Re: Assessing edema-1+, 2+, etc.

Snickers&DtCoke · Aug 11, 2008

This is how I've always interpreted it.... veterans PLEASE correct me if I'm wrong!!

WHen pressing with fingers on an edemetous (swollen d/t excess fluid) area, your fingers may leave a indentation that remains a few seconds... no marks but swollen is non-pitting edema... if your finger leaves indentation of about 1 fingerwidth deep it is 1+, 2 fingers deep 2+ and 3 fingers deep (not a good thing for your patient) is 3+. This usually happens on ankles and lower extremeties of CHF patients. and lots of times begin LASIX or have their LASIX dose increased to combat this. Legs should be elevated as much as possable as well.

We had a woman dieing d/t renal failure and she had pitting edema Bilateral extremeties up to abdomen. We left hand prints on her when we T&P her. :-(

Murse901, MSN, RN · Aug 11, 2008

From what I've always been told, it doesn't have to do with finger depth, but time. If the pitting resolves in under 15 seconds, it's 1+. 15-30 seconds, 2+. 30-60 seconds, 3+. Anything over 60 seconds, 4+.

The finger width or depth is going to depend on how many fingers and how deep you press in, so that wouldn't be a reliable measure (i.e. if I only use 1 finger, it can only be classified as 1+, etc).

nessajune21 · Aug 11, 2008

We are currently taught in nursing school that pitting edema is graded by indention.

0: none

+1: trace, 2mm- slight indent, normal contour

+2: moderate, 4mm- lasts longer than +1, fairly normal contour

+3: deep, 6mm- remains several seconds after pressing, obvious swelling

+4: very deep, 8mm+- remains for prolonged period(possibly minutes), gross swelling

* There is also Brawny edema in which fluid can no longer be displaced, hence, no pitting.

beachcomber64 · Aug 11, 2008

Thanks so much for ya'll's replies on assessing edema. It will help a bunch.:typing