Question

A patients ankles appear swollen. When the nurse assesses the edema, the skin depresses 6 mm, and the depression lasts 2 minutes. The nurse should document this finding as:

1)
Trace edema.
2)
+1 edema.
3)
+2 edema.
4)
+3 edema.

Answer 1

The nurse should document the patient's skin depression as +2 edema, which indicates a moderate level of pitting edema lasting for a short duration.

Step-by-step explanation:

When it comes to assessing and documenting edema, healthcare professionals often use a grading scale to classify the severity. In the scenario described, the patient's ankle skin depresses 6 mm and the depression lasts for 2 minutes after being palpated; this would be documented as +2 edema. Edema grading typically ranges from +1, which indicates slight pitting that disappears quickly, to +4, which signals very deep pitting that lasts for a prolonged period of time. +2 edema is indicative of moderate pitting that lasts for a short while but does not resolve immediately.

Understanding edema is crucial as it can be a symptom of various underlying health issues that may require medical treatment. Factors contributing to edema can include heart failure, renal failure, and certain medications such as vasodilators. In practice, edema that displays as persistent pitting when pressure is applied is a clear indication that fluid is accumulating in the interstitial spaces, often requiring further clinical evaluation and intervention.