While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention ( JVD ) when lying flat in bed. Which action should the nurse take next?

Question

Quizplus · Accepted Answer

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 a 30- to 45-degree angle or more. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. The nurse will document the JVD in the record if it persists when the head is elevated.

While Assessing a Patient Who Was Admitted with Heart Failure