Jugular vein distention
Jugular vein distention is the abnormal fullness and height of the pulse waves in the internal or external jugular veins. For a patient in a supine position with his head elevated 45 degrees, a pulse wave height greater than 1¼" to 1½"(3 to 4 cm) above the angle of Louis indicates distention. Engorged, distended veins reflect increased venous pressure in the right side of the heart, which in turn, indicates an increased central venous pressure. This common sign characteristically occurs in heart failure and other cardiovascular disorders, such as constrictive pericarditis, tricuspid stenosis, and obstruction of the superior vena cava.
Emergency Actions
Evaluation of jugular vein distention involves visualizing and assessing venous pulsations. (See Evaluating jugular vein distention.) If you detect jugular vein distention in a patient with pale, clammy skin who suddenly appears anxious and dyspneic, take his blood pressure. If you note hypotension and paradoxical pulse, suspect cardiac tamponade. Elevate the foot of the bed 20 to 30 degrees, give supplemental oxygen, and monitor cardiac status and rhythm, oxygen saturation, and mental status. Start an I.V. line for medication administration, and keep cardiopulmonary resuscitation equipment close by. Assemble the needed equipment for emergency pericardiocentesis (to relieve pressure on the heart). Throughout the procedure, monitor the patient’s blood pressure, heart rhythm, and respirations.
History
If the patient isn’t in severe distress, obtain a personal history. Has he recently gained weight? Does he have difficulty putting on shoes? Are his ankles swollen? Ask about chest pain, shortness of breath, paroxysmal nocturnal dyspnea, anorexia, nausea or vomiting, and a history of cancer or cardiac, pulmonary, hepatic, or renal disease. Obtain a drug history, noting diuretic use and dosage. Is the patient taking drugs as prescribed? Ask the patient about his regular diet patterns, noting a high sodium intake.
Physical assessment
Begin the physical examination by checking the patient’s vital signs. Tachycardia, tachypnea, and increased blood pressure indicate fluid overload that’s stressing the heart. Inspect and palpate the patient’s extremities and face for edema. Then weigh the patient and compare that weight to his baseline.
Auscultate his lungs for crackles and his heart for gallops, a pericardial friction rub, and muffled heart sounds. Inspect his abdomen for distention, and palpate and percuss for an enlarged liver. Finally monitor urine output and note any decrease.
Medical causes
Cardiac tamponade
Cardiac tamponade, a life-threatening condition, produces jugular vein distention along with anxiety, restlessness, cyanosis, chest pain, dyspnea, hypotension, and clammy skin. It also causes tachycardia, tachypnea, muffled heart sounds, a pericardial friction rub, weak or absent peripheral pulses or pulses that decrease during inspiration (pulsus paradoxus), and hepatomegaly. The patient may sit upright or lean forward to ease breathing.
Heart failure
Right-sided heart failure commonly causes jugular vein distention, along with weakness, anxiety, cyanosis, dependent edema of the legs and sacrum, steady weight gain, confusion, and hepatomegaly. Other findings include nausea and vomiting, abdominal discomfort, and anorexia due to visceral edema. Ascites is a late sign. Massive right-sided heart failure may produce anasarca and oliguria.
If left-sided heart failure precedes right-sided heart failure, jugular vein distention is a late sign. Other signs and symptoms include fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, tachypnea, tachycardia, and arrhythmias. Auscultation reveals crackles and a ventricular gallop.
Hypervolemia
Markedly increased intravascular fluid volume causes jugular vein distention, along with rapid weight gain, elevated blood pressure, bounding pulse, peripheral edema, dyspnea, and crackles. An S3 gallop may be heard on auscultation.
Pericarditis (chronic constrictive)
Progressive signs and symptoms of chronic constrictive pericarditis include jugular vein distention that’s more prominent on inspiration (Kussmaul’s sign). The patient usually complains of chest pain. Other signs and symptoms include fluid retention with dependent edema, hepatomegaly, ascites, and pericardial friction rub.
Superior vena cava obstruction
An obstruction, such as a tumor or, rarely, thrombosis, may gradually lead to jugular vein distention when the veins of the head, neck, and arms fail to empty effectively, causing facial, neck, and upper arm edema. Metastasis of a malignant tumor to the mediastinum may cause dyspnea, cough, substernal chest pain, and hoarseness.
Special considerations
If the patient has cardiac tamponade, prepare him for pericardiocentesis. If he doesn’t have cardiac tamponade, restrict fluids and monitor his intake and output. Insert an indwelling urinary catheter if necessary. If the patient has heart failure, administer a diuretic. Routinely change his position to avoid skin breakdown from peripheral edema. Prepare the patient for a central venous or pulmonary artery catheter insertion in order to measure right- and left-sided heart pressure.
Pediatric pointers
Jugular vein distention is difficult (sometimes impossible) to evaluate in most infants and toddlers because of their short, thick necks. Even in school-age children, measurement of jugular vein distention can be unreliable because the sternal angle may not be the same distance (2" to 2¾" [5 to 7 cm]) above the right atrium as it is in adults.
Patient counseling
Teach the patient with heart failure about appropriate treatments, including dietary restrictions (such as a low-sodium diet). Explain the importance of monitoring daily weight and reporting a gain of 1 to 2 lb (0.5 to 1 kg)/day. Have the patient slowly resume daily activities, but make sure he schedules rest periods into his routine.
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.
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