A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient’s legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?
A.
2+ Pitting Edema
B.
3+ Pitting Edema
C.
1+ Non-Pitting Edema
D.
4+ Pitting Edema
E.
4+ Pitting Edema
The correct answer and Explanation is :
The correct answer is:
D. 4+ Pitting Edema
Explanation:
Edema refers to the accumulation of fluid in tissues, leading to swelling, particularly in the lower extremities. Pitting edema occurs when pressure applied to the swollen area leaves a noticeable “pit” or indentation that persists for a while.
Edema is typically graded on a scale from 1+ to 4+, based on the depth of the indentation and how long the pit remains after pressure is released:
- 1+ Edema: Slight pitting, with a very small indentation (2 mm) that disappears rapidly (within a few seconds).
- 2+ Edema: Moderate pitting, with a pit depth of about 4 mm. The indentation disappears in about 10-15 seconds.
- 3+ Edema: Deeper pitting, with a 6-mm pit. The indentation lasts for 30 seconds or more.
- 4+ Edema: Very deep pitting, with an 8-mm pit or greater. The indentation can last for 2 to 5 minutes or longer.
In the given case, the nurse observes an 8-mm pit that remains for 4 minutes after pressing. According to the grading scale, this corresponds to 4+ pitting edema, which is the most severe form of pitting edema.
Significance:
4+ pitting edema often indicates severe fluid retention, which could be related to underlying conditions like heart failure, renal failure, or liver disease. This degree of edema requires further assessment and potentially urgent intervention to address the underlying cause. The presence of such significant edema can also compromise skin integrity and increase the risk of infection, particularly in immobile patients. The management of 4+ edema involves reducing fluid overload through diuretics and addressing the underlying health condition contributing to fluid retention.