Jugular Vein Distention NCLEX Review Care Plans
Nursing Study Guide on Jugular Vein Distention (JVD)
Jugular vein distention (JVD) also called Jugular venous distention happens when there is an increased pressure in the vena cava. JVD manifests as a bulge on the side of the neck.
The bulging jugular vein appears to be similar to a raised tube or rope just below the surface of the skin. The healthcare provider can measure the height of the bulge to know the central venous pressure (CVP) which can indicate the blood flow from the head to the heart.
High CVP as exhibited by jugular vein distention is a warning sign of heart failure; however, JVD can also be caused by other cardiac conditions.
Signs and Symptoms of Jugular Vein Distention (JVD)
JVD itself is a sign of a cardiac problem; however, there are symptoms that may happen alongside JVD which can help indicate the underlying cause of JVD. These include:
- rapid heart rate or tachycardia
- heart palpitations
- cyanosis – blue lips (central) or fingernails (peripheral)
- shortness of breath or difficulty breathing
- wheezing or choking
- decreased alertness
- passing out or becoming unresponsive
- chest pain, tightness, or pressure
- not being able to produce any urine
- rapid weight gain
- excessive sweating
Causes and Risk Factors of Jugular Vein Distention (JVD)
The jugular veins located on each side of the neck work as passageways for the movement of the blood from the head to the largest vein in the body called the superior vena cava (SVC). T
his vein is responsible for transporting blood to the heart and lungs. Jugular vein distention or JVD occurs when the pressure in the SVC increases, causing the jugular vein to bulge and become more visible.
The increase in the SVC pressure may be a result of a blockage due to a clot or tumor, blood accumulation in the chamber/s of the heart, or blood backing up in the veins. The following are the known causes of JVD:
- Right-sided heart failure. The right ventricle of the heart works harder to compensate for blood accumulation in the lungs that is usually caused by a pre-existing left ventricle failure. In time, the right ventricle becomes weak and can no longer pump blood effectively, causing right-sided heart failure and an eventual bulging of the jugular vein due to continuous blood accumulation.
- Tricuspid valve stenosis
- Pulmonary hypertension
- SVC obstruction
- Cardiac tamponade
- Constrictive pericarditis
The following are the risk factors that may increase the likelihood of JVD:
- high blood pressure
- coronary artery disease
- congenital heart defects
- heart attack
- sleep apnea
- irregular heartbeats
- alcohol use or abuse
- some medications
Complications of Jugular Vein Distention (JVD)
The following medical conditions can result from untimely and/or inappropriate treatment of JVD:
- Cardiac arrest
- Cognitive problems, especially thinking and memory
- Renal dysfunction
- Hepatic dysfunction
Diagnosis of Jugular Vein Distention (JVD)
- Physical examination – the physician will measure the height of the bulge of JVD to indicate CVP; the patient will be asked to lie down on the exam table with the head at 45 degrees. The patient will be asked to turn his/her head to the side while the physician measures the CVP; normal CVP is 6 to 8 centimeters of water (cm H2O).
- Medical history – to check for medical history of cardiac disorders
- Vital signs – auscultation to assess any abnormality in heart sounds (e.g., murmur for tricuspid valve stenosis)
- Electrocardiogram – to check for any arrhythmia accompanied by JVD
- Imaging – echocardiogram can be done to check for heart failure, valve disease, or other cardiac issues
- Blood tests – to check for any renal or hepatic problems that may affect the cardiovascular system which can relate to the emergence of JVD
Treatment for Jugular Vein Distention (JVD)
The treatment of JVD depends on its cause, which is usually heart failure.
- Medications. Several medications are used in combination to treat heart failure and consequently JVD. These include:
- Angiotensin-converting enzyme (ACE) inhibitors – promote vasodilation of the blood vessels, which results to the lowering the pressure and improving the blood flow
- Beta blockers – reduce heart rate and blood pressure
- Angiotensin II receptor blockers – similar to ACE inhibitors and can be used if the patient does not tolerate ACE inhibitors
- Digitalis or digoxin – improves the contraction of heart muscles, regulate heart rhythm and reduces heartbeat.
- Inotropes – improve the function of the heart to pump blood in severe heart failure
- Diuretics – facilitate elimination of excess fluid in the body through urination
- Inotropes – intravenous medications used in people with severe heart failure in the hospital to improve heart pumping function and maintain blood pressure
- Surgical interventions. These include coronary bypass surgery, heart valve repair or replacement, and heart transplant. It may also involve the insertion of medical devices such as implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy (CRT), and ventricular assist devices (VADs).
- Lifestyle changes. An important part the treatment plan for a patient with JVD and cardiac disorder is to change several habits that are linked to the disease. These include smoking cessation, blood pressure control, diabetes management, dietary changes, stress management, exercise and increase in physical activity.
Nursing Care Plans for Jugular Vein Distention (JVD)
Nursing Care Plan 1
Nursing Diagnosis: Decreased Cardiac Output related to increased pressure in the superior vena cava (SVC) secondary to increased preload and afterload and impaired contractility as evidenced by jugular vein distention, irregular heartbeat, heart rate of 128, dyspnea upon exertion, and fatigue.
Desired outcome: The patient will be able to maintain adequate cardiac output.
|Measure the height of the bulge or distention of the jugular vein. Ask the patient to lie down on the exam table with the head at 45 degrees. Ask him/her to turn his/her head to the side to measure the central venous pressure (CVP).||The physician will measure the height of the bulge of JVD to indicate CVP. The normal CVP is 6 to 8 centimeters of water (cm H2O).|
|Assess the patient’s vital signs and characteristics of heart beat at least every 4 hours. Assess breath sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Breath sounds of crackles/rales are important signs of heart failure. The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.|
|Administer the cardiac medications and diuretics as prescribed.||To alleviate the symptoms of heart failure and to treat the underlying condition.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target reach as set by the physician.|
|Educate patient on stress management, deep breathing exercises, and relaxation techniques.||Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. Chronic stress may also cause an increase in adrenaline levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels.|
Nursing Care Plan 2
Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures as evidenced by jugular vein distention, shortness of breath, SpO2 level of 85%, and crackles upon auscultation.
Desired Outcome: The patient will have improved oxygenation and will not show any signs of respiratory distress.
|Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the targe.t value as set by the physician.|
|Encourage small but frequent meals. He||To avoid abdominal distention and diaphragm elevation which lead to a decrease in lung capacity.|
|Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position.||Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.|
Nursing Care Plan 3
Nursing Diagnosis: Fatigue related to decreased oxygenation of the blood as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The patient will establish adequate energy levels and will demonstrate active participation in necessary and desired activities.
|Ask the patient to rate fatigue level (mild, moderate, or severe fatigue). Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.||To gradually increase the patient’s tolerance to physical activity. Sedentary lifestyle is a risk factor to develop severe heart disease.|
|Encourage the patient to follow a low cholesterol, high caloric diet. Refer to the dietitian as needed.||To increase energy levels while promoting a lower risk for a worsening heart condition.|
|Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To allow the patient to relax while at rest. To allow enough oxygenation in the room.|
|Refer the patient to physiotherapy / occupational therapy team as required.||To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.|
Other possible nursing diagnoses:
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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