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.) Cyclic edema associated with increased aldosterone secretion may occur in premenopausal women.

Action stat!

Quickly determine the extent and severity of edema, including the degree of pitting. (See Edema: Pitting or nonpitting? page 226.) If the patient has severe edema, promptly take his vital signs, oxygen saturation, 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 a 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.

History and physical examination

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. 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.

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 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.

Heart failure.Severe, generalized pitting edema—occasionally anasarca—may follow leg edema late in this disorder. The 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, a slowed mental response, diaphoresis, and pallor. Dyspnea, orthopnea, tachycardia, and fatigue typify leftsided 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, which is 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, it's 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, a nonproductive cough, a pericardial friction rub, jugular vein distention, dysphagia, and a fever.

Pericarditis (chronic constrictive).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.

Renal failure.With acute renal failure, generalized pitting edema occurs as a late sign. 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 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, if the patient can tolerate it.

▪ Periodically reposition him to avoid pressure ulcers.

▪ If the patient develops dyspnea, lower his limbs, elevate the head of the bed, and administer oxygen.

▪ Prevent skin breakdown by placing a pressure mattress on the patient's bed.

▪ Restrict fluids and sodium, and administer a diuretic.

▪ Monitor the patient's intake and output and daily weight.

▪ Monitor serum electrolyte levels—especially sodium and albumin.

▪ Prepare the patient for blood and urine tests, X-rays, echocardiography, or an electrocardiogram.

Patient teaching

▪ Explain signs and symptoms of edema that the patient should report.

▪ Discuss food or fluid restrictions.

▪ Explain the underlying cause of the patient's edema and its treatment.

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Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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