Edema of the leg
Leg edema is a common sign that results when excess interstitial fluid accumulates in one or both legs. It may affect just the foot and ankle or extend to the thigh and may be slight or dramatic, pitting or nonpitting.
Leg edema may result from venous disorders, trauma, and certain bone and cardiac disorders that disturb normal fluid balance. (See Understanding fluid balance, page 244.) It may result from nephrotic syndrome, cirrhosis, acute and chronic thrombophlebitis, chronic venous insufficiency (most common), cellulitis, lymphedema, and drugs. However, several nonpathologic mechanisms may also cause leg edema. For example, prolonged sitting, standing, or immobility may cause bilateral orthostatic edema. This pitting edema usually affects the foot and disappears with rest and leg elevation. Increased venous pressure late in pregnancy may cause ankle edema. Constricting garters or pantyhose may mechanically cause lower-extremity edema.
History
To evaluate the patient, first ask how long he has had the edema. Did it develop suddenly or gradually? Does it decrease if he elevates his legs? Is it painful when touched or when he walks? Is it worse in the morning, or does it get progressively worse during the day? Ask about a recent leg injury, surgery, or illness that may have immobilized the patient. Does he have a history of cardiovascular disease? Finally, obtain a drug history.
Physical assessment
Begin the physical examination by examining each leg for pitting edema. (See Differentiating between pitting and nonpitting edema, page 245.) Because leg edema may compromise arterial blood flow, palpate or use Doppler ultrasonography to auscultate peripheral pulses to detect any insufficiency. Observe leg color and look for unusual vein patterns. Then palpate for warmth, tenderness, and cords, and gently squeeze the calf muscle against the tibia to check for deep pain. If leg edema is unilateral, dorsiflex the foot to look for Homans’sign, which is indicated by calf pain. Finally, note skin thickening or ulceration in the edematous areas.
Medical causes
Burns
Two days or less after injury, leg burns may cause mild to severe edema, pain, and tissue damage. Depending on the degree of the burn, the patient may also have erythema; blisters; white, brown, or leathery tissue; or charring.
Cellulitis
With cellulitis, pitting edema and orange peel skin are caused by a streptococcal or staphylococcal infection that most commonly occurs in the lower extremities. Cellulitis is also associated with erythema, warmth, and tenderness in the infected area.
Envenomation
Mild to severe localized edema may develop suddenly at the site of a bite or sting, along with erythema, pain, urticaria, pruritus, and a burning sensation. Later signs include nausea, vomiting, weakness, muscle cramps, fever, chills, hypotension, headache, and, in severe cases, dyspnea, seizures, and paralysis.
Heart failure
Bilateral leg edema is an early sign of right-sided heart failure. Other signs and symptoms include weight gain despite anorexia, nausea, chest tightness, hypotension, pallor, tachypnea, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations, ventricular gallop, and inspiratory crackles. Pitting ankle edema, hepatomegaly, hemoptysis, and cyanosis signal more advanced heart failure.
Hypoproteinemia
Malnourished patients suffer bilateral leg edema secondary to decreased protein and osmotic pressures. Malnutrition also typically causes muscle weakness; lethargy; anorexia; diarrhea; apathy; dry, wrinkled skin; and signs of anemia, such as dizziness and pallor.
Leg trauma
Mild to severe localized edema may form around the site of leg trauma. Ecchymoses or bleeding, pain or numbness, and paralysis may occur. If a fracture has occurred, deformities may be present.
Nephrotic syndrome
Nephrotic syndrome is commonly seen in children and results in bilateral leg edema. It’s associated with polyuria and eyelid swelling. Generalized pitting edema may also occur as well as ascites, fatigue, malaise, depression, and pallor.
Osteomyelitis
When osteomyelitis, a bone infection, affects the lower leg, it usually produces localized, mild to moderate edema, which may spread to the adjacent joint. Edema typically follows fever, localized tenderness, and pain that increases with leg movement.
Rupture of popliteal cyst
A ruptured popliteal (Baker’s) cyst can cause sudden onset of unilateral calf pain and edema, usually after walking or exercising. This type of cyst is common in patients with arthritis. It can compress vascular structures and cause severe edema and thrombophlebitis.
Thrombophlebitis
Both deep and superficial vein thrombosis may cause unilateral mild to moderate edema. Deep vein thrombophlebitis may not produce symptoms or may cause mild to severe pain, warmth, and cyanosis in the affected leg as well as fever, chills, and malaise. Superficial thrombophlebitis typically causes pain, warmth, redness, tenderness, and induration along the affected vein.
Venous insufficiency (chronic)
Moderate to severe, unilateral or bilateral leg edema occurs in patients with chronic venous insufficiency. Initially, the edema is soft and pitting; later, it becomes hard as tissues thicken. Other signs include darkened skin and painless, easily infected stasis ulcers around the ankle. Venous insufficiency generally occurs in females.
Other causes
Coronary artery bypass surgery
Unilateral venous insufficiency may follow saphenous vein retrieval.
Medications
Estrogen, hormonal contraceptives, lithium, nonsteroidal anti-inflammatory drugs, vasodilators, and drugs that cause sodium retention can cause bilateral leg edema.
Special considerations
Provide an analgesic and an antibiotic as needed. Have the patient avoid prolonged sitting or standing, and elevate his legs as necessary. A compression boot (Unna’s boot) may be used to help reduce edema. Monitor the patient’s intake and output, and check his weight and leg circumference daily to detect any change in the edema. Prepare him for diagnostic tests, such as blood and urine studies and X-rays. Determine the need for dietary modifications, such as water and sodium restrictions. Monitor the affected extremity for skin breakdown.
Pediatric pointers
Uncommon in children, leg edema may result from osteomyelitis, leg trauma or, rarely, heart failure.
Patient counseling
Show the patient with leg edema how to apply antiembolism stockings or bandages to promote venous return. Encourage him to perform leg exercises. Teach him about any dietary or fluid restrictions.
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 Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Ear swelling
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