||
| Renal failure with uraemia | 153 | ||
| Hypotension | 155 | ||
| Description | 155 | ||
| Condition/s associated with | 155 | ||
| Mechanism/s | 155 | ||
| Addison’s disease | 155 | ||
| Hypothyroidism | 155 | ||
| Sign value | 155 | ||
| Polydipsia | 158 | ||
| Description | 158 | ||
| Condition/s associated with | 158 | ||
| More common | 158 | ||
| Less common | 158 | ||
| Mechanism/s | 158 | ||
| Sjögren’s syndrome | 158 | ||
| Psychogenic polydipsia | 158 | ||
| Primary hyperaldosteronism | 158 | ||
| Polyuria | 159 | ||
| Description | 159 | ||
| Condition/s associated with | 159 | ||
| More common | 159 | ||
| Less common | 159 | ||
| Mechanism/s | 159 | ||
| Diabetes mellitus | 159 | ||
| Diabetes insipidus | 160 | ||
| Post-obstructive diuresis | 160 | ||
| Lithium | 162 | ||
| References | 163 | ||
| Figure Credits | 164 | ||
| Index | 166 | ||
| A | 166 | ||
| B | 166 | ||
| C | 167 | ||
| D | 168 | ||
| E | 168 | ||
| F | 168 | ||
| G | 168 | ||
| H | 168 | ||
| I | 169 | ||
| J | 169 | ||
| K | 169 | ||
| L | 169 | ||
| M | 169 | ||
| N | 170 | ||
| O | 170 | ||
| P | 170 | ||
| R | 171 | ||
| S | 171 | ||
| T | 172 | ||
| U | 172 | ||
| V | 172 | ||
| W | 172 |