1+ 2+ 3+ Edema Rating Scale?

[Daytonite, BSN, RN]

Erin (who is trying to get ahead of her studies). . .

Edema is evaluated on it's ability to pit. The examiner's fingers are pressed into a dependent area of the patient's skin for 5 seconds. Areas used to check for pitting are the sacrum if the patient is bedridden, or the lower leg. If pitting edema is present, the fingers will sink into the tissue and leave an impression of the fingers when they are removed. This pitting is graded on a scale of +1 to +4 as follows:

 

	Definition
Grade +1	(Trace) Mild pitting, 2mm indent, slight indentation, rapid return to normal
Grade +2	(Mild) Moderate pitting, 4mm indent, rebounds in a few seconds
Grade +3	(Moderate) Deep pitting, 6mm indent, 30 seconds
Grade +4	(Severe) Very deep pitting, 8mm indent, > 30 seconds to return to normal

[Antikigirl, ASN, RN]

I rate it on the pitting by how many seconds it takes to return to normal after an indent. If it takes 1-3 seconds I rate it a one, 4-6 seconds a two, more a three and after that I tell them how many seconds and say beyond a three.

Now I push down till a good blanch happens, then count...and I do it on multiple sites. I also take the time since I am there to feel for pedal pulses and let my MD know if I was able to find them easily or not...and I get lucky here because I know my patients well...if I can find them normally...if not I say that I don't know if they normally have easy to find pedal pulses.

Rating edema becomes natural to tell after a while I think...and with non pitting...well that is enough for me just to tell my MD's..."hey we have non pitting" and I describe skin tone, color, nailbeds, hair placement (that tells you volumes actually about circulation!), nail condition, temp of the extremity, any numbness/tingling, pain, changes in mobility...you name it (well I tell that for pitting too)! AND especially if there is skin damage r/t this! I have been told I am overly efficient by my other nurses..but the docs..they love me!!

But edema is my game really...I work at an assisted living facility where everyone seems to have a degree of CHF, or diabetes, or other conditions where edema is just fairly normal. SO is lasix..LOL! OH those poor folks...they may not know most of their meds..but they know that one..they call it the "pee like a race horse pill"...or "little, white, peeing all night" (my humor has been transfered to my clients..can you tell? LOL).

Did you know that lasix was actually made for race horses? Yeppers! It was produced to encourage lower water weight in horses so they were lighter...then a smart doc said..hmmmm fluid regulation..and the rest is history :). So when a client says "I am peeing like a race horse" tell them "yep...you are!!"...LOL! 

[Energizer Bunny]

This is what my Health Assessment text says:

1+ Mild pitting, slight indentation, no perceptable swelling of the leg

2+ Moderate pitting, indentation subsides rapidly

3+ Deep pitting, indentation remains for a short time, leg looks swollen

4+ Very deep pitting, indentation lasts a long time, leg is very swollen

HTH.....

[Antikigirl, ASN, RN]

Rating edema with the 0-4 score is something you do get use to when you start seeing edema really. There are different theories on cm's down per score...but typically most MD's and RN's don't go by that strict of scale...it is a eye thing.

Say I have a patient who seems to have some ankle swelling but not too much for me to go WHOA! Just a small amount. I press one finger into the most swelling area and rate the time it takes for the pit to come back to normal and rate it according to that. Now considering it wasn't that much swelling in the first place...it proably won't be more than a 1...

The biggest dx thing is the pitting or nonpitting! Make sure you document that! Then I always check pedal pulses and cap refill on all toes.

Another interesting item is to look at the hair patterns on the legs! If it is patchy hair placement you have a probelm (unless they aren't very good at shaving for ladies...must know when last time they shaved), that can mean poor circulation (ie, hair not growing well!). Good hair placement usually means this maybe a newer probelm if they have edema. Big toe hair is another indicator but not always. Nails too...but in older patients it is rather hard since nails can get thick or long due to poor hygiene (if they can't reach or have help to clip toe nails...or diabetes), so I use that as another guage if indicated (again...I have seen many feet so I have that eye for it).

Redness or pain in the area also is a bad sign. Follow up with that at all times with the MD.

My advice is if you can have Nurses show you edema (not limited to pedal), and gain as much 'eye' experience as you can it will be a snap!

Good luck! :)

[happystudent, RN]

when you press your finger into the skin. it makes a pit. Then you decied how deep it is by how far down the indentation is. +1+2+3

personally, any edema is bad....

[Antikigirl, ASN, RN]

That is what I learned originally too! BUT, you may not get a doc responding to a +1 as much as not only giving your percieved scale, but the other s/sx I mentioned. So I always tend to discribe more than just the edema scale...

I have had patients with acute onset that have never had edema before...and when I say +1 to a doc, they may not be as concerned as I am...so I always mention: change of condition, new onset of pitting pedal edema, bilateral lower extemities within normal color and temp, with good blanch at 1 second, ppx4 (pedal pulses), and normal hair placement bilateral legs, resident states "my ankels are very stiff...I have never had this before", and has increased anxiety for fall. No hx of edema mentioned in chart. Please advise.

See...a little more writing sure, but gives a bit more than "acute onset of +1 pitting edema bilateral extremities". (thank goodness I write fast and clearly...or at least I think clearly..LOL!).

[Energizer Bunny]

I see what you mean, Triage....something that will come with experience, I'm sure. It makes perfect sense, though...I'm glad you mentioned it!

[Antikigirl, ASN, RN]

Well I learned this pretty quick being harrassed by paramedics all the time..LOL! Oh boy they really drilled in how to do a 'report' to them so that I would make even a burned out doc listen! LOL! So I have to thank them big time...it isn't just what you know..or what you relay...it is whom you are having to work with and sometimes...around! That comes with experience 

To this day if I don't do a good report to the paramedics..they tell my hubby and boy do I get it..LOL!!!

[Blackcat99]

Thanks all for your great information. I suffer from CRS. Can't remember s###. :

[mommy2boys]

Is there a way to rate the different levels of edema (if there are different levels of edema)?

I'm studing for a class (medical terminology) and was wondering if there were levels of edema or if it's a all or nothing type thing. I'm going to ask when we get back from spring break but that's going to be in a week.

TIA

Erin (who is trying to get ahead of her studies:lol2: )

[ragincajunstudent]

its a 0-4 rating scale. 0 being none 4 being massive edema.

its judged on how long the skin stays pitted after you press on it and how much the skin pits.

[mommy2boys]

Thanks for the info. You all are really great to take time to help out us students.

Erin