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Clinical Nursing Experience (11 63 274) Edema

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John Marsh
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University of Windsor

Clinical Nursing Experience (11 63 274)

which degree of edema will result in a 6-mm deep indentation upon pressure application?

Edema
Edema is the abnormal accumulation of fluid in certain tissues within the body. The accumulation of
fluid may be under the skin – usually in dependent areas such as the legs (peripheral edema, or ankle
edema), or it may accumulate in the lungs (pulmonary edema). The location of edema can provide the
health care practitioner the first clues in regard to the underlying cause of the fluid accumulation.
What Are the Symptoms of Edema?
Symptoms will depend on the cause of edema.
Peripheral edema
Symptoms of peripheral edema include swelling of the affected area(s), which causes the surrounding
skin to “tighten.” The swelling from peripheral edema is gravity-dependent (it will increase or decrease
with changes in body position). The skin over the swollen area appears tight and shiny, and often when
pressure is applied to the area with a finger, an indentation appears. This is called pitting edema.
Pitting edema is classified based on the depth and duration of the indentation. The following scale is
used to rate the severity:
 Grade 1: The pressure applied by the doctor leaves an indentation of 0–2 millimeters (mm) that
rebounds immediately. This is the least severe type of pitting edema.
 Grade 2: The pressure leaves an indentation of 3–4 mm that rebounds in fewer than 15 seconds.
 Grade 3: The pressure leaves an indentation of 5–6 mm that takes up to 30 seconds to rebound.
 Grade 4: The pressure leaves an indentation of 8 mm or deeper. It takes more than 20 seconds to
rebound.

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Clinical Nursing Experience (11 63 274) Edema

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