A nurse is assessing a client’s lower extremities and notes 6 mm pitting edema. Which of the following is appropriate documentation of this assessment finding?
A.
1+
B.
4+
C.
3+
D.
2+
The correct answer and Explanation is :
The correct answer is C. 3+.
Explanation:
Edema is the accumulation of fluid in tissues, leading to swelling. Pitting edema refers to a condition where pressure applied to the skin results in a visible indentation that persists for some time after the pressure is removed. Nurses assess the degree of pitting edema based on the depth of the indentation and how long it takes for the skin to rebound.
Edema is graded on a scale from 1+ to 4+, with each level indicating the severity of the pitting:
- 1+ edema: Mild pitting with a depth of approximately 2 mm, with the skin returning to normal almost immediately.
- 2+ edema: Moderate pitting with a depth of about 4 mm, with a noticeable indentation that rebounds in a few seconds.
- 3+ edema: More severe pitting with a depth of about 6 mm, and the indentation takes longer to return to normal, typically around 10–20 seconds.
- 4+ edema: Severe pitting with a depth of 8 mm or more, and the indentation may persist for longer than 20–30 seconds.
In this scenario, the nurse observed a 6 mm pitting edema. According to the pitting edema scale, a 6 mm depth correlates with 3+ edema. Therefore, the appropriate documentation for this assessment finding is 3+.
Accurate documentation of edema is critical for monitoring the progression or improvement of a client’s condition, particularly in cases of heart failure, renal failure, or other conditions that may lead to fluid retention. This helps in guiding treatment decisions and evaluating the effectiveness of interventions such as diuretics, fluid restriction, or elevation of the extremities.