› Assessing Edema

Assessing Edema 

Edema is observable swelling from the accumulation of fluid in the interstitial spaces of body tissues. Edema can occur anywhere in the body. Depending on the location, the edema can be specified descriptively.

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Types of Edema to be Assessed

  • Generally, swelling in the feet, ankles and legs is referred to as peripheral edema
  • Edema specifically of the foot is called pedal edema
  • When fluid collects in the lungs it is called pulmonary edema and can be heard as rales with the stethoscope. 
  • If the fluid is not within the lungs themselves but in the chest cavity, then the fluid is called pleural effusion
  • Ascites, or fluid retention in the abdominal cavity is another place for fluid to collect. 
  • Excess fluid in the brain is cerebral edema.
  • Anasarca is extreme generalized edema refers to the severe, widespread accumulation of fluid in the all of the tissues and cavities of the body at the same time.
  • Dependent edema means edema that occurs when the limbs are hanging down and gravity pulls the fluid to the lowest point

There can be many systemic reasons for the buildup of fluids including diseases of the heart, liver, and kidneys as well as localized reasons such as DVT (Deep Vein Thrombosis)

Fluid retention can occur rather rapidly in some patients, so having a baseline is a good idea.

Methods For Assessing Edema

Not every type of edema can be measured by the nurse but most can if not directly, then indirectly.

Daily weights at the same time every day utilizing the same scale and having the patient wear the same clothing to minimize variance due to external factors is one way to measure any changes. 

Patients with Heart Failure are usually told by their physician, and reinforced by the nurse that any increase in 2-3 lbs. in one day or 5 lbs. over the course of a week needs to be reported. 

There is no way someone can gain that kind of weight from overeating. This kind of weight gain is not fat and not muscle, it is fluid.

Another way of assessing fluid retention is by listening to the lungs for rales or assessing the amount of shortness of breath a patient may be having. The more fluid that builds up in the lungs, the less room the lungs have to exchange oxygen. You can learn more about assessing lungs by going to this page.  

An additional way in assessing edema is by using a tape measure around extremities or the abdomen. The important part with this is to make sure you are measuring at the same point each and every time.  So it is best to describe where exactly you do this. For example, “immediately over the umbilicus”, or “1 inch below the knee cap”.  

Increase in size of the circumference of any body part indicates increased fluid retention.

Assessing edema includes determining if it is pitting or non-pitting.  Pitting edema is when pressure is applied to the skin and enough force to be able to depress the area.  The amount of depression indicates the amount of pitting.

Degrees of Pitting Edema

  • +1 pitting edema = trace = barely perceptible depression
  • +2 pitting edema = mild = 0.6 cm depression with rebound in less than 15 seconds
  • +3 pitting edema = moderate = 0.6 to 1.3 cm depression with rebound in 15 to 30 seconds
  • +4 pitting edema = severe = 1.3 to 2.5 cm depression with rebound of greater than 30 seconds

When assessing edema, pressing into a patient’s extremity is done firmly and smoothly as opposed to trying to punch the leg. Think in terms of pressing your thumb into a memory foam pillow to obtain a depression.

Pitting edema can also be noted when people wear socks that are too tight, or shoes that are too tight, or somebody puts on an ace wrapped that is inconsistently applied.

When you have bedbound patients that don’t move themselves in bed often or must be turned by a caretaker, make sure you check their hips and back of the body and legs.  Excess fluid can pool at the back of the body.  

Non-pitting edema does not show any lasting depression.  It can be difficult on obese patients to determine if you’re seen non-pitting edema at the ankle or the patient is just large.  Which is why having a baseline by measuring or weighing can be helpful.

Controlling Edema

After assessing edema and documenting what you have found in your nurse's notes, the next step is follwoing any orders from the physician to control the swelling. Patients with peripheral edema many times are ordered by the Physician to use either TED hose which is an abbreviation for Thrombus Embolic Deterrent or using compression ace wraps to reduce the amount of swelling by pushing the excess fluid out of the legs and hopefully into the circulatory system where the excess can be filtered out by the kidneys.

Other ways of controlling edema is through diet and restricted salt intake, or elevation of the legs so that gravity can pull the excess fluid back into the circulatory system.  When asking a patient to elevate their legs, the usual phrase is “toes above the nose”, meaning that they must elevate the legs high enough so that they are literally in a Trendelenburg position.  

Of course patients rarely do this at home, but any elevation of legs is better than none.

Related Pages

Cardiovascular Nursing Skills

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