Question

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; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented?

a) Grade 1
b) Grade 2
c) Grade 3
d) Grade 4

Answer 1

The nurse had documented Grade 2 edema, characterized by a 6-mm pit that persists for several seconds after pressing, indicating fluid accumulation in the tissues.

Step-by-step explanation:

The nurse documented a case of Grade 2 edema. Edema is the accumulation of excess water in the tissues, often seen in the extremities. When assessing for edema, one common method used is the pitting test, where a finger is pressed into the suspected area and then removed. The presence and duration of the remaining depression, or pit, can help determine the severity of edema. Grades of edema are typically classified based on the depth of the pit and how quickly it rebounds. A 6-mm pit that remains for several seconds is indicative of Grade 2 edema. Fluid volume excess and associated swelling can be caused by various medical conditions and thus require appropriate diagnosis and treatment.