Edema, generalized
Edema, generalized: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
A common sign in severely ill patients, generalized edema is the excessive accumulation of interstitial fluid throughout the body. Its severity varies widely; slight edema may be difficult to detect, especially if the patient is obese, whereas massive edema is immediately apparent.
Generalized edema is typically chronic and progressive. It may result from cardiac, renal, endocrine, or hepatic disorders as well as from severe burns, malnutrition, or the effects of certain drugs and treatments.
Common factors responsible for edema are hypoalbuminemia and excess sodium ingestion or retention, both of which influence plasma osmotic pressure. (See Understanding fluid balance, page 244.) Cyclic edema associated with increased aldosterone secretion may occur in premenopausal women.
Emergency Actions
Quickly determine the location and severity of edema, including the degree of pitting. (See Differentiating between pitting and nonpitting edema, page 245.) If the patient has severe edema, promptly take his vital signs, and check for jugular vein distention and cyanotic lips. Auscultate the lungs and heart. Be alert for signs of heart failure or pulmonary congestion, such as crackles, muffled heart sounds, or ventricular gallop. Unless the patient is hyposensitive, place him in Fowler’s position to promote lung expansion. Prepare to administer oxygen and an I.V. diuretic. Have emergency resuscitation equipment nearby.
History
When the patient’s condition permits, obtain a complete medical history. First, note when the edema began. Does it move throughout the course of the day — for example, from the upper extremities to the lower, periorbitally, or within the sacral area? Is the edema worse in the morning or at the end of the day? Is it affected by position changes? Is it accompanied by shortness of breath or pain in the arms or legs? Find out how much weight the patient has gained. Has his urine output changed in quantity or quality?
Next, ask about previous burns or cardiac, renal, hepatic, endocrine, or GI disorders. Ask the patient to describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.
Physical assessment
Begin the physical examination by comparing the patient’s arms and legs for symmetrical edema. Also, note ecchymoses and cyanosis. Assess the back, sacrum, and hips of the bedridden patient for dependent edema. Palpate peripheral pulses, noting whether hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment.
Medical causes
Angioneurotic edema or angioedema
Recurrent attacks of acute, painless, nonpitting edema involving the skin and mucous membranes — especially those of the respiratory tract, face, neck, lips, larynx, hands, feet, genitalia, or viscera — may be the result of a food or drug allergy or emotional stress; they may also be hereditary. Abdominal pain, nausea, vomiting, and diarrhea accompany visceral edema; dyspnea and stridor accompany life-threatening laryngeal edema.
Burns
Edema and associated tissue damage vary with the severity of the burn. Severe generalized edema (4+) may occur within 2 days of a major burn; localized edema may occur with a less severe burn. Depending on the degree of edema, the patient may experience signs and symptoms of reduced or absent circulation and airway obstruction.
Cirrhosis
Edema is a late sign of cirrhosis, a chronic disease. Accompanying signs and symptoms include abdominal pain, anorexia, nausea and vomiting, hepatomegaly, ascites, jaundice, pruritus, bleeding tendencies, musty breath, lethargy, mental changes, and asterixis.
Heart failure
Severe, generalized pitting edema — occasionally anasarca — may follow leg edema late in a patient with heart failure. The edema may improve with exercise or elevation of the limbs and tends to be worse at the end of the day. Other classic late findings include hemoptysis, cyanosis, marked hepatomegaly, clubbing, crackles, and a ventricular gallop. Typically, the patient also experiences tachypnea, palpitations, hypotension, weight gain despite anorexia, nausea, slowed mental response, diaphoresis, and pallor. Dyspnea, orthopnea, tachycardia, and fatigue signal left-sided heart failure; jugular vein distention, enlarged liver, and peripheral edema signal right-sided heart failure.
Myxedema
With myxedema, a severe form of hypothyroidism, generalized nonpitting edema is accompanied by dry, flaky, inelastic, waxy, pale skin; a puffy face; and an upper eyelid droop. Observation also reveals masklike facies, hair loss or coarsening, and psychomotor slowing. Associated findings include hoarseness, weight gain, fatigue, cold intolerance, bradycardia, hypoventilation, constipation, abdominal distention, menorrhagia, impotence, and infertility.
Nephrotic syndrome
Although nephrotic syndrome is characterized by generalized pitting edema, the edema is initially localized around the eyes. With severe cases, anasarca develops, increasing body weight by up to 50%. Other common signs and symptoms are ascites, anorexia, fatigue, malaise, depression, and pallor.
Pericardial effusion
With pericardial effusion, generalized pitting edema may be most prominent in the arms and legs. It may be accompanied by chest pain, dyspnea, orthopnea, nonproductive cough, pericardial friction rub, jugular vein distention, dysphagia, and fever.
Renal failure
Generalized pitting edema occurs as a late sign of acute renal failure. With chronic renal failure, edema is less likely to become generalized; its severity depends on the degree of fluid overload. Both forms of renal failure cause oliguria, anorexia, nausea and vomiting, drowsiness, confusion, hypertension, dyspnea, crackles, dizziness, and pallor.
Other causes
Drugs
Any drug that causes sodium retention may aggravate or cause generalized edema. Examples include antihypertensives, corticosteroids, androgenic and anabolic steroids, estrogens, and nonsteroidal anti-inflammatory drugs, such as phenylbutazone, ibuprofen, and naproxen.
Treatments
I.V. saline solution infusions and enteral feedings may cause sodium and fluid overload, resulting in generalized edema, especially in patients with cardiac or renal disease.
Special considerations
Position the patient with his limbs above heart level to promote drainage. Periodically reposition him to avoid pressure ulcers. If the patient develops dyspnea, lower his limbs, elevate the head of the bed, and administer oxygen. Massage reddened areas, especially where dependent edema has formed (for example, the back, sacrum, hips, buttocks). Prevent skin breakdown in these areas by placing a pressure mattress, lamb’s wool pad, or flotation ring on the patient’s bed. Restrict fluids and sodium, and administer a diuretic or I.V. albumin.
Monitor intake and output and daily weight. Also monitor serum electrolyte levels — especially sodium and albumin. Prepare the patient for blood and urine tests, X-rays, echocardiography, or an electrocardiogram.
Pediatric pointers
Renal failure in children commonly causes generalized edema. Monitor fluid balance closely. Remember that fever and diaphoresis can lead to fluid loss, so promote fluid intake.
Kwashiorkor, a protein-deficiency malnutrition that’s more common in children than in adults, causes anasarca.
Geriatric pointers
Elderly patients are at greater risk for developing edema for several reasons, including decreased cardiac and renal function and, in some cases, poor nutritional status. Use caution when giving older patients I.V. fluids or medications that can raise sodium levels and thereby increase fluid retention.
Patient counseling
Teach patients with known heart failure or renal failure to watch for edema; explain that it’s an important sign of decompensation that indicates the need for immediate adjustment of therapy. Teach the patient about dietary restrictions as indicated, including modifying sodium, potassium, and fluid intake.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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