Edema, generalized
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 127.) Cyclic edema associated with increased aldosterone secretion may occur in premenopausal females.
Act Now: Quickly determine the location and severity of edema, including the degree of pitting. (See Edema: Pitting or nonpitting? page 128.) 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 cardiac failure or pulmonary congestion, such as crackles, muffled heart sounds, or ventricular gallop. Unless the patient is hypotensive, place him in Fowler’s position to promote lung expansion. Prepare to administer oxygen and an I.V. diuretic. Have emergency resuscitation equipment nearby.
Assessment
History
When the patient’s condition permits, obtain a complete medical history. First, note when and where 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. Have the patient describe his diet so you can determine whether he suffers from protein malnutrition. Explore his drug history, and note recent I.V. therapy.
Physical examination
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 his hands and feet feel cold. Finally, perform a complete cardiac and respiratory assessment. Also, obtain a baseline weight for this patient.
Pediatric pointers
Renal failure in children commonly causes generalized edema. Monitor fluid balance closely. Remember that fever or diaphoresis can lead to fluid loss, so promote fluid intake.
Kwashiorkor — protein-deficiency malnutrition — is more common in children than in adults and causes anasarca.
Geriatric pointers
Elderly patients are more likely to develop 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.
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, or they may 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.
Cirrhosis
Edema that usually starts in the legs and thighs and may progress to the degree of anasarca. 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 heart failure. Edema may improve with exercise or elevation of the limbs and is typically worse at the end of the day. Among other classic late findings are hemoptysis, cyanosis, marked hepatomegaly, clubbing, crackles, and a ventricular gallop. Typically, the patient has tachypnea, palpitations, hypotension, weight gain despite anorexia, nausea, slowed mental response, diaphoresis, and pallor. Dyspnea, orthopnea, tachycardia, and fatigue typify left-sided heart failure; jugular vein distention, enlarged liver, and peripheral edema typify right-sided heart failure.
Malnutrition
Anasarca in malnutrition may mask dramatic muscle wasting. Malnutrition also typically causes muscle weakness; lethargy; anorexia; diarrhea; apathy; dry, wrinkled skin; and signs of anemia, such as dizziness and pallor.
Myxedema
With myxedema — the severe form of hypothyroidism — generalized nonpitting edema is accompanied by dry, flaky, inelastic, waxy, pale skin, a puffy face, and an upper eyelid droop. Assessment 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.
Pericarditis (chronic constructive)
Resembling right-sided heart failure, pericarditis usually begins with pitting edema of the arms and legs that may progress to generalized edema. Other signs and symptoms include ascites, Kussmaul’s sign, dyspnea, fatigue, weakness, abdominal distention, and hepatomegaly.
Protein-losing enteropathy
Increased albumin levels lead to progressive generalized pitting edema in protein-losing enteropathy. The patient may also have mild fever and abdominal pain with bloody diarrhea and steatorrhea.
Renal failure
With acute renal failure, generalized pitting edema occurs as a late sign. With chronic 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.
Septic shock
A late sign of septic shock — a life-threatening disorder — generalized edema typically develops rapidly. The edema is pitting and moderately severe. Accompanying it may be cool skin, hypotension, oliguria, tachycardia, cyanosis, thirst, anxiety, and signs of respiratory failure.
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-inflammatories, such as celecoxib, ibuprofen, and naproxen.
Medical treatments
I.V. saline solution infusions and internal feedings may cause sodium and fluid overload, resulting in generalized edema, especially in patients with cardiac or renal disease.
Nursing considerations
Position the patient with his limbs above heart level to promote drainage unless positioning increases respiratory difficulty. Reposition him to avoid pressure ulcers at least every 2 hours. 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, air mattress, 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 lev-els — especially sodium and albumin. Prepare the patient for blood and urine tests, X-rays, echocardiography, or an electrocardiogram.
Patient teaching
Teach the patient with known heart failure or renal failure and the patient’s caregivers to watch for edema; explain that it’s an important sign of decompensation that indicates the need for immediate adjustment of therapy. Discuss foods and fluids he should avoid. Provide information related to medications prescribed and the importance of medication, diet, and activity compliance.
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Ankle swelling
» Next page: Edema of the leg (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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