While assessing a patient with heart failure, the nurse notes that the patient has jugular venous distension (JVD) when lying flat in bed. The nurse's next action will be to

Question

Quizplus · Accepted Answer

When assessing for and documenting JVD, the nurse should document the angle at which the patient is positioned. When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not clinically significant) finding. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists when the patient is at 30 to 45 degree angle or more. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. Comparison of the volume and pressure of the jugular veins is not included in jugular vein assessment.

While Assessing a Patient with Heart Failure, the Nurse Notes