The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees.The nurse knows that this finding indicates:

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Because no cardiac valve exists to separate the superior vena cava from the right atrium,the jugular veins give information about activity on the right side of the heart.They reflect filling pressures and volume changes.Normal jugular venous pulsation is 2 cm or less above the sternal angle.Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with right-sided heart failure.

The Findings from an Assessment of a 70-Year-Old Patient with Swelling