Introduction[edit | edit source] Show
Right foot and ankle edema- 2 weeks post-surgery Oedema is defined as a palpable swelling produced by an accumulation of fluid in the intercellular tissue that results from an abnormal expansion in interstitial fluid volume.
The rapid development of generalized pitting edema associated with the systemic disease requires prompt diagnosis and management. [1] Assessment of Oedema[edit | edit source]History - Should include:
Physical Examination - In physical examination, pitting, tenderness, skin changes, and temperature are evaluated.[1]
Methods to Quantitatively Assess Peripheral Oedema[edit | edit source]There are various methods used in research to assess peripheral edema.[3] The most commonly used tools to measure edema are:
Water displacement and ankle circumference had shown a high inter-examiner agreement (intraclass correlation coefficient 0.93, 0.96 right; 0.97, 0.97 left).
The volumeter:
Advantage - It is the gold standard tool for the measurement of edema.[5] Disadvantages - There are various disadvantages to these methods in a clinical setting.
[6] 2. Girth measurements (with a tape measure)
The circumferential method is one of the girth measurement techniques. For consistent measurements, each upper extremity or lower extremity is marked with a semi-permanent marker at a certain part with reference to the bony prominences,[3]
It is also one of the girth measurement techniques. It is more reliable than the circumferential method as it covers a bigger area. A tension-controlled measuring tape is preferred to wrap around the ankle/foot or hand for the measurement of edema than standard tape.[5][3] A figure of 8 method is usually preferred in ankle and hand swelling. It has its own specific points across for consistency.
[7]
[8] 3. Pitting edema Assessment - Press firmly with your thumb for at least 2 seconds on each extremity
Pit depth and the time needed for the skin to return to its original appearance (recovery time) are recorded. The grading of edema is determined by pit depth (measured visually) and recovery time from grade 0-4. The scale is used to rate the severity and the scores are as follows:
Conclusion[edit | edit source]
Pitting Oedema
Focus assessment on: symmetry of swelling, pain, edema change with dependence, skin findings (hyperpigmentation, stasis dermatitis, lipodermatosclerosis, atrophie blanche, ulcerations), and history of venous thromboembolism[9] References[edit | edit source]
What should the nurse include in the Focus assessment of a client diagnosed with peripheral arterial disease PAD in the lower extremities?Physical examination findings suggestive of PAD include abnormal pulses, audible bruits, nonhealing lower extremity wounds, lower extremity gangrene, elevation pallor, dependent rubor, delayed capillary refill, and cool extremities ( Table 2 ).
When assessing for acute arterial occlusion What would the nurse include?The six Ps (pain, pallor, poikilothermia, pulselessness, paresthesia, paralysis) are the classic presentation of acute arterial occlusion in patients without underlying occlusive vascular disease.
Which statement made by a student nurse concerning how do you conduct the retrograde filling test indicates that the nurse needs further teaching?Which statement made by a student nurse concerning how to conduct the retrograde filling (Trendelenburg) test indicates that the nurse needs further teaching? "Release the compression on the saphenous vein after having the client stand for about 20 seconds, and observe for slow filling."
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