Case Study – Understanding Edema in a 65-Year-Old Patient

Case Study – Understanding Edema in a 65-Year-Old Patient

John, a 65-year-old accountant, presented with progressive swelling in his ankles and lower legs. His medical history includes hypertension and type 2 diabetes, managed with an antihypertensive and an oral hypoglycemic agent. Despite medication compliance, John has experienced shortness of breath and increased fatigue during his daily walks. Physical examination revealed pitting edema in his lower extremities, and blood tests indicated decreased albumin levels.

Edema occurs when there is an imbalance between oncotic pressure and hydrostatic pressure in the capillaries, as stated by Lent-Schochet and Jialal (2023). In John’s case, hydrostatic pressure exceeds colloid osmotic (oncotic) pressure, which thus promotes fluid filtration into the interstitial space and leads to swelling. The lymphatic system plays a crucial role in the development and resolution of edema by recovering excess tissue fluid (lymph) and returning it to the bloodstream. This process involves lymph capillaries absorbing the interstitial fluid, which then passes through larger lymphatic vessels, then through lymph nodes for filtration, and finally drains into the venous system via the thoracic duct or right lymphatic duct.

To alleviate John’s painful swelling, a nurse would likely administer an isotonic solution. This choice helps maintain fluid balance without causing additional fluid shifts that could exacerbate edema. Hypertonic solutions could draw more fluid out of cells, while hypotonic solutions could lead to increased intracellular fluid, neither of which would be beneficial in managing edema (Ernstmeyer & Christman, 2021).

Hypertension and diabetes contribute significantly to John’s development of edema. Hypertension increases the hydrostatic pressure within capillaries, promoting fluid leakage into the interstitial space (Malek & Soufi, 2023). Diabetes can damage blood vessel walls and affect kidney function, leading to altered urine output and further fluid retention. Both conditions can exacerbate the permeability of capillaries, worsening edema. John’s decreased albumin levels also reduce oncotic pressure, decreasing fluid reabsorption back into the capillaries.

References

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Chapter 15 Fluids and Electrolytes. In Nursing Fundamentals. Nursing Fundamentals – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK591820/

Lent-Schochet, D., & Jialal, I. (2023, May 1). Physiology, edema. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK537065/

Malek, R., & Soufi, S. (2023). Pulmonary edema. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557611/

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The lymphatic system works alongside the circulatory system to ensure excess tissue fluid is recovered into the bloodstream. This recovered fluid is known as lymph. Edema occurs when fluid accumulates in the interstitial space, leading to swelling of the affected body part. Edema is often associated with conditions affecting the cardiovascular, renal, or hepatic systems Common causes of edema include increased capillary filtration, reduced reabsorption, and obstructed lymphatic drainage. Other common causes include kidney failure that leads to water retention and hypertension, aging that can increase the permeability of capillaries, and poor venous return that prevents fluids from flowing back to the heart.

As fluid accumulates in tissues, oxygen delivery and waste removal are impaired, and tissues may begin to die. If edema occurs in the lungs (pulmonary edema), this can result in suffocation. If edema occurs in the cerebrum, this can result in headaches, nausea, seizures, and come. Severe edema can cause circulatory shock.

Patient Background:
John is a 65-year-old man who presents to the clinic with complaints of swelling in his ankles and lower legs. He reports that the swelling has been progressively worsening over the past few weeks. John has a medical history of hypertension and type 2 diabetes. His current medications include an antihypertensive to regulate his blood pressure and an oral hypoglycemic agent to regulate his blood sugar. He has been compliant with his medications and has not experienced any adverse effects.

John works as an accountant and spends long hours at his desk. He mentions that he has noticed increased fatigue and shortness of breath during his daily walks, which he attributes to the swelling in his legs. He denies any chest pain, palpitations, or recent illnesses.

Desired Outcomes:

1. To assess the underlying cause of John’s peripheral edema.
2. To develop a plan for managing John’s edema, addressing the contributing factors.
3. To educate John on self-management strategies and the importance of adherence to the treatment plan.

Findings:
John’s blood pressure is well-controlled at 130/80 mmHg. John’s blood glucose levels are within the target range. Physical examination reveals pitting edema in both ankles and lower legs. John denies recent changes in medication, dietary habits, or exercise routine. Blood tests revealed that John has decreased albumin levels.

Questions:

1. Which of the following best describes the balance between hydrostatic pressure and oncotic pressure in capillaries?
2. Hydrostatic pressure exceeds colloid osmotic (oncotic) pressure, promoting fluid filtration.
3. Colloid osmotic pressure exceeds hydrostatic pressure, promoting fluid reabsorption.
4. Hydrostatic pressure and oncotic pressure are equal, resulting in no net fluid movement.
5. Both hydrostatic and oncotic pressures are negligible in capillaries.
6. Describe the role of the lymphatic system in the development and resolution of edema.
7. Trace the pathway of lymph starting from the interstitial fluid to the bloodstream.
8. What type of solution would you expect the nurse to give John to alleviate the painful swelling: hypertonic, hypotonic, or isotonic? Why?
9. How do John’s diabetes and hypertension contribute to his development of edema? (Hint: think about the impact on blood vessel walls, urine output, and the relationship between blood pressure and how capillaries)

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