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Difficulty: EasyBasic Care and Comfort

An older adult client is admitted to the medical-surgical floor with severe bilateral lower extremity edema associated with chronic venous insufficiency. What is the most appropriate action by the nurse to manage the client's swelling and promote comfort?

  1. Elevate the client's legs above the level of the heart while restingAnswer
  2. B
    Position a firm pillow directly under the client's knees
  3. C
    Delegate calf massage to the unlicensed assistive personnel (UAP) to reduce fluid
  4. D
    Maintain the client's legs in a dependent position when sitting in a chair

Answer

The most appropriate action is to elevate the client's legs above the level of the heart while resting.
Elevating the lower extremities above the level of the heart is a fundamental nursing intervention for chronic venous insufficiency. Gravity assists the compromised venous valves in returning blood and interstitial fluid back to the central circulation, thereby decreasing hydrostatic pressure in the legs, reducing edema, and improving client comfort.

Step-by-Step Solution

1
Assess the pathophysiology of the client's discomfort
The client has bilateral lower extremity edema due to chronic venous insufficiency, which causes fluid to pool in the legs.
Understanding the cause of the edema directs the appropriate positioning intervention.
2
Determine the optimal positioning to counteract fluid pooling
Elevation of the extremities above the heart is selected as the primary intervention.
Gravity facilitates the return of venous blood and lymphatic fluid back to the central circulation, effectively reducing peripheral swelling.
3
Ensure the chosen intervention avoids safety hazards
Avoid placing pressure behind the knees (popliteal space) and avoid massaging the calves.
Popliteal pressure impedes blood flow, and calf massage can dislodge a deep vein thrombosis.

Key Concept

Proper positioning and gravity to promote venous return
Estimated Time:45s
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Topics

Basic Care and Comfort

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