Edema of the arm
Edema of the arm: Excerpt from Handbook of Signs & Symptoms (Third Edition)
The result of excess interstitial fluid in the arm, arm edema may be unilateral or bilateral and may develop gradually or abruptly. It may be aggravated by immobility and alleviated by arm elevation and exercise.
Arm edema signals a localized fluid imbalance between the vascular and interstitial spaces. (See Understanding fluid balancepage 239.) It commonly results from trauma, venous disorders, toxins, or certain treatments.
Emergency interventions
Remove rings, bracelets, and watches from the patient's affected arm. These items may act as a tourniquet. Make sure that the patient's sleeves don't inhibit fluid drainage or blood flow.
History and physical examination
When taking the patient's history, one of the first questions to ask is, “How long has your arm been swollen?” Then find out if the patient also has arm pain, numbness, or tingling. Does exercise or arm elevation decrease the edema? Ask about recent arm injury, such as burns or insect stings. Also, note recent I.V. therapy, surgery, or radiation therapy for breast cancer.
Determine the edema's severity by comparing the size and symmetry of both arms. Use a tape measure to determine the exact girth, and mark the location where the measurement was obtained in order to make comparative measurements later. Make sure to note whether the edema is unilateral or bilateral, and test for pitting. (See Edema Pitting or nonpitting? page 240.) Next, examine and compare the color and temperature of both arms. Look for erythema and ecchymoses and for wounds that suggest injury. Palpate and compare radial and brachial pulses. Finally, look for arm tenderness and decreased sensation or mobility. If you detect signs of neurovascular compromise, elevate the arm.
Medical causes
Angioneurotic edema
Angioneurotic edema is a common reaction that's characterized by the sudden onset of painless, nonpruritic edema affecting the hands, feet, eyelids, lips, face, neck, genitalia, or viscera. Although swelling usually doesn't itch, it may burn and tingle. If edema spreads to the larynx, signs of respiratory distress may occur
Arm trauma
Shortly after a crush injury, severe edema may affect the entire arm. Ecchymoses or superficial bleeding, pain or numbness, and paralysis may occur.
Burns
Twodays or less after injury, arm burns may cause mild to severe edema, pain, and tissue damage.
Envenomation
Envenomation by snakes, aquatic animals, or insects initially may cause edema around the bite or sting that quickly spreads to the entire arm. Pain, erythema, and pruritus at the site are common; paresthesia occurs occasionally. Later, the patient may develop generalized signs and symptoms, such as nausea, vomiting, weakness, muscle cramps, a fever, chills, hypotension, a headache and, in severe cases, dyspnea, seizures, and paralysis.
Superior vena cava syndrome
Bilateral arm edema usually progresses slowly and is accompanied by facial and neck edema. Dilated veins mark these edematous areas. The patient also complains of a headache, vertigo, and vision disturbances.
Thrombophlebitis
Thrombophlebitis, which can result from peripherally inserted central catheters and arm portocaths, may cause arm edema, pain, and warmth. Deep vein thrombophlebitis can also produce cyanosis, a fever, chills, and malaise; superficial thrombophlebitis alsocauses redness, tenderness, and induration along the vein.
Other causes
Treatments
Localized arm edema may result from infiltration of I.V. fluid into the interstitial tissue. A radical or modified radical mastectomy that disrupts lymphatic drainage may cause edema of the entire arm, as can axillary lymph node dissection. Also, radiation therapy for breast cancer may produce arm edema immediately after treatment or months later.
Special considerations
Treatment of the patient with arm edema varies according to the underlying cause. General care measures include elevation of the arm, frequent repositioning, and appropriate use of bandages and dressings to promote drainage and circulation. Make sure to provide patients with meticulous skin care to prevent breakdown and formation of pressure ulcers. Also, administer an analgesic and anticoagulant as needed.
Pediatric pointers
Arm edema rarely occurs in children, except as part of generalized edema, but it may result from arm trauma, such as burns and crush injuries.
Edema of the face
Facial edema refers to either localized swelling — around the eyes, for example — or more generalized facial swelling that may extend to the neck and upper arms. Occasionally painful, this sign may develop gradually or abruptly. Sometimes it precedes the onset of peripheral or generalized edema. Mild edema may be difficult to detect; the patient or someone who's familiar with his appearance may report it before it's noticed during assessment.
Facial edema results from disruption of the hydrostatic and osmotic pressures that govern fluid movement between the arteries, veins, and lymphatics. (See Understanding fluid balancepage 239.) It may result from venous, inflammatory, and certain systemic disorders; trauma; allergy; malnutrition; or the effects of certain drugs, tests, and treatments.
Emergency interventions
If the patient has facial edema associated with burns or if he reports recent exposure to an allergen, quickly evaluate his respiratory status. Edema may also affect his upper airway, causing life-threatening obstruction. If you detect audible wheezing, inspiratory stridor, or other signs of respiratory distress, administer epinephrine. For the patient in severe distress — with absent breath sounds and cyanosis — tracheal intubation, cricothyroidotomy, or tracheotomy may be required. Always administer oxygen.
History and physical examination
If the patient isn't in severe distress, take his health history. Ask if facial edema developed suddenly or gradually. Is it more prominent in early morning, or does it worsen throughout the day? Has the patient gained weight? If so, how much and over what length of time? Has he noticed a change in his urine color or output? In his appetite? Take a drug history and ask about recent facial trauma.
Begin the physical examination by characterizing the edema. Is it localized to one part of the face, or does it affect the entire face or other parts of the body? Determine if the edema is pitting or nonpitting, and grade its severity. (See Edema Pitting or nonpitting? page 240.) Next, take the patient's vital signs, and assess his neurologic status. Examine the oral cavity to evaluate dental hygiene and look for signs of infection. Visualize the oropharynx and look for soft-tissue swelling.
Medical causes
Allergic reaction
Facial edema may characterize local allergic reactions and anaphylaxis. With life-threatening anaphylaxis,angioneurotic facial edema may occur with urticaria and flushing. (See Recognizing angioneurotic edema.) Airway edema causes hoarseness, stridor, and bronchospasm with dyspnea and tachypnea. Signs of shock, such as hypotension and cool, clammy skin, may also occur. A localized reaction produces facial edema, erythema, and urticaria.
Cavernous sinus thrombosis
Cavernous sinus thrombosis, a rare but serious disorder, may begin with unilateral edema that quickly progresses to bilateral edema of the forehead, base of the nose, and eyelids. It may also produce chills, a fever, a headache, nausea, lethargy, exophthalmos, and eye pain
Chalazion
A chalazion causes localized swelling and tenderness of the affected eyelid, accompanied by a small red lump on the conjunctival surface.
Conjunctivitis
Conjunctivitis causes eyelid edema, excessive tearing, and itchy, burning eyes. Inspection reveals a thick purulent discharge, crusty eyelids, and conjunctival injection. Corneal involvement causes photophobia and pain.
Dacryoadenitis
Severe periorbital swelling characterizes dacryoadenitis, which may also cause conjunctival injection, purulent discharge, and temporal pain.
Dacryocystitis
Lacrimal sac inflammation causes prominent eyelid edema and constant tearing. With acute cases, pain and tenderness near the tear sac accompany purulent discharge.
Facial burns
Burns may cause extensive edema that impairs respiration. Additional findings include singed nasal hairs, red mucosa, sooty sputum, and signs of respiratory distress such as inspiratory stridor.
Facial trauma
The extent of edema varies with the type of injury. For example, a contusion may cause localized edema, whereas a nasal or maxillary fracture causes more generalized edema. Associated features also depend on the type of injury.
Herpes zoster ophthalmicus (shingles)
With shingles, edematous and red eyelids are usually accompanied by excessive tearing and a serous discharge. Severe unilateral facial pain may occur several days before vesicles erupt.
Myxedema
Myxedema eventually causes generalized facial edema; waxy, dry skin; hair loss or coarsening; and other signs of hypothyroidism.
Nephrotic syndrome
Commonly the first sign of nephrotic syndrome, periorbital edema precedes dependent and abdominal edema. Associated findings include weight gain, nausea, anorexia, lethargy, fatigue, and pallor.
Orbital cellulitis
The sudden onset of periorbital edema marks orbital cellulitis. It may be accompanied by a unilateral purulent discharge, hyperemia, exophthalmos, conjunctival injection, impaired extraocular movements, a fever, and extreme orbital pain.
Preeclampsia
Edema of the face, hands, and ankles is an early sign of preeclampsia. Other characteristics include excessive weight gain, a severe headache, blurred vision, hypertension, and midepigastric pain.
Rhinitis (allergic)
With rhinitis, red and edematous eyelids are accompanied by paroxysmal sneezing, itchy nose and eyes, and profuse, watery rhinorrhea. The patient may also develop nasal congestion, excessive tearing, a headache, sinus pain and, sometimes, malaise and a fever.
Sinusitis
Frontal sinusitis causes edema of the forehead and eyelids. Maxillary sinusitis produces edema in the maxillary area as well as malaise, gingival swelling, and trismus. Both types are also accompanied by facial pain, a fever, nasal congestion, purulent nasal discharge, and red, swollen nasal mucosa.
Superior vena cava syndrome
Superior vena cava syndrome gradually produces facial and neck edema accompanied by thoracic or jugular vein distention. It also causes central nervous system symptoms, such as a headache, vision disturbances, and vertigo.
Trachoma
With trachoma, edema affects the eyelid and conjunctiva and is accompanied by eye pain, excessive tearing, photophobia, and eye discharge. Examination reveals an inflamed preauricular node and visible conjunctival follicles.
Trichinosis
Trichinosis is a relatively rare infectious disorder that causes the sudden onset of eyelid edema with a fever (102° to 104° F [38.9° to 40° C]), conjunctivitis, muscle pain, itching and burning skin, sweating, skin lesions, and delirium.
Other causes
Diagnostic tests
An allergic reaction to contrast media used in radiologic tests may produce facial edema.
Drugs
Long-term use of glucocorticoids may produce facial edema. Any drug that causes an allergic reaction (aspirin, antipyretics, penicillin, and sulfa preparations, for example) may have the same effect.
Herb alert
Ingestion of the fruit pulp of ginkgo biloba can cause severe erythema and edema and the rapid formation of vesicles. Feverfew and chrysanthemum parthenium can cause swelling of the lips, irritation of the tongue, and mouth ulcers. Licorice may cause facial edema and water retention or bloating, especially if used before menses.
Surgery and transfusion
Cranial, nasal, or jaw surgery may cause facial edema, as may a blood transfusion that causes an allergic reaction.
Special considerations
Administer an analgesic for pain, and apply cream to reduce itching. Unless contraindicated, apply cold compresses to the patient's eyes to decrease edema. Elevate the head of the bed to help drain the accumulated fluid. Urine and blood tests are commonly ordered to help diagnose the cause of facial edema.
Pediatric pointers
Normally, periorbital tissue pressure is lower in children than in adults. As a result, children are more likely to develop periorbital edema. In fact, periorbital edema is more common than peripheral edema in children with such disorders as heart failure and acute glomerulonephritis. Pertussis may also cause periorbital edema.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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