In which of the following disorders would the nurse expect to assess sacral edema in a bedridden client?
A. Diabetes
B. Pulmonary emboli
C. Renal failure
D. Right-sided heart failure
Correct Answer: D. Right-sided heart failure
The most accurate area on the body to assess dependent edema in a bed-ridden client is the sacral area. Sacral, or dependent, edema is secondary to right-sided heart failure. This is because the heart is too weak to pump blood around the body properly, so the blood gathers in front of the heart. Because of this, and due to the increased blood pressure in the veins, fluid seeps out into the surrounding tissue. This may cause swelling in the legs or a build-up of fluid in the abdomen. If the person spends a lot of time lying down, the edema might show up on his or her back (called sacral edema).
Option A: If there is a lack of the protein albumin in the blood, fluid can leak out of blood vessels more easily. Low protein in the blood can be caused by extreme malnutrition, as well as kidney and liver diseases which mean that the body loses too much or produces too little protein.
Option B: Venous insufficiency can cause edema in the feet and ankles, because the veins are having trouble transporting enough blood all the way to the feet and back to the heart. This means that it gathers in the legs, and fluid is forced out of the blood vessels into the surrounding tissue. Edema can also be caused by varicose veins.
Option C: Kidney disease could cause edema in the legs and around the eyes, because when the kidneys do not remove enough sodium and water from the body, the pressure in the blood vessels starts building up, which can lead to edema.
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