Blood Transfusion Reactions: A Comprehensive Nursing Guide

Blood Transfusion Reactions: A Comprehensive Nursing Guide

William J. Kelly, MSN, FNP-C
William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

Blood transfusion reactions are common within the hospital setting because so many blood products are given. Transfusing blood products that are lacking or actively being lost (i.e. GI bleed) is literally life-saving treatment.

In this article, we will talk about the different blood products, why they are given, and then dive into each type of blood transfusion reaction, what causes them, their signs and symptoms, and how to manage them as the nurse.

Acute Hemolytic Transfusion Reaction

What are blood products?

There are multiple different blood products that are transfused within the hospital, and each one can have adverse reactions called blood transfusion reactions.

Packed Red Blood Cells (PRBCs)

Packed Red Blood Cells or PRBCs are given to patients when their hemoglobin levels are low. This is called anemia. Some common causes of anemia that may need a transfusion include:

  • Acute and chronic blood loss (i.e. GI Bleed)
  • Untreated ongoing Anemia (Iron-deficiency anemia)
  • Destruction of blood cells
  • Decreased production of red blood cells (i.e. Chemotherapy, aplastic anemia)

PRBCs are usually ordered when hemoglobin levels drop below 7g/dL, but it depends on the nature of the patient’s anemia as well as their medical history and their hemodynamic stability (are their vital signs normal?)

1 to 2 units will be ordered of PRBCs depending on how low the patient’s hemoglobin level is, as well as if there is active blood loss. Each unit of PRBCs should increase the hemoglobin by about 1g/dL.

Before blood products are given, a type and screen is done to verify the patient’s blood type and screen for any antibodies that may require special blood. The exception is if the patient has significant ongoing hemorrhage and the patient needs emergent blood. In this case, O Negative blood is given as they are the universal donor.

Each unit of blood will take about 2 hours to transfuse, but the maximum amount of time is 4 hours when the blood will expire. In emergencies, blood can be run as fast as needed, often with pressure bags.

Fresh Frozen Plasma (FFP)

Fresh Frozen Plasma or just Plasma is the portion of whole blood that doesn’t include the red blood cells, which contains clotting factors.

Some reasons FFP may be ordered for your patient include:

  • Massive blood transfusions
  • Severe liver disease or DIC
  • Coumadin with bleeding or surgery (in addition to Vitamin KL when Kcentra not available)
  • Factor deficiency with bleeding or surgery

In massive transfusions, you replace 1 unit of FFP for every unit of PRBCs replaced (along with 1 unit of platelets).

Platelets

Platelets are a blood product that help the body form blood clots and prevent bleeding.

These can often become low from various autoimmune disorders, cancers and chemotherapies, medication reactions, and liver disease.

Platelets are replaced when platelet levels are low, termed thrombocytopenia. Platelets are usually ordered for:

  • Active bleeding with platelet count <50,000/microL
  • Thrombocytopenia in need of invasive procedure or surgery
  • To prevent spontaneous bleeding, usually when platelet levels <10,000/microL

Most platelets that are given are obtained by “apheresis”. One apheresis unit is equal to 4-6 “pooled random donor units”. 1 unit of platelets by apheresis should increase the platelets by about 30K.

Why are Blood products Given?

Blood products are given whenever the blood levels are too low, or when there is acute bleeding. While this will depend on each specific patient and clinician, blood products are generally given when:

  • PRBCs are given when hemoglobin is below 7 or there is ongoing blood loss with hemodynamic compromise
  • Platelets are given when active bleeding with levels <50K, or when <10K.
  • FFP is given with massive blood transfusions, severe liver disease or DIC, or as a coumadin reversal option.

Blood Transfusion Reactions

As with any medication or fluid, there are possible adverse reactions that can occur and that you need to monitor for.

Because we are infusing blood products from a donor, this adds an increased risk of adverse reactions to occur.

Because of this, nurses must monitor their patients very closely during blood product transfusions. The nurse must stay with the patient the first 15 minutes of a blood transfusion (may change depending on specific facility protocol), and frequently check vital signs.

There are common blood reactions, and then there are more rare and severe reactions that can occur.

Acute Hemolytic Transfusion Reaction

An acute hemolytic transfusion reaction is a rare life-threatening blood transfusion reaction to receiving blood, specifically PRBCs.

This happens when incompatible blood is accidentally infused with the patient. This is why the patient’s blood type is checked in the first place so that an appropriate donor can be given.

Compatible blood is outlined below:

Acute Hemolytic Transfusion Reaction

When having a true acute hemolytic reaction, the patient will quickly experience:

  • Fever and/or chills
  • Severe flank pain or back pain
  • Signs of DIC (like oozing form IV site)
  • Hypotension
  • Urine turning red or brown (hemoglobinuria)

This is a severe reaction as the patient’s own immune system and the donor’s immune system attack each other, destroying blood products and causing damage in the process. The patient may experience hemodynamic instability including life-threatening hypotension.

If this reaction occurs, the nurse should:

Acute Hemolytic Reaction: Nursing Steps

If an acute hemolytic reaction is suspected, the nurse should:

  1. Stop the blood immediately and check vitals
  2. Hang NS through a patent IV line. Pt should be ordered least 100-200ml/hr to prevent oliguria/renal failure, or boluses if hypotensive
  3. Notify the MD/APP and blood bank, or call an RRT if unstable
  4. Recheck identifying tags and numbers on blood
  5. Administer diuresis as ordered in those at risk for volume overload
  6. Additional testing may include DIC testing and additional blood compatibility and screenings.
  7. Transfer the patient if required

The Provider should guide treatment, but these are serious reactions and would likely need monitoring in the ICU.

Your facility should have a specific protocol in the event of significant blood transfusion reactions, which often involves re-testing the patient as well as re-testing the blood unit itself.

Acute Hemolytic Blood Transfusion Reaction

Anaphylactic Transfusion Reaction

An anaphylactic transfusion reaction is a severe allergic reaction to something within the blood product. These are rare, with an estimated 1 in 20-50K transfusions.

This reaction occurs seconds to minutes after starting the transfusion.

The recipient is severely allergic to something within the donor blood, which they may have antibodies against, specifically those who are IgA deficient or haptoglobin deficient.

Signs of an anaphylatic reaction include:

  • Urticaria
  • Wheezing and/or Respiratory Distress
  • Angioedema (facial swelling)
  • Hypotension with/without Shock

Treatment involves immediately stopping the transfusion, and then treatment with standard anaphylactic medications. These medications include:

  • Solumedrol 125mg IV STAT
  • Benadryl 50mg IV STAT
  • PEPCID 20mg IV STAT
  • IV Fluids

More significant interventions may be needed, including:

  • Epinephrine .3mg IM STAT +/- IV epinephrine drip with severe bronchospasm or airway edema
  • Vasopressors for hypotension
  • Oxygen and Intubation

The blood cannot be restarted, and additional testing will need to be performed, and blood from another donor will have to be given.

Anaphylactic Blood Transfusion Reaction

Urticarial Transfusion Reaction

An urticarial transfusion reaction is a less severe allergic reaction to a component within the blood products, but much more common, occurring in 1-3% of blood transfusions. This is an antigen-antibody interaction, usually with donor serum proteins.

Patients with this blood transfusion reaction will develop urticaria (hives) with no other allergic signs/symptoms such as wheezing, angioedema, or hypotension.

When an urticarial transfusion reaction occurs:

  1. Immediately stop the transfusion
  2. Check Vital signs and ask the patient for other symptoms (like trouble breathing or facial/throat swelling, dizziness, chest pain, etc)
  3. Notify the Provider
  4. Give IV antihistmine as ordered
  5. Restart blood if hives resolve and no other signs of allergic reaction develop

When an urticarial transfusion reaction is diagnosed, stop the blood for 15-30 minutes, give IV antihistamine like Benadryl, and then restart the infusion once hives resolve but slowly and cautiously. Check your specific facility’s protocol.

Urticarial Blood Transfusion Reaction

Febrile Non-Hemolytic Transfusion Reaction (FNHTR)

A febrile non-hemolytic transfusion reaction is exactly what it sounds like – the patient develops a fever after/during a transfusion, but they are not experiencing other signs of a hemolytic reaction.

This is usually due to a systemic response to cytokines which developed during the process of storing the blood.

These are very common, occurring in .1-1% of all transfusions.

This fever will occur 1-6 hours after the transfusion begins.

Signs/symptoms include:

  • Fever (38-39*+ C)
  • Chills
  • Severe Rigors
  • Mild dyspnea

If the temperature is more than 39°C or 102.2°F, consider a hemolytic transfusion reaction.

Whenever there is a fever present, the main thing to consider is if this could be the first sign of a more serious transfusion reaction such as a hemolytic reaction, TRALI (see below), or Sepsis.

If there is just a fever and no other significant reaction is suspected, antipyretics should be be given, usually Acetaminophen 650-975mg PO. The transfusion can usually be continued but monitored closely.

Future transfusions should be “leukocyte reduced”, which is a process that removes most of the white blood cells within the blood.

Febrile Non-Hemolytic Blood Transfusion reaction

Transfusion-Associated Acute Lung Injury (TRALI)

Transfusion-Associated Acute Lung Injury, known as TRALI, is a rare but one of the severe blood transfusion reactions that can occur after transfusion of a blood product.

This is when the transfused product activates the recipient’s neutrophils, causing acute lung damage.

Patients at risk for TRALI include patients with:

  • Liver transplants
  • Chronic ETOH abuse
  • Smokers
  • Volume overload
  • Shock

The patient will experience sudden and severe respiratory failure during or shortly after a transfusion, but up to 6 hours after the transfusion. This is often associated with:

  • Hypoxia
  • Fever
  • Hypotension
  • Cyanosis

New bilateral infiltrates on CXR are often seen.

TRALI: Nursing Actions

When TRALI is suspected, the nurse should:

  1. Stop the transfusion immediately
  2. Check vitals and ask patient their symptoms
  3. Call an Rapid Response if the patient is in respiratory distress and/or hypoxic/hypotensive (or notify Provider in ED/ICU).
  4. Support oxygen status (oxygen, intubation if needed)
  5. Support blood pressure (fluid boluses, vasopressors if needed)
  6. Notify the Blood Bank
  7. Obtain a Stat portable CXR
  8. Follow any additional orders / administer any additional medications

Sometimes steroids are given, although evidence is not great.

These patients may need to be intubated and will likely need to be transferred to the ICU and closely monitored.

They do not seem to be at increased risk for TRALI to occur again with a different transfusion in the future, however, donors who are implicated are banned from donating ever again.

TRALI

Transfusion-Associated Sepsis

Transfusion-Associated Sepsis is a life-threatening blood transfusion reaction that can occur with the administration of contaminated blood products which are infected with bacteria.

The patient will start developing signs or symptoms within 5 hours after the infusion, but usually around 30 minutes.

Signs/Symptoms of transfusion-associated sepsis includes:

  • Fever >39ºC or 102.2ºF, sometimes hypothermia
  • Rigors
  • Tachycardia >120bpm or >40bpm above baseline
  • Rise or fall of systolic BP 30mmHg
  • Abdominal pain or back pain
  • Nausea and vomiting

Remember that Transfusion-associated Sepsis, Acute Transfusion Hemolytic Reaction, and TRALI can all have similar symptoms.

SEPSIS: Nursing Actions

If transfusion-associated sepsis is suspected, the nurse should:

  1. Stop the transfusion immediately
  2. Check vitals and quickly assess the patient
  3. Notify the Provider (Call an RRT if patient unstable)
  4. Support oxygen and hemodynamic status with oxygen, fluids, etc
  5. Obtain blood work from opposite arm (blood cultures, Coombs test, plastma-free hgb, and repeat crossmatch
  6. Administer ordered antibiotics ASAP (Usually Vanco/Zosyn)
  7. Notify the Blood Bank
  8. Follow any additional orders / administer any additional medications
Transfusion Associated Sepsis

Transfusion-Associated Circulatory Overload (TACO)

Transfusion-Associated circulatory overload, also known as TACO, is when the patient develops acute volume overload after administration of blood products.

This blood transfusion reaction is fairly common, occurring in up to 1% or more of transfusions. This can occur up to 12 hours after the transfusion is given, and risk factors include patients with:

  • CHF
  • End-Stage Renal Failure (i.e. on dialysis)
  • Extremes of age
  • Small stature & low body weight

The more units transfused and the quicker transfused, the higher risk of TACO (just like with IV fluids).

Patients will develop symptoms of respiratory distress which include:

  • Dyspnea
  • Tachypnea
  • Hypoxia
  • Orthopnea

The patient will also usually develop hypertension.

Remember TRALI can have similar symptoms, as well as a pulmonary embolism.

TACO: Nursing Actions

When TACO is suspected, the nurse should:

  1. Stop the transfusion immediately
  2. Check vitals and quickly assess the patient (pay attention to respiratory status and breath sounds)
  3. Notify the Provider (Call an RRT if patient unstable)
  4. Support oxygen status with supplementary oxygen, BIPAP, or intubation if needed
  5. Make sure a STAT portable CXR is ordered/performed
  6. Administer diuretics as ordered (i.e. 40mg IV Lasix)
  7. Follow any additional orders / administer any additional medications

In milder cases, the patient may just require diuretics and supplemental oxygen. More severe cases may require Bipap or intubation.

  CLINICAL TIP

It is a smart idea for the Provider to order 20mg IV Lasix in-between units when multiple units of blood are ordered in someone with a history of CHF or who is very old. If it is not ordered and you feel it may benefit the patient, offer this suggestion to the Provider as it can prevent TACO from occurring.

“Hey this is Jan calling from Med-surg, I just wanted to make sure you didn’t want any Lasix in-between blood units for Mark Smith in 147-2, as they have a history of CHF?”

TACO blood transfusion Reaction

Primary Hypotensive Reactions

Primary hypotensive reactions are very rare, but occur when there is a sudden drop in systolic blood pressure >30 mmHg within minutes of starting a transfusion.

The blood pressure normalizes once the transfusion is stopped. While rare, other severe blood transfusion reactions can also have hypotension, so the patient will need to be evaluated to rule those out as well.

Patients who take an ACE inhibitor like lisinopril are at increased risk for this to occur.

This is also more common with platelet administration.

And those are the acute blood transfusion reactions that can occur when administering blood in the hospital.

Keep in mind that there can also be transmission of infections such as HIV and hepatitis, although very rare and will not present itself during the transfusion or shortly after.

REFERENCES

Kleinman, S., & Kor, D. (2022). Transfusion-related acute lung injury (TRALI). In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-related-acute-lung-injury-trali

Silvergleid, A. (2022). Approach to the patient with a suspected acute transfusion reaction. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/approach-to-the-patient-with-a-suspected-acute-transfusion-reaction

Silvergleid, A. (2022). Immunologic transfusion reactions. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/immunologic-transfusion-reactions

Silvergleid, A. (2022). Transfusion-associated circulatory overload (TACO). In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-associated-circulatory-overload-taco

Spelman, D., & MacLaren,G. (2022). Transfusion-transmitted bacterial infection. In UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/transfusion-transmitted-bacterial-infection

18 Acute Skin Rashes for Nurses to Know (with pictures)

18 Acute Skin Rashes for Nurses to Know (with pictures)

William J. Kelly, MSN, FNP-C
William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

Skin rashes are a common reason why patients and parents seek medical care. Skin rashes can look gross and are often uncomfortable – whether they itch, burn, or cause pain.

Many causes of skin rashes are temporary, but some are chronic and can be ongoing.

Understanding the most common types of skin rashes and their treatment will be important, as you will run into skin-related problems in any setting of healthcare.

Oxygen delivery devices and flow rates FB

Skin Rashes: Taking the History

In order to successfully diagnose a skin rash, you need to know which questions to ask.

Timing is an important factor to consider. How long has the rash been there, does it come and go? Did the rash look different when it first occurred, and how has it changed? If it occurred before, what was it and what treatment worked?

Associated symptoms can be key in making the right diagnosis. Does it itch, burn, or is it painful? Are there any fevers, chills, pain anywhere else in their body?

Related activities that may have caused or worsen the rash should be investigated. This includes things like sunlight exposure, being out in the woods, using a new skin product like shampoos or lotions, or new medications or foods.

Treatments that the patient has already tried should be evaluated, which usually includes OTC creams and sometimes prescribed medications from a previous diagnosis or from another recent healthcare visit. This may be Benadryl cream, steroid cream (like hydrocortisone), moisturizers, etc.

A detailed past medical history and current medications should be evaluated as well.

Meds that are more likely to cause a rash include:

  • Antibiotics
  • Anti-epilepsy medications
  • allopurinol

The Skin Rash Physical Exam

When looking at skin rashes, they are described using various describers which have different meanings and significance.

A lesion is a general umbrella term that essentially means any non-normal “spot” or region.

Macules are lesions that are flat, <1 cm in diameter, and have different pigmentation from the base skin color. These are called patches when they are >1cm.

  • Macules: Café au Lait, freckles
  • Patches: Vitiligo

Papules are like macules, except they are raised and palpable, also <1cm, and have different coloring from the base skin color. Lesions >1cm are termed plaques. Pustules are papules with purulent fluid inside.

  • Papules: Acne, moles, warts
  • Pustule: Cystic Acne, Folliculitis
  • Plaque: Psoriasis

Purpura are red-purple discolored lesions that do not blanch. Blanching is when you press on an area of skin and it turns white from capillary compression. Purpura occurs due to leakage of blood into the extra-capillary space.

Vesicles are small papules <1cm that contains clear or bloody fluid. Bullae are bigger than 1cm.

  • Vesicles: Shingles
  • Bullae: Bullous pemphigoid

Wheals are elevated irregular-shaped areas of edema that are pale or erythematous. An example of this is urticaria like with an allergic reaction.

These lesions and skin rashes can present in certain patterns and distributions, which can also help you successfully identify the rash.

Skin rashes can be clustered in small groups, grouped together in some fashion, linear (in a line), following the dermatome (termed zosteriform), and even coalescing together. Various rashes have certain patterns which can make the diagnosis easier.

IMPORTANT DISCLAIMER!

The following images are examples of how these rashes present on white and light-skinned individuals. For examples of how these rashes may present in darker-skinned individuals, please check out @brownskinmatters on Instagram.

20 COMMON SKIN RASHES

TABLE OF CONTENTS

Allergy-Related Rashes

CONTACT DERMATITIS

Contact dermatitis is when the skin has a reaction to something that it has come into contact with. 80% of cases are caused by an irritant, and 20% are caused by allergens. Contact dermatitis is the most common dermatologic diagnosis.

Irritant contact dermatitis is very common and often occurs from exposures to heavy metals, strong acids, rubbing alcohol, and certain ingredients in soaps and lotions. Patients often complain of pain or burning with some itching.

The skin will typically look erythematous, dry, and irritated. There may be pustules present as well.

In Allergic contact dermatitis, common causes include nickel, black hair dye, topical medications, latex, and various cosmetics and environmental exposures (like poison ivy or poison oak). Allergic dermatitis tends to be itchier with less pain or burning. There may be vesicles present as well.

Treatment for these includes steroids for the reaction, and benadryl for the itching. If the lesion is smaller, a topical steroid like Triamcinolone 0.5% once daily for 2-4 weeks can be effective. If the lesion is more widespread, systemic steroids can be used like prednisone.

ALLERGIC URTICARIA

Urticaria or hives are itchy raised wheals that are often erythematous or pale. They are often a response to an allergy such as in anaphylaxis, but many cases of urticaria are non-allergic and some are idiopathic (aka we don’t know why).

Allergic urticaria occur after contact with an allergen. These allergens can be in the environment (like dust or pollen), in food (like nuts or dyes), and in medications like with antibiotics. Urticaria can also occur after bug bites and stings.

Treatment for urticaria skin rashes depends on the underlying cause, but in cases of allergic cause includes anthistamines like benadryl, and sometimes steroids like prednisone.

ECZEMA

Eczema, also termed atopic dermatitis, is a chronic allergic-related chronic skin condition which is very itchy.

Ecezema involves very dry skin that is erythematous with oozing and crusting, excoriation from scratching, and eventual lichenification (when the skin becomes thick and leathery).

In adults, eczema skin rashes often occurs on skin flexures like the elbows and behind the knees, on the face, neck, and hands, but can occur anywhere.

All patients with eczema should liberally use a water-based emollient moisturizer like Cetaphil, Aquafor, or CeraVe.

Since eczema is a chronic condition, it cannot be taken away completely, but there are treatments that can help. Depending on the severity of the eczema, lower or higher strength steroid creams can be used once or twice daily for 2-4 weeks.

  • Low Potency: Hydrocortisone 2.5%
  • Mid Potency: Triamcinolone 0.1%
  • High Potency: Usually not prescribed for eczema

Clinical Note: Higher potency steroids on the face or thinner areas of skin have a higher risk for atrophy and permanent discoloration, so use cautiously and for limited amounts of time.

For more severe eczema, topical calcineurin inhibitors can be used as well or even monoclonal antibodies. A dermatologist should be the ones to prescribe these advanced medications.

AUTOIMMUNE-RELATED RASHES

PSORIASIS

Psoriasis is a type of chronic autoimmune skin rash condition. This is characterized by erythematous flaking thick patches of skin. They can be itchy and even burn.

Treatment for psoriasis depends on the severity of the disease, but can range from topical steroids, retinoids, tacrolimus, or at times systemic steroids and immunomodulators.

VIRAL-RELATED RASHES

SHINGLES

Shingles, also called Herpes zoster, occurs from reactivation of inactive varicella virus within the body (the chicken pox virus). Shingles almost always occurs in adults and usually >50 years old.

Shingles begins as an erythematous maculopapular rash that develops fluid-filled vesicles that scab over in 7-10 days and clear up by 2-4 weeks. The rash will follow 1-2 dermatomes (termed zosteriform), and should not cross the midline. Shingles is often very painful and can itch, which may even precede the rash.

Treatment involves pain control. Antivirals like acyclovir can be started within 72 hours that the lesion develops, otherwise they are unlikely to be beneficial.

Shingles is very contagious, especially if any vesicles pop open until the lesion scab over.

PITYRIASIS ROSEA

Pityriasis rosea is a self-limiting rash thought to be secondary to viral infections. Skin rashes and reactions secondary to viruses are termed viral exanthems. This is often preceded by a viral prodrome including headache, malaise, arthralgias, and/or chills.

Pityriasis rosea starts as a herald patch which is a single oval-shaped erythematous macule or patch on the trunk with central clearing. 1-2 weeks later, a christmas tree pattern will appear on trunk with similar smaller lesions.

There is no specific treatment for pityriasis rosea, and only time will cause the rash to resolve. Pityriasis can be itchy so benadryl can help. This is not contagious.

HAND-FOOT-MOUTH

Hand Foot and Mouth disease is a viral rash that occurs due to the Coxsackie Virus A16 and some other enteroviruses.

HFM typically occurs in outbreaks every few years in the summer months. 

While HFM usually affects children, it can easily spread to parents and family members via droplets. Adults and teenagers will often have systematic symptoms including fevers, body aches, and flu-like symptoms. HFM may be preceded by upper respiratory symptoms by a few days. 

The HFM rash appears on the palms, soles, buttock, and mouth of patients. The oral lesions have football shaped vesicles that are very painful and are on the soft palate, buccal mucosa, gums, and tongue. The posterior pharynx is unaffected. 

Skin lesions are red papules with a red halo, then become gray vesicles, then ulcers after the vesicles rupture, then heal 7-10 days later. 

Like all viruses, treatment is symptomatic. Antipyretics and NSAIDs for pain and fevers and topical lidocaine for painful oral lesions. Keeping the patient well-hydrated is very important. 

In severe cases, the patient can have altered mental status from encephalitis or myocarditis.

MEASLES

Measles, once nearly eradicated, has begun to make a comeback, largely due to the growing Anti-Vax movement. However, since COVID cases have dropped again. The measles, caused by the morbillivirus, causes 150,000 deaths per year worldwide, usually in those less than 5 years old.

The rash itself is an red-brown maculopapular rash that starts 3-5 days after systemic symptoms of severe cough, nasal congestion, red eyes, high fevers, and photophobia. 

The rash starts on the forehead and spreads to the face, neck, trunk, extremities. It spreads to the palms and soles in 50% of patients. 

Koplik spots are small white spots with red halos in the mouth on the inside of the cheeks that occur early in measles, which is very specific to measles.

Treatment is largely supportive with antipyretics, analgesics, vitamin A, and hydration. More severe cases will need hospitalization and sometimes the antiviral medication Ribavirin.

FUNGAL RASHES

INTERTRIGO

Intertrigo is inflammation and infection of the skin folds, usually in obese individuals with diabetes. This is often a fungal infection, but can have a bacterial component as well.

Candida is the most common fungus, with erythema, scaling, satellite lesions, and foul odor.

Common sites include the groin, axillae, underneath the breasts, and inbetween fat rolls.

These places will often be itchy, burning, and may smell bad.

When in the groin region, this is often called tinea cruris

Prevention and treatment includes measures to reduce friction, reduce moisture (talcom powder), use of barrier cream or ointment, and wearing breathable fabric.

The fungal infections can be treated with topical antifungals including clotrimazole cream or nystatin powder 2-3x per day.

TINEA CORPORIS

Tinea corporis, also known as ringworm, is a fungal infection of the trunk or extremities. This is spread via skin-to-skin contact with an infected individual or animal, but can also be picked up by fomites. This is also common in athletes like wrestlers and in warm-moist locker rooms where fungus likes to live.

Tinea corporis is a pruritic, round, erythematous or hyperpigmented, scaly patch or plaque with a raised border. They can coalesce together as well. Pustules can appear as well, although not as common.

Treatment inovlves the use of topical antifungals 1-2x/day for 1-3 weeks. An example includes Clotrimazole 1% BID. More severe infections may need oral antifungals.

BACTERIAL RASHES

CELLULITIS

Cellulitis is a local bacterial skin infection. This starts as some sort of breach to the skin barrier (small cut or puncture), and subsequent infection of the skin and surrounding soft tissue.

Cellulitis presents as localized erythema, edema, pain, and warmth to touch. This often presents in a unilateral leg, but can present anywhere on the body.

Cellulitis may be associated with systemic symptoms such as fevers, chills, and generalized malaise. Sometimes abscesses can form.

Cellulitis is treated with PO antibiotics, but if significant systemic symptoms, high risk, or severe disease – IV antibiotics may be necessary.

  • PO: keflex 500mg QID x 7 days
  • IV: Ancef 1gm q8h

MRSA is resistant to certain antibiotics such as those above. Risk factors for MRSA include a personal history of MRSA, recent hospitalization, surgery, or nursing home stay; recent antibiotic use, immunocompromised, open wounds, etc.

The following antbiotics should cover MRSA:

  • PO: Bactrim, Clindamycin, or Doxycycline
  • IV: Vancomycin, Linezolid, or Daptomycin

FOLLICULITIS

Folliculitis is a bacterial infection of the hair follicle, usually caused by staph aureus.

This causes a tender, red, elevated papule/pustule. These skin rashes can occur anywhere where hair follicles are. This is common after hot tub use in young healthy individuals.

If mild, folliculitis is self-limiting and may not need any specific treatment. A topical antibiotic like Mupirocin ointment TID x 7 days can be used.

More significant folliculitis can be treated with PO antibiotics like dicloxacillin, keflex, or another antibiotic with good gram positive coverage.

FURUNCLE & CARBUNCLE

A furuncle is a larger painful infection of a hair follicle which is deeper than folliculitis. Another term for furuncle is a boil.

A furuncle is a well-circumscribed painful erythematous lesion which is full of purulent fluid. This can extend into the dermis and soft tissue, leading to skin abscess. These often occur in areas of friction such as the buttock, axillae, extremities, breasts, etc.

Multiple furuncles can coalesce together to form a carbuncle.

Smaller lesions can be successfully treated with warm compresses, but larger more significant lesions will need treated with Incision & Drainage.

PO antibiotics are often given, however may not be necessary if I&D is performed. They should be given if there is cellulitis present, significant comorbidities like diabetes, with systemic symptoms, or unreliable follow-up. 

PO antibiotic choices are the same for cellulitis, except MRSA should probably be covered regardless.

Personal hygeine should be encouraged as this can help prevent skin abscesses from occurring.

 BITE-RELATED SKIN RASHES

There are plenty of bugs that can bite, sting, and infest our skin, leaving skin rashes behind.

BED BUGS

Bed bugs inhabit typically houses and beds that are somewhat unclean (very common in group homes and homeless shelters). They feed on blood which causes a local reaction in the skin.

While not everyone reacts the same to these bites, they will typically present as itchy papules or wheals, macules, or bullae. They have a habit of appearing in a linear pattern, indicating the bed bug’s trajectory. These can show up when the patient wakes up but can take a few days.

Treatment includes benadryl for itching, and if there is significant itching, a low to medium potency topical steroid can be used.

Maintaining good hygiene is essential, and a pest service will need to be used to clear out an infestation.

FLEA BITES

Flea bites occur when fleas are transmitted from animals to humans. This is usually due to infested domesticated cats or dogs who transmit the fleas to their owners.

When a flea bites, it will cause pruritic papules, most common on the ankles.

An antihistamine like benadryl or zyrtec can be given for itching. Ice packs and calamine lotion can also help with the itching. Topical steroids are usually not necessar but can help.

SPIDER BITES

Spider bites are actually pretty rare, as many spiders do not have fangs strong enough to pierce human skin. They also usually do not bite unless they are provoked or about to be squished.

Most cases of “spider bites” are something else (i.e. furuncle, abscess, MRSA, etc).

When there is a real spider bite – a papule, pustule, or wheal will appear. Two small central fang marks can often be visualized in the center. The most common areas are in the axillae, the waist, and the ankles/feet.

Most spider venoms are benign and only cause a local reaction. Black widows, funnel web, and phoneutria spiders are more poisonous and the patient may have systemic symptoms including body aches, hypertension, tachycardia, abdominal pain, etc.

Brown recluse spiders can cause systemic symptoms, but often causes a more significant local reaction with potential necrosis.

Treatment for simple spider bites involves cleaning the area, and they will spontaneously resolve in 7-10 days. If there is associated cellulitis, appropriate antibiotics should be given as above. More severe reactions may need more supportive care and hospitalization.

SCABIES

Scabies is more common in children but can happen in adults as well. It is also associated with poor hygiene and crowded living conditions similar to bed bugs.

Scabies is not exactly a bite, but rather an infestation of the scabies mite into the patient’s skin where they burrow and lay eggs, leaving behind nasty skin rashes.

Scabies rash appears initially as tiny to small erythematous papules, and will often form vesicles or pustules. They will often present in lines as the mites burrow through the epidermis. This can be easily noticeable in the web spaces of the fingers, wrists, and elbows.

Scabies is very itchy as well, and itching may persist 2-6 weeks after treatment.

Benadryl can help with the itching, but scabies will need treated with Permethrin 5% cream applied to the entire body, left on overnight (8-14 hours), and washed off in the morning. This should be reapplied in one week.

Everything else in the house that could be infested should be cleaned. Bedding and clothing within the last 48 hours should be washed in hot water and heat-dried. Non-washable items should be placed in plastic bags for at least 1 week (stuffed animals, etc).

ERYTHEMA MIGRANS

Erythema migrans is the “bulls eye rash” of early lymes disease.

This rash occurs in about 90% of lymes cases, and occurs 3-30 days after getting bit by a deer tick that carries lymes.

The initial rash will be a small red painless papule, which will expand over a few days and turn into a circular erythematous rash with central clearing and induration. This resolves in weeks if left untreated.

Treatment for this rash is treatment of the underlying Lymes disease. Lymes should be treated with doxycycline 100mg BID x 21 days.

Be sure to have your patient EAT with and directly after doxycycline, as it can cause significant GI upset and pill esophagitis.

5 Appendicitis Signs you Don’t Want to Miss!

5 Appendicitis Signs you Don’t Want to Miss!

Published: February 10, 2021

Last Updated: October 31, 2022

William Kelly, MSN, FNP-C

Author | Nurse Practitioner

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Appendicitis diagram

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Knowing Appendicitis signs is super important for nurses and medical professionals.

Appendicitis is the number one cause for abdominal pain needing emergent surgery. Missing appendicitis can lead to worsened outcomes including sepsis, perforation, longer hospital stays, and an increased chance of death.

The Appendix and Appendicitis Signs

The appendix is a small appendage at the beginning of the large intestine which stems off of the cecum.

The actual function of the appendix is unknown, although there are some theories that it assists with maintaining healthy gut bacteria as well as with the immune system.

The appendix can become blocked and inflamed which leads to appendicitis, which is inflammation of the appendix.This is usually blocked by a small piece of feces that occludes the appendix, termed a fecalith.Fecolith appendicitis

The appendix can also be blocked by stones, lymphoid tissue, infections, and even cancer.

This blocked appendix eventually develops bacterial overgrowth, ischemia, and possibly can even perforate the bowel. It can cause sepsis and severe infection.

Many cases of appendicitis happen between the ages of 10-30. While common in children, it also occurs in young adults and sometimes even older individuals.

Abdominal pain is very common, and sometimes it can be difficult to tell what is causing it because there are so many potential causes of abdominal pain.

Pain in the abdominal doesn’t always present where you would expect as well. There are specific physical exam appendicitis signs which can be used to raise the suspicion of appendicitis.

symptoms

A patient who presents with appendicitis will often complain of the following appendicitis symptoms:

  • General malaise, indigestion, or change in bowel habits
  • Vague abdominal pain, usually near the umbilicus, which eventually migrates toward right lower quadrant (RLQ)
  • Nausea and/or vomiting
  • Fever

There are other symptoms as well, but these are the most common. As you can see – these are not super specific aside from the location of the pain which can be a late sign.

Up to 33% of patients can have retrocecal or pelvic appendix which can cause right flank pain or pelvic pain instead of the typical RLQ pain. This is why it is so important to know not only appendicitis symptoms but also appendicitis signs.

The physical exam is super important when evaluating abdominal pain. There are multiple physical exam maneuvers that you can do as the nurse or APP to detect appendicitis signs and further guide the need for imaging.

Related Article: 5 Advanced Physical Exam Maneuvers

Appendicitis signs - FB

1. Mcburney’s Sign

The first appendicitis sign to know is Mcburney’s sign. This is the bread and butter of recognizing appendicitis.

Mcburney’s sign, also known as Mcburney’s point tenderness is when the patient’s most tender area is 1.5-2 inches from the anterior superior iliac spine in the direction of the umbilicus. Ok… so where exactly is that?Appendicitis signs - Mcburneys sign

Draw an imaginary line from the anterior superior iliac spine to the naval, and approximately 1/3 down the line closer to the iliac spine is Mcburney’s point.

If you press generally in the RLQ and they are tender, appendicitis should be high up in your differential.

If a patient has abdominal pain with this being their most tender area, they should undergo further testing to rule out acute appendicitis.

Mcburney’s sign is 50-94% sensitive, and 75-86% specific for appendicitis. This means if the pain is specific to this location, it very well could be appendicits.

Other causes of RLQ tenderness include kidney stones, ovarian cysts or torsion, ectopic pregnancy, testicular torsion, abdominal wall strain, or some other type of abdominal condition.

2. Guarding and Rebound Tenderness

Appendicitis signs - GuardingGuarding is when a patient involuntarily tenses their abdominal muscles when you palpate.

Rebound tenderness is when the pain temporarily worsens when you suddenly release pressure.

While these aren’t specific appendicitis signs, they indicate potential peritonitis which is inflammation of the inside of the abdominal wall cavity.

Causes of peritonitis include ruptured appendicitis, perforated bowel in another area like with perforated diverticulitis, or direct infection through trauma or with peritoneal dialysis.Appendicitis signs - Rebound

Any guarding or rebound with abdominal pain should raise suspicion for serious pathology, and CT imaging should be highly considered.

Bottom line – if the patient is tender in the RLQ and they are guarding and have rebound tenderness – this is highly suspicious for acute ruptured appendicitis.

Related Article: 6 Steps for Sepsis Management

Appendicitis signs - Rovsings

3. Rovsing’s Sign

Rovsing’s sign is when you palpate the left lower quadrant and the patient is tender in the right lower quadrant (RLQ) area.

This indicates local peritoneal irritation. This is also called indirect tenderness.

This appendicitis sign is only 22-68% sensitive, and 58-96% specific. This means it’s not always going to be present with appendicitis, but if it is there – you should be ruling appendicitis out.

4. Psoas Sign

Psoas sign is when the patient lies supine and attempts to flex their hip against resistance. Place your hand on their thigh and ask them to lift their leg. If they have pain in the RLQ – this is a positive Psoas sign.

Alternatively, you can lie them on their left side and passively extend their right hip behind them. If this causes pain in the RLQ – this is also a positive Psoas sign.

This appendicitis sign checks for irritation of the iliopsoas muscle. This because the iliopsoas muscle lies in close proximity to the appendix.

The Psoas sign tends to correlate more with retrocecal appendicitis. This is when the appendage is in the direction of the colon behind the cecum, which can present in up to 33% of cases.

5. Obturator Sign

The Obturator Sign is when the patient is lying supine, and you passively flex their hip and knee, and then internally rotate. If this causes pain in the RLQ – this is a positive obturator sign.

Sometimes the appendix lies in close proximity to the right obturator internus muscle. This specific sign is associated with a pelvic appendix when the appendix tip migrates in the direction of the pelvis.

Appendicitis Management

After using these appendicitis signs into your physical exam, you should have a pretty good idea of how suspicious you are of appendicitis.

The next steps usually involve abdominal imaging.

In children and sometimes pregnant women, this can be a RLQ ultrasound. However, in most adults, this involves a CT abdomen/pelvis with contrast.

The CT abdomen/pelvis is the preferred test for appendicitis and has the highest sensitivity. This is recommended to be done with IV contrast, with or without PO contrast. If the patient has a BMI <25, it is a good idea to use PO contrast to enhance visualization of the appendix. The use of PO contrast is often facility dependent.

CT abdomen/pelvis is also great because it can give you possible alternative causes of abdominal pain. The downside is the obvious radiation exposure.

Once appendicitis is diagnosed, antibiotics should be started and surgery should be consulted emergently.

Antibiotics for acute appendicitis include:

  • Zosyn
  • Flagyl + Ceftriaxone or Cefepime
  • Ertapenem

For a full list, please look out the EMRA app. or read about the management here on UpToDate

Ultimately, the patient will likely need emergent surgery to remove the appendix, although rarely it can be just managed medically with antibiotics.

Don’t forget about these essential appendicitis signs to incorporate into your physical exam of your patient!

Adverse Drug Reactions Nurses NEED to know

Adverse Drug Reactions Nurses NEED to know

Medications are a huge part of modern medicine and how we treat disease, but there are many adverse drug reactions that can occur.

As nurses, it is important to educate our patients about these adverse drug reactions, what to expect, and what to do if they are experienced by our patients.

Some of these medication reactions are ingrained in us, but others are less commonly taught.

Make sure you remember to educate your patients who are being prescribed these medications!

adverse drug reaction - featured image

Antibiotics and Adverse Drug Reactions

Antibiotics are essential in treating bacterial disease, but they don’t come without their own side effects!

There are many different classes of antibiotics. Because of this, some adverse drug reactions apply to only certain antibiotics, and some apply to antibiotics as a whole.

1. Diarrhea and Antibiotics

All antibiotics can cause diarrhea. This is due to normal “good” bacteria in your intestines being killed by the antibiotic, leading to imbalances digestion.

While all antibiotics can cause diarrhea, there are certain antibiotics that are more likely to cause diarrhea.

These include amoxicillin, cephalosporins, clindamycin. When mixed with clavulanic acid, diarrhea tends to be more pronounced (i.e. Augmentin).

Clostridium Difficicile (CDIFF) is an opportunistic diarrheal infection that can lead to profuse diarrhea and can be difficult to treat.

Antibiotics increase the risk of CDIFF – especially broad-spectrum antibiotics like cephalosporins, fluoroquinolones, and clindamycin.

Patient Education Example: “Some watery diarrhea and mild cramping can be expected while on antibiotics. Make sure to stay hydrated if this occurs. If you have excessive diarrhea, severe abdominal pain, abdominal swelling, fever, or blood or pus in your diarrhea – you should contact your doctor or return to the emergency department”. 

adverse Drug Reactions - Abx and diarrhea

2. Allergic Reactions

All medications and antibiotics can cause allergic reactions.

True allergic reactions cause itchy hives and potentially swelling of the face, eyes, lips, or mouth. It can even cause swelling of the airways and lead to wheezing and stridor.

When giving any prescribed medications, the patient should always be educated on the potential signs of an allergic reaction.

Patient Education Example: “All new medications can cause allergic reactions, and mild-moderate allergic reactions are common with antibiotics. If you develop a red, raised, itchy rash, immediately stop taking the antibiotic and call your doctor. If you develop swelling of the face, eyes, lips, tongue, or shortness of breath – this is potentially a life-threatening severe allergic reaction called anaphylaxis, and you should seek immediate medical care or call 911.”

Adverse Drug Reaction - Allergic

3. Rifampin and Birth Control

Antibiotics were frequently thought to interact with birth control… but this is somewhat of a myth.

There is no convincing evidence that any antibiotic other than Rifampin interacts with birth control.

Rifampin is not a commonly prescribed antibiotic but is the recommended treatment for tuberculosis.

There is a concern that antibiotics as a whole can affect the gut microbiome which may alter estrogen levels, but this has not been proven and is likely untrue.

If patients are prescribed rifampin, they should be educated to use backup protection for up to 1 month after they finish the rifampin.

Patient Education Example: “While commonly believed to interact with birth control, there’s no evidence that most antibiotics do. If you want to be safe, you can use a backup method like condoms while taking the antibiotic, and up to a few days to a month after you finish.”

Adverse Drug Reaction - Rifampin and OCP

4. Doxycycline and GI Upset

Doxycycline is commonly given for infections including cellulitis, URIs, tick-borne illnesses, pneumonia, STDS, and more.

Doxycycline works great, but it does have some significant adverse drug reactions that we need to educate our patients about.

Doxycycline can cause some significant GI upset, including nausea, vomiting, and diarrhea.

Educating the patient to take this pill with food or milk can help, although it may inhibit some absorption of the drug.

Doxycycline (and clindamycin) can cause drug-induced esophagitis which can lead to significant inflammation and pain within the esophagus.

To prevent this, educate the patient to take Doxycycline with a full glass of water, milk, or eat food afterward, and stay upright for 30 minutes after taking it.

Patient Education Example: “Doxycycline can cause significant nausea and vomiting, and drinking milk or eating food directly after taking it can help minimize this. If not, drink with a full glass of water and remain upright for 30 minutes afterwards to prevent any damage to your esophagus.”

Adverse Drug Reaction - Doxycyline pill esophagitis

5. Flagyl and ETOH

Metronidazole, or Flagyl, or is commonly given for intestinal infections like colitis or diverticulitis, and for vaginal infections like trichomoniasis.

Flagyl is traditionally taught to NEVER be taken with alcohol as this can cause a “disulfiram-like reaction”.

Flagyl + ETOHDisulfiram causes excessive nausea, vomiting, and other unpleasant symptoms when mixed with alcohol.

Evidence of this severe reaction occurring with Flagyl is somewhat lacking, but it can sometimes occur. Educate the patient on this potential reaction, but if they do drink they may be fine.

It is never a bad idea to recommend against taking medications with alcohol.

Patient Education Example: “Flagyl can potentially cause nausea and vomiting if taken with alcohol. Avoid any alcohol consumption while taking it”. 

6. Fluoroquinolones and Tendon Rupture

Fluoroquinolones are a powerful class of antibiotic which kill a broad-spectrum of bacteria.

These are commonly utilized to treat UTIs, Abdominal infections, and Pneumonia.

Fluoroquinolones have fallen out of favor recently due to their large number of potential side effects, even if rare.

These side effects include:

  • Hyper/hypoglycemia
  • Peripheral neuropathy
  • CNS effects (seizures, increased ICP, tremors)
  • Psych reactions (psychosis, hallucinations, deririum, etc)
  • Aortic aneurysm and dissection
  • Tendonitis and tendon rupture.

Sometimes these antibiotics are still needed, so be sure to educate the patient on these possible side effects.

The tendinopathy can occur hours or days after starting the antibiotic or sometimes delayed for months.

This is more likely to occur in those >60 years old, those on steroids, with diabetes or kidney failure, or with extended therapy.

Patient Education Example: “Cipro can rarely cause significant side effects like inflammation and even rupture of your tendons, most commonly the Achilles tendon above your heel. If you feel any swelling or pain in this area or near another joint, immediately stop taking and contact your doctor”.

Adverse Drug Reaction - Tendon rupture

Non-Antibiotics and Adverse Drug Reactions

Antibiotics are not the only cause for adverse drug reactions, and every medication has expected side effects.

While there are many potential adverse effects for every single medication, there are a few common or interesting side effects you should know to educate your patients on!

7. Dexamethasone and the Burning Crusade

Dexamethasone is a steroid given for various reasons, including sore throats, cerebral edema, migraines, and various other conditions in and out of the hospital.

Dexamethasone is commonly ordered IV in the ED and hospital. One interesting side effect that you need to warn your patients about perineal discomfort when given IV.

When given rapidly, perineal discomfort (burning or tingling) can occur.

I’ve personally heard “MY CROTCH IS ON FIRE!”.

This is usually short-lived but can cause significant discomfort and be shocking for the patient if not warned.

Dilute the dexamethasone in NS and infuse over 15-30 minutes to help minimize this side effect.

Patient Education Example: “I’m going to give you some IV Dexamethasone to help with your condition. Sometimes it can cause brief burning or discomfort in your groin, but we are giving it slowly to try and prevent that. It can still happen though, so if it does I just want you to be aware.” 

Related Content: 

8. Adverse Drug Reactions with Opioids

Opioids like Oxycodone or Hydrocodone are commonly given for pain and can be a great tool we can use to offer relief to our patients.

Unfortunately, opioids do have significant side effects that need to be taught to our patients.

Opioids cause respiratory depression and this is how opioid overdoses kill people.

But appropriate doses, it shouldn’t cause significant respiratory depression unless mixed with other medications or alcohol.

Opioids also cause drowsiness and even stupor, so anything that requires a high level of mental alertness needs to be avoided.

This includes driving or operating heavy machinery.

Patient Education Example: “Oxycodone helps your pain but can cause drowsiness, so you shouldn’t drive or operate any heavy machinery. It can increase your risk of falls, so be careful on the stairs. You should never take this medication with alcohol, other opiates, or benzodiazepines like Xanax or Ativan.”

Related Content: Opioid Alternative Analgesics in the ER

9. Anticoagulants and Bleeding

Adverse Drug Reaction - Brain bleedAnticoagulants are often necessary to prevent blood clots in those with a history of DVT, PE, or Atrial Fibrillation.

Unfortunately, they also hinder the body’s natural ability to clot when injured.

This can lead to ineffective clotting and an increased risk of bleeding. Patients on blood thinners should take extra precautions to prevent trauma like falls.

If there is a head injury, these patients should be evaluated by a medical professional, preferably within the ED where a CT scan can be obtained to rule out an intracranial bleed.

Patient Education Example: “Eliquis helps prevent blood clots, but it also increases your chance of bleeding. If you fall or sustain any injury, you should be evaluated by a doctor. If you hit your head, you should call your doctor or come to the ER.”

Every medication has adverse drug reactions, but we should be knowledgeable about these common or potentially serious reactions, and educate our patients!

Is there any other drug reaction that you are sure to educate your patients about? Let us know in the comments!

adverse drug reaction - Pin

Advanced Physical Exam Maneuvers

Advanced Physical Exam Maneuvers

When becoming a nurse, we are taught how to assess our patients and perform a physical exam. We talk with them and make sure they are alert and oriented, we listen to their lungs and heart, check for leg swelling or redness, and are making sure there are no significant changes every shift. However, there are many advanced physical exam maneuvers that are not taught to us in nursing school.

This may be because these advanced physical exam maneuvers tend to guide diagnosis and “nurses don’t diagnose”. However, performing advanced physical exam techniques can help you recognize serious conditions in your patient, which you can notify the Provider about and improve patient outcomes.

Physical Exam

1. Extraocular Muscles

Extraocular Muscles (EOMs) are responsible for eye movement and are largely innervated by the third cranial nerve – the oculomotor cranial nerve, as well as the 4th and 6th cranial nerves. Intact EOMs suggests that those three cranial nerves are intact, but also is important in ruling out a central lesion such as a stroke or a mass – although a more thorough cranial nerve assessment is required.

When looking at the extremes of vision, sometimes nystagmus can occur. Nystagmus is defined as a fine rhythmic oscillation of the eyes. A few beats at the lateral gaze extremes can be normal,  but any excessive nystagmus, especially when the eyes or more centered, can suggest vertigo, seizure activity, Chiari malformation, stroke, or a mass.

Additionally, testing EOMs in your physical exam can be useful to test when evaluating for orbital cellulitis. Orbital cellulitis is an infection of the orbital structures and muscles. As you might expect, when the extraocular muscles are infected, they are inflamed and painful. This means testing of the EOMs often is painful, especially when looking in a certain direction. Painful EOMs in association with swelling or redness of the eye or surrounding area should prompt a CT of the orbits with contrast to rule out any orbital cellulitis. Orbital cellulitis often requires IV antibiotics, whereas periorbital cellulitis can usually be discharged home with PO antibiotics and close ophthalmology follow-up.

EOMs should be tested whenever there is any neurologic complaint (possible strokes, vertigo, seizures), or when you suspect periorbital or orbital cellulitis.

To test EOMs – hold out a finger or a pen approximately 2 feet away from the patient’s eyes. Ask them to follow your finger or object with their eyes only. Now move your finger/object in the six cardinal directions, making a large “H” in the air. To the right, upper right, lower right, then to the left, upper left, and lower left (see illustration).

An abnormal exam is when these movements are painful, when they cause dizziness, or when one or both eyes are unable to gaze in a specific direction. The latter can indicate a brain lesion such as a stroke, so this is a major physical exam finding that you don’t want to miss and is part of your NIH scale!

Be sure to check out my advanced cranial nerve assessment for more information on proper neurological assessments! Keep reading for more advanced physical assessments!

 

    2. Jugular Vein Distention

    Jugular vein distention, or JVD, is just that – when the jugular veins are bulging or distended. Pressure in the jugular veins indicates right atrial pressure, which can be helpful when evaluating patients with known or suspected heart failure, volume overload, or even pulmonary embolisms.

    Testing the Jugular venous pressure isn’t exactly easy, and sometimes a “gestalt” JVD is noted by healthcare providers. This can usually be noticed when the patients are in clear volume overload.

    JVD can be tested whenever you suspect a patient to have volume overload or increased right atrial pressures. This means whenever you suspect heart failure, volume overload in renal failure patients, or a pulmonary embolism.

    JVD can be “noticed” with a bulging external jugular vein when the patient is between 30 and 45 degrees semi-fowlers, with their head turned toward their left. You should be evaluating their right side as this is the most accurate indication of right atrial pressures. The higher they are sitting up while maintaining jugular venous distention, the higher the pressure is.

    If you want to get technical, you can also measure – but most of us don’t carry around a measuring device. I have never seen a non-specialty clinician actually perform this in real life. However, to officially test the jugular venous pressure, you want to elevate the head of the bed to approximately 30-45 degrees. Have the patient turn their head to the left. Identify the top of the venous pulsations of the external jugular vein, or preferably the internal jugular vein. You can not directly visualize the internal jugular vein, but should be able to see the pulsations. Use a pen to “draw” or visualize a horizontal line from the top of the pulsations to above the sternal angle. This is the notch where the sternum begins. Now measure how high this horizontal line is above the skin. Then add 5cm because the right atrium is approximately 5cm deep. The total is the patient’s estimated central venous pressure (CVP).

    Remember that normal CVP are 0-8 cm H2O. Anything higher is considered abnormal and could indicate the increased right atrial pressures.

    Hepatojugular Reflux

    The hepatojugular reflux (HJR) is an additional physical exam maneuver to help determine possible heart failure exacerbation or other conditions which could increase venous pressures. This is often performed if JVD is not obvious but clinical suspicion remains.

    To test the HJR, position the patient the same as JVD. Apply gentle pressure over the RUQ or mid-abdomen for 10-60 seconds, and watch for increased JVD. Normal patients should have a decrease in JVP (less distention) with this physical exam maneuver since it should decrease venous return. Those with fluid overload and heart failure will have an increase >3cm in measured JVP.

    Related article: “Interpreting Cardiac Labs”

     

      3. Murphy’s Sign

      Murphy’s sign is a physical maneuver to determine the possibility of cholecystitis or inflammation of the gallbladder. This can be a great physical exam test to aid in the clinical suspicion of acute cholecystitis (inflammation of the gallbladder).

      Murphy’s sign is tested when a patient presents with abdominal symptoms such as abdominal pain, nausea, or vomiting. You can also perform this physical exam maneuver if the patient has a fever of unknown etiology – especially in the elderly or those who may not be able to verbally express pain.

      To check for Murphy’s sign, place your fingers firmly in the patient’s right upper quadrant underneath the patient’s ribs, and ask the patient to take a deep breath. This is considered deep subcostal palpation, and on inspiration, the diaphragm pushes the gallbladder towards your palpating fingers, which should be painful if the gallbladder is inflamed.

      A positive’s Murphy sign is indicated when during inspiration, the patient has an acute increase in pain that will often cause them to stop inspiring mid-way through their breath. In true acute cholecystitis – this is often positive as Murphy’s sign as high sensitivity (97%) for acute cholecystitis, however, it is much less specific (48%) – this means that it could indicate other pathology within the liver or surrounding area.

       

        4. Costovertebral Angle Tenderness (CVAT)

        Costovertebral angle tenderess (CVAT or CVA tenderness) is a physical exam maneuver that is often used when evaluated potential kidney stones or other inflammatory renal pathology. The costovertebral angle is the angle “formed by the lower border of the 12th rib and the transverse process of the upper lumbar vertebrae.” Basically – On the back when the ribs end on each side – approximately where the kidneys lie. If there is a condition which has your kidney’s or surrounding structures inflamed and irritable, percussion over this area often causes acute worsening of pain.

        CVA tenderness should be checked whenever the clinician suspects a kidney stone or pyelonephritis. Often, this means the patient is presenting with flank pain, back pain, or some form of dysuria – whether painful urination, difficulty going, or even hematuria.

        To check for CVA tenderness – place one hand over their costovertebral angle on their back, and percuss with your other fist. You don’t want to be too forceful because if they do have a kidney stone – this can be very painful. However, you also want to make sure you are not percussing too lightly. Percuss a few times on each side.

        Positive CVA tenderness is when the patient reports pain with percussion. From my own experience – this is often very painful for those with acute kidney stones. However, I have also had plenty of patient’s with negative CVA tenderness who ended up having acute renal pathology including kidney stones.

         

          5. McBurney’s Sign

          Not to be confused with Murphy’s sign above, McBurney’s sign is an advanced physical exam maneuver to help raise suspicion for acute appendicitis.

          Mcburney’s point tenderness is when the patient’s most tender area is 1.5-2 inches from the anterior superior iliac spine in the direction of the umbilicus. Draw an imaginary line from the anterior superior iliac spine to the naval, and approximately 1/3 down the line closest to the the iliac spine is the “sweet spot”.

          If a patient has abdominal pain with this being their most tender spot, they should undergo further testing to rule out acute appendicitis. Mcburney’s sign is 50-94% sensitive, and 75-86% specific.

            McBurney's Sign for acute appendicitis

            As always, these advanced physical exam maneuvers should always be used with clinical judgment as part of a full history and physical exam. Hopefully these advanced physical maneuvers can help aid in your diagnosis. Nurses are constantly at the bedside, and knowing these physical exam maneuvers can help strengthen your physical assessment skills.

            Let me know if you found these helpful below in the comments!

            Be sure to also check out:

            The Cranial Nerve Assessment for Nurses

            The Cranial Nerve Assessment for Nurses

            The cranial nerve assessment is an important part of the neurologic exam, as cranial nerves can often correlate with serious neurologic pathology. This is important for nurses, nurse practitioners, and other medical professionals to know how to test cranial nerves and what cranial nerve assessment abnormalities may indicate. This becomes especially important when evaluating potential new strokes.

            In school, cranial nerves tend to be something you memorize and then forget the day after the test. But they are important in testing a patient’s neurologic status, as an abnormality in a cranial nerve can indicate a central lesion (stroke, tumor, bleed, etc).

            Every nurse should at the least know how to do a basic cranial nerve assessment, specifically the visual acuity and pupillary light reflex. When evaluating a stroke, The NIH scale is a method to evaluate the severity of a stroke. This scale walks you through evaluating many of the cranial nerves, but not all of them. If you want to feel confident when you chart “Cranial nerves II-XII grossly intact”, then keep reading!

            1. The Olfactory Nerve (CNI)

            The olfactory nerve is responsible for the sense of smell. Although rarely tested in practice, alterations in smell can be caused by serious intracranial pathology (brain tumors, strokes, TBI), neurodegenerative diseases like Alzheimer’s, Parkinson’s, or MS, or benign and transient causes such as the common cold.

            If both branches of the olfactory nerve are damaged, this can lead to permanent anosmia (loss of smell) and can lead to food tasting bland and decreased appetite. In most individuals, the sense of smell decreases over time, with up to 75% of individuals older than 80 have some degree of anosmia.

             How to test the Olfactory Nerve

            The olfactory nerve is almost never tested within an acute care setting such as in the hospital. However, this is sometimes tested in outpatient neurology offices. To test the olfactory nerve, blindfold the patient and have them smell and identify common scents such as vanilla, cinnamon, coffee, or peppermint while covering up one nostril at a time. Do not use ammonia or alcohol as these can trigger intranasal trigeminal nerve receptors and bypass the olfactory nerve.

            2. The Optic Nerve (CNII)

            The optic nerve is the second of the cranial nerves and is responsible for vision. This nerve transmits signals perceived in the retina and cones of the retina to the occipital lobe. This is commonly tested within the clinical setting and for a variety of presentations.

            Partial or complete loss of vision can be caused by conditions such as:

            • Diabetes
            • Intracranial pathology (ischemia, stroke, tumors)
            • Inflammation or infection of the eye
            • Toxicity

            How to test the Optic Nerve

            When testing the optic nerve, you need to examine the visual fields, the visual acuity, and the pupillary light reflex. All three are an important part of the cranial nerve assessment, although the pupillary light reflex involves cranial nerve 3 as well.

            Testing the Visual Fields (II)

            If the patient loses part of their vision on one side, it is termed partial hemianopia, and if they lose complete vision on one side it is complete hemianopia. There are a few different ways to test visual fields, but here is an easy way. Stand one arm length away from the patient and ask them to cover up one eye or do it for them if they are unable. Close your own eye on the same side. Now hold up numbers with your fingers at each of the four corners of their vision. Once satisfied, test the other eye.

            Testing the Visual Acuity (II)

            Nurses often assess visual acuity, and most emergency departments will have a Snellen eye chart to use. The distance the patient stands depends on the visual acuity chart (it should say). If you do not have easy access to this, there is an app you can get on your phone which is super helpful!

            Have the patient stand the appropriate distance away and have them cover up one eye. Do not have them forcibly close the eye as this can somewhat inhibit their ability to see out of their open eye. Ask the patient to read the 20/20 line on the chart. On a standard Snellen eye chart, this would be 20 feet away. If the patient gets more than half wrong, move onto the line above. Stop once the patient gets over 50% right. Mark this down and test the other eye. If they wear glasses – have them wear their glasses for this as well!

            Pupillary Light Reflex (II, III)

            The pupillary light reflex tests both cranial nerves II and III. First, inspect both pupils and make sure they are equal in size and shape. Then dim the lights if possible and shine a penlight directly into the right eye. Both pupils should constrict and maintain symmetry. Note if they are brisk or sluggish and if they are symmetric. Remove the light source and watch both eyes dilate equally as well. Do the same for the left eye.

            3. The Oculomotor Nerve (CNIII)

            The oculomotor nerve controls the majority of the extraocular muscles. It is primarily responsible for eye movement, eyelid movement, and pupillary constriction. If there is any oculomotor nerve impairment, there will be a pupillary dilation, ptosis (drooping eyelid), and outward deviation of the eye – termed abduction. When a patient has diplopia (double vision), it is often due to a unilateral lesion on this cranial nerve. In most cases, third nerve palsy resolves over weeks to months.

            Causes of oculomotor nerve palsy include:

            • Intracranial aneurysm
            • Microvascular ischemia (in diabetics especially)
            • Trauma: Severe blows to head with skull fracture

            Testing Extraocular Muscles (III, IV, VI)

            To test the oculomotor nerve, you need to assess the EOMs. Testing the EOMs also tests cranial nerves IV and VI, as all three nerves are responsible for eye movement.

            Hold your finger or a pen 2 feet in front of the patient’s eyes midline and have the patient focus on it with both eyes. Ask the patient to follow your finger or pen with only their eyes, moving the pen to the right, back to the midline, and then to the left and back again. Do this again for up and down. Lastly, do this again to the down-left diagonal angle, and then the down-right diagonal angle. You should have tested a total of 6 different directions – termed the “6 cardinal directions”.

            Eye movement should be symmetric, smooth, and moving in all directions. At each extremity of vision, you should be observing excessive nystagmus. Nystagmus is repetitive uncontrolled eye movement.

            Conjugate nerve palsy is when both eyes are unable to look in a specific direction during your testing. This most commonly occurs in the horizontal directions. This is usually due to a stroke within or near the brain stem.

            The pupillary light reflex listed above is also used to assess the oculomotor nerve.

            4. CN IV: The Trochlear Nerve

            The fourth cranial nerve, the trochlear nerve, innervates the superior oblique muscle of the eyes. This means it controls the downward movement of the eyeball and prevents it from rolling upward. When there is a fourth nerve palsy, patients will often complain of vertical diplopia and/or tilting of objects. This may be most noticeable when in a downward gaze such as when going down the stairs. They may also have a head tilt, as the visual changes improve with tilting of the head. On exam, the eye will with deviated upward and rotated outward.

            Testing the trochlear nerve involves evaluating the patient’s extra-ocular movements as described above.

            5. CN V: The Trigeminal Nerve

            The Trigeminal nerve is the 5th cranial nerve and responsible for facial sensation, as well as moving the muscles involved with biting and chewing. This has three branches including the ophthalmic V1, maxillary V2, and Mandibular V3. Compression of this nerve root can cause trigeminal neuralgia – a rare but painful condition.

            How to test the Trigeminal Nerve

            To test the trigeminal nerve, you are testing their facial sensation. Lightly touch both sides of the forehead and ask if they felt the same. Do this on the cheek, and then the chin. If the patient is uncooperative, you can test their corneal reflex. Do this by having the patient look right, then touch their left cornea with a whisp of cotton. They should blink. Do this on both sides.

            6. CN VI: The Abducens Nerve

            The sixth cranial nerve, the abducents nerve innervates the lateral rectus muscle of the eye. This means its responsible for outward movement of the eyes. Patients with dysfunction of this nerve will be unable to outwardly move their eyes. This causes horizontal diplopia, where the double images are side-by-side, which is worse at far distances.

            This nerve is often the first nerve compressed when there is any increased intracranial pressure (ICP). However, more common causes include vascular disease (diabetes, hypertension, atherosclerosis) or trauma.

            To test the abducents nerve, test the EOMs as described above.

            7. CN VII: The Facial Nerve

            Cranial nerve VII is the facial nerve, which controls the muscles of facial expression, as well as the sensation of taste of the front of the tongue. Facial nerve palsy can occur for various reasons, the most common being Bell’s palsy. Some other common causes include stroke, Lymes disease, trauma, or even diabetes.

            How to test the Facial Nerve

            To test the facial nerve, you must assess the patient’s facial expressions. Have the patient close their eyes tightly, then have them open their eyes. Ask them to frown, looking for symmetry in the forehead muscles. Have them smile and look for any drooping or asymmetry.

            Clinical Tip: To differentiate Bell’s palsy from stroke, assess the patient’s use of their forehead muscles. Peripheral nerve lesions (such as with Bell’s palsy) cause paresis of the entire side of the face. Central lesions tend to only effect the lower portion of the face. This is not always the case though, so you must use clinical judgement. Bell’s palsy should have no other associated neuro deficits. Check out my Infographic for more information!

            8. CN VIII: The Vestibulocochlear Nerve

            The vestibulocochlear nerve, also called the auditory vestibular nerve, is responsible for hearing and balance. Vestibular neuritis is when the nerve becomes inflamed and can cause vertigo, dizziness, and balancing difficulties – most likely from a viral infection.

            How to test the Vestibulocochlear Nerve

            While not routinely tested within the hospital, the vestibulocochlear nerve involves testing both hearing and balance. Hearing is tested by holding your fingers a few inches away from their ears and rubbing them together. If they can hear, then that is a pass. Test their balance by assessing their gait while walking. The presence of nystagmus can also indicate vestibular dysfunction.

            9. CN IX: The Glossopharyngeal Nerve

            The glossopharyngeal nerve is partially responsible for the sensation of taste, pharyngeal sensation, as well as for the gag reflex. A damaged glossopharyngeal nerve can cause a loss of taste in part of the tongue and cause trouble swallowing.

            How to test the Glossopharyngeal Nerve

            Palatal Movement (IX, X)

            Instead of doing the gag reflex which can be very uncomfortable for patients, you can instead assess palatal movement. Do this by having the patient yawn or say “ahh”, and observe their palate movement for symmetry. If this is abnormal, consider testing the gag reflex.

            Gag Reflex (IX, X)

            When performing the cranial nerve assessment, the easiest way to test the glossopharyngeal nerve is to test their gag reflex, however, this is usually not necessary in the clinical setting. Remember that approximately 20% of people will not have a gag reflex at baseline. Check both sides of the pharyngeal wall by gently poking the pharynx with a cotton swab.

            Dysarthria (IX, X, XII)

            There is no specific test for this but listen to the patient’s speech. Assess for any slurred speech or abnormality of the voice. Ask the patient or the family if it sounds different than normal.

            10. CN X: The Vagus Nerve

            The Vagus nerve innervates the hearts, lungs, and digestive tract, along with a few muscles. Most noticeably, it controls the heart rate, GI motility, sweating, and speech. It is also partially responsible for the gag reflex (along with cranial nerve IX).

            Overstimulation of the vagal nerve can drop the heart rate and cause syncope, termed vasovagal syncope. Activities that stimulate the vagal nerve include bearing down, holding breath, carotid massage, or extreme fear or stress.

            There are even implantable vagus nerve stimulators that can help slow down the firing of neurons within the brain and thus help manage seizures.

            How to test the Vagus Nerve

            The only real way to test the vagus nerve is via the gag reflex as described above.

            11. CN XI: The Accessory Nerve

            The accessory nerve innervates the sternocleidomastoid and trapezius muscles. This means it is responsible for tilting/rotating the head as well as shrugging the shoulders. This nerve can be damaged after neck surgery or blunt force trauma.

            How to test the Accessory Nerve

            To test the trapezius muscle, ask the patient to shrug both of their shoulders at the same time. Then apply some downward pressure with both hands and ask them to shrug both shoulders against the resistance.

            To test the sternocleidomastoid, place a hand against their cheek and ask them to rotate their head against resistance in each direction. If you notice weakness, this indicates the opposite side is the weaker muscle.

            12. CN XII: The Hypoglossal Nerve

            The hypoglossal nerve controls most of the movement of the tongue. This means it is highly responsible for speech and swallowing. Damage to the hypoglossal nerve is rare, but if so are likely to be caused by tumors or gunshot wounds. Other causes include stroke or neurodegenerative disease.

            How to test the Hypoglossal Nerve

            To test the hypoglossal nerve, ask the patient to stick out their tongue. If the tongue deviates to one side, this indicates hypoglossal nerve dysfunction on the side of deviation. Then ask them to move their tongue from side to side rapidly. Additionally, listen for dysarthria when the patient is speaking as described above.

            Cranial Nerve Assessment Cheat sheetCranial Nerve Assessment Cheat Sheet

            How’s that for a refresher?  Although we may have forgotten some of the in’s and out’s of the cranial nerve assessment, this should serve as a reminder for how to examine cranial nerves. Hopefully, after reading this, you can feel more confident in your neurologic assessment!

            If you need an easy cranial nerve assessment handout, you can download my handout here! This is the perfect cheat-sheet that you can refer to in practice when assessing cranial nerves!

            References:

            Gelb, D. (2019). The detailed neurologic examination in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/the-detailed-neurologic-examination-in-adults

            Lee, A. G. (2019). Third cranial nerve (oculomotor nerve) palsy in adults. In UpToDate. Retrieved from https://www.uptodate.com/contents/third-cranial-nerve-oculomotor-nerve-palsy-in-adults

            Lee, A. G. (2019). Fourth cranial nerve (trochlear nerve) palsy. In UpToDate. Retrieved from https://www.uptodate.com/contents/fourth-cranial-nerve-trochlear-nerve-palsy

            Mullen, M. T. (2014). Differentiating Facial Weakness Caused by Bell’s Palsy vs. Acute Stroke. Journal of Emergency Medical Services39(5). Retrieved from https://www.jems.com/2014/05/07/differentiating-facial-weakness-caused-b

            Oculomotor Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/neuroscience/oculomotor-nerve

            Olfactory Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/neuroscience/olfactory-nerve

            Rea, P. (2014). Clinical Anatomy of the Cranial Nerves. Cambridge, MA: Academic Press.

            Trigeminal Nerve. (n.d.). Retrieved from https://www.sciencedirect.com/topics/medicine-and-dentistry/trigeminal-nerve