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 11⁄49 to 11⁄29 (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.
Action stat!
Evaluating jugular vein distention involves visualizing and assessing venous pulsations. (See Evaluating jugular vein distention.) If you detect jugular vein distention in the patient with pale, clammy skin who suddenly appears anxious and dyspneic, take his blood pressure. If you note hypotension and a 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. Insert an I.V. catheter 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, respirations, and pulse oximetry.
History and physical examination
If the patient isn't in severe distress, obtain a 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.
Next, perform a physical examination, beginning with 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 with 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 compare to fluid intake.
Medical causes
Cardiac tamponade.Cardiac tamponade is a life-threatening condition that 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.Sudden or gradual development of right-sided heart failure commonly causes jugular vein distention, along with weakness and 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.
Pericarditis (chronic constrictive).Progressive signs and symptoms of restricted heart filling 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 a pericardial friction rub.
Superior vena cava obstruction.A tumor or, rarely, thrombosis of the superior vena cava 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, a cough, substernal chest pain, and hoarseness.
Nursing considerations
▪ If the patient has cardiac tamponade, prepare him for pericardiocentesis.
▪ Restrict fluids and monitor 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 central venous or pulmonary artery catheter insertion to measure right- and left-sided heart pressure and to monitor fluid status.
Patient teaching
▪ Explain food and fluid restrictions.
▪ Teach the patient to perform daily weight monitoring.
▪ Explain signs and symptoms that require immediate medical attention.
▪ Explain the importance of scheduled rest periods.
Pictures
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.
Other Book Chapters Related to Pericardial effusion
Read excerpts from these other book chapters related to Pericardial effusion:
Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Pericardial effusion
» Next page: Pericardial friction rub (Nursing: Interpreting Signs and Symptoms)
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