Small Help needed with Assessment!!!!

twentytenRN · Mar 19, 2010

Yes, generally you examine all over. Edema can happen anywhere and could be caused by different pathologies. First place to look in a bedridden patient would be the sacrum for sacral edema. Fluid will begin to pool here first due to gravity. Check both lower extremities, check for pitting and grade it appropriately. Also check the upper extremeties as well.

CaLLaCoDe, BSN, RN · Mar 19, 2010

My main concern when it comes to edema is checking the lower sacral area and lower leg and ankle. When the edema pits (pitting edema), I will usually rate it a 1+ to 4+ depending on the severity. Usually I will assess as much of the patient's body as the patient will agree to or as I see may be of significant concern.

A concern regarding the lower leg might be fluid overload as seen in CHF (Especially if the lungs when auscultating have light crackles). A concern regarding the sacral area might be skin integrity which is also a concern with lower extremity edema. Possible actions: STDs, turn often, increase level of activity, request an order for Lasix to remove some of the excess fluid. Hope this helps. Good luck.

rita.kumar83 · Mar 19, 2010

Thanks for the answers. But I was wondering how to check for edema, is there a specific way? How do you assess for edema all over the body. Do you just take a look without touching the area (skin)? Thanks.

twentytenRN · Mar 19, 2010

You mainly rely on visual inspection, just looking at it you can see if the area has edema or not. You can and need to palpate the lower extremities for pitting edema near the ankles. Patients can also get edema around the eyes, called perioribital edema and this is assessed just by visual inspection.

Hope this helps.

mamamerlee, LPN · Mar 19, 2010

Although you can see there may be swelling, you must gently depress the skin to see if a 'pit' develops. Start at the top of the foot, and work up to mid-shin to determine how far up the leg it may go - may be up to the knees or even higher at times. Check the sacrum in bedridden pts, and the hands. Pts sometime report feeling stiff or swollen.

You do not need to wear gloves to do this unless the pt has open areas, or has such severe edema that she is 'weeping' thru the skin.

laurance · Mar 19, 2010

You do not need to wear gloves to do this unless the pt has open areas, or has such severe edema that she is 'weeping' thru the skin.

When assessing pts its a good idea to wear gloves anyway, just a good habbit to get into. The only time i would recomend not wearing gloves is when you are offering a patient theraputic touch.

filipina in Australi · Mar 19, 2010

Re:small help needed with assessment!!!

Press the site with your index finger to start with toes then up to find out the extension.

CaLLaCoDe, BSN, RN · Mar 19, 2010

When assessing pts its a good idea to wear gloves anyway, just a good habbit to get into. The only time i would recomend not wearing gloves is when you are offering a patient theraputic touch.

I agree using gloves is a good thing, especially when dealing with patient's skin. You never know what you may find. One time I was helping to transfer a patient ( I was new and naive); the patient showed no evidence of blood or ooze anywhere on his person, until I placed my hand under his right shoulder to help another nurse with the transfer. During the transfer I noticed something wet on my hand. After visually inspecting and finding blood, I rushed to the sink and doused my hands with antibacterial soap! So, sure you want to be personable and kind, however using gloves when inspecting someone for the first time is a wise choice. And I doubt a patient would find it disheartening!

rita.kumar83 · Mar 20, 2010

Thanks for the reponses. But do I need to check for edema all over the pt's body with my index finger? Still confused:confused:...Plzzz, I really need to pass this assessment.

craziechiq, BSN, RN · Mar 21, 2010

my instructor told me to press down over the bone with the index finger to check for edema.