Edema is swelling caused by fluid buildup in the tissues. It can occur in any part of the body but is most noticeable in the face, arms, hands, legs, and feet.
Edema is a common manifestation of many underlying health conditions, such as congestive heart failure, kidney disease, or liver cirrhosis. It can also occur suddenly from an allergic reaction or an adverse effect of a medication. Some instances of edema are benign and will resolve independently, such as from pregnancy or prolonged sitting.
Edema can be systemic or localized, such as with the following examples:
- Cerebral Edema: A serious and life-threatening type of edema characterized by fluid buildup in the brain.
- Pulmonary Edema: Another serious type of edema that occurs when fluid accumulates in the lungs causing shortness of breath and respiratory distress.
- Lymphedema: Typically occurs in the arms and legs and is associated with problems in the lymph nodes.
- Peripheral Edema: A clinical manifestation of health conditions associated with the circulatory system, kidneys, or lymph nodes.
- Periorbital Edema: Swelling around the eyes.
- Angioedema: Swelling that involves subcutaneous or submucosal tissue, often caused by an allergic reaction.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Excess Fluid Volume
- Ineffective Health Maintenance
- Risk for Impaired Skin Integrity
- Risk for Unstable Blood Pressure
Nursing Process
The management of edema depends on its severity and the underlying condition. Mild edema will usually not require any interventions, as the swelling will subside on its own. Edema that affects organs like the brain and lungs or causes serious symptoms like respiratory distress require immediate management.
Nurses provide interventions that can help improve swelling, such as repositioning and dietary restrictions. Lifestyle modifications may be needed to reduce the recurrence of edema along with adherence to the management of the underlying condition causing the edema.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to edema.
Review of Health History
1. Note the patient’s complaints and general symptoms.
The patient may report shortness of breath or chest pain in instances of pulmonary edema. For peripheral edema or lymphedema, the patient may report clothes or jewelry fitting tighter. Limbs may feel heavier or fuller. Angioedema may cause itching, abdominal pain if the gastrointestinal tract is affected, or difficulty swallowing or breathing if the airways are affected.
2. Ask about diet and lifestyle.
Fluid may accumulate in various body parts if foods high in sodium are consumed. Prolonged standing or sitting can cause dependent edema, which is when fluid pools in the extremities due to gravity.
3. Determine the underlying cause.
Underlying medical conditions that may cause edema include the following:
- Congestive heart failure
- Pericarditis
- Deep vein thrombosis
- Chronic venous insufficiency
- Kidney disease
- Traumatic brain injury
- Acute respiratory distress syndrome
- Pulmonary embolism
- Chronic obstructive pulmonary disease
- Obstructive sleep apnea
- Liver disease
- Thyroid disorders
- Cellulitis
- Malnutrition
- Pregnancy
4. Track the patient’s medication list.
The following medications may cause edema:
- Anti-hypertensives (calcium channel blockers, minoxidil, or beta-blockers)
- Antidepressants
- Chemotherapy
- Hormones
- Thiazolidinediones
- NSAIDs
- Corticosteroids
Physical Assessment
1. Perform a detailed physical examination.
The nurse’s physical exam should depend on the patient’s medical history and current presentation. For example, a patient exhibiting a CHF exacerbation should have a detailed cardiovascular assessment.
2. Inspect the skin.
Chronic or severe cases of edema may contribute to skin alterations. Assess for changes in pigmentation, erythema, temperature, thickening or hardening, and breakdown, such as ulcerations.
3. Monitor vital signs.
The nurse may recognize changes in vital signs that correlate with fluid retention causing edema. Remain alert for increases in temperature, blood pressure, pulse rate, and respiratory rate and a drop in oxygen saturation.
4. Weigh the patient.
Weight is another indicator of fluid retention. Daily weights should be obtained in patients with a history of recurrent fluid retention, such as CHF, kidney, or liver disease.
5. Grade the edema.
To determine the severity of peripheral edema, press a finger on a swollen area for five to fifteen seconds. Remove the pressure and observe for an indentation. Measure the rate of indention rebound and degree of pitting using the following scale:
- Grade 0: Nonpitting
- Grade 1+: Immediate rebound with 2 mm pit.
- Grade 2+: Less than 15-second rebound with 3 to 4 mm pit.
- Grade 3+: Rebound between 15-60 seconds with a 5 to 6 mm pit.
- Grade 4+: Rebound between 2 to 3 minutes with an 8 mm pit.
Diagnostic Procedures
1. Perform testing to investigate underlying conditions.
Anticipate the following tests for patients with a cardiovascular history:
- Serum brain natriuretic peptide (BNP)
- ECG
- Echocardiogram
- Chest radiography
- Doppler ultrasonography
The following tests are recommended for renal diseases:
- Basic metabolic profile
- Serum creatinine
- Urinalysis
- Renal ultrasonography
For liver disease, consider these lab tests:
- AST and ALT
- Albumin
2. Consider further imaging.
If DVT is suspected, an ultrasound should be performed. In cases of lymphedema, lymphoscintigraphy can detect blockages in the lymphatic system.
3. Perform ankle-brachial index testing.
This test compares the blood pressure in the ankle and arm to evaluate blood flow alterations and diagnose venous insufficiency.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with edema.
1. Treat the underlying condition.
Treatment of edema is dependent on the cause. Management can include conservative interventions, medications, skin care, or surgery in life-threatening situations, such as with cerebral edema.
2. Administer diuretics as prescribed.
The recommended course of treatment for hepatic, renal, and cardiovascular causes of edema often includes diuretics to rid the body of excess fluid.
3. Implement fluid restrictions.
Along with diuretic administration, the patient may be placed on oral fluid restrictions to reduce fluid overload.
4. Adhere to dietary recommendations.
In some instances of edema, limiting sodium in the diet will help reduce fluid retention and subsequent swelling.
5. Encourage position changes and elevation.
Edema can result from a sedentary lifestyle or prolonged sitting or standing. Encourage the patient to change positions frequently. Elevate the legs to encourage circulation.
6. Administer anticoagulants.
Administer heparin, warfarin, or other anticoagulants to prevent and treat DVT.
7. Apply compression.
Encourage compression for chronic venous insufficiency and lymphedema to prevent fluid accumulation. Apply support stockings, socks, or pneumatic sleeves to the affected extremity. Compression therapy is contraindicated in peripheral arterial disease.
8. Protect the skin.
Edematous areas are prone to skin breakdown. Inspect the skin for irritation and ensure the area is kept clean and dry.
9. Educate on lymphatic massage.
Manual lymphatic drainage is a massage technique that aids in moving lymphatic fluid through the body for proper removal.
10. Monitor pregnant patients closely.
Swelling of the lower extremities is normal in pregnancy due to increased blood volume and pressure from the growing uterus. If swelling is sudden or severe or occurs in the hands or face, the nurse should be alerted to the possibility of preeclampsia, and immediate evaluation is required.
11. Support lifestyle modifications.
Edema resulting from chronic conditions may require lifestyle modifications such as weight loss, dietary changes, and regular physical activity.
12. Provide health education.
Edema can be a sign of deterioration that requires immediate evaluation, especially in cases of cardiac, liver, or kidney disease. Educate the patient on signs and symptoms to monitor for and when to seek assistance. Encourage adherence to dietary, activity, and medication recommendations.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for edema, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for edema.
Decreased Cardiac Output
Decreased cardiac output may be associated with increased preload and altered venous return, leading to increased fluid in the vascular space.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Cardiovascular disease process
- Fluid retention
As evidenced by:
- Edema
- Fatigue
- Altered blood pressure
- Jugular vein distention
- Weight gain
Expected outcomes:
- Patient will demonstrate adequate cardiac output as evidenced by vital signs within normal parameters.
- Patient will adhere to their medication regimen to manage symptoms of decreased cardiac output, such as edema, weight gain, and dyspnea.
Assessment:
1. Assess for symptoms of heart failure.
Heart failure is a significant cause of decreased cardiac output and edema. Monitor for associated symptoms of fluid retention such as dyspnea at rest, activity intolerance, cough, fatigue, jugular vein distention, S3 gallop, and arrhythmias.
2. Consider other causes affecting cardiac output.
The nurse should assess for other conditions and lifestyle factors that may affect cardiac output and contribute to edema, such as diet, hypertension, diabetes, obesity, hormonal abnormalities, sleep apnea, and pregnancy.
3. Assess the patient’s blood pressure and heart rate.
Peripheral edema commonly presents with hypervolemia, but the nurse should obtain the patient’s vital signs to assess their hemodynamic status.
4. Monitor the patient’s intake and output.
Patients with decreased cardiac output may experience reduced kidney perfusion, resulting in fluid retention and edema. Accurate monitoring of intake and output can help plan and monitor the effectiveness of the treatment regimen.
Interventions:
1. Administer medications as ordered.
Diuretics treat fluid retention and edema caused by decreased cardiac output.
2. Review the patient’s medication list.
Patients with decreased cardiac output may be prescribed beta-blockers, calcium channel blockers, or vasodilators. These medications are known to cause edema and may require alternatives to manage symptoms.
3. Gradually increase physical activity.
The patient should be encouraged and assisted in increasing their activity once it is safe to do so, as this improves cardiac output and circulation to reduce fluid accumulation.
4. Apply compression stockings or intermittent sequential pneumatic compression sleeves.
Compression devices applied to the lower legs promote venous return, reducing edema and preventing deep vein thrombosis.
Excess Fluid Volume
Excess fluid build-up in the body causes edema. Edema is characterized by excess fluid accumulating in the skin and surrounding tissues.
Nursing Diagnosis: Excess Fluid Volume
Related to:
- Disease processes
- Cardiac dysfunction
- Renal dysfunction
- Inflammatory process
- Loss of plasma proteins
- Excessive fluid intake
- Excessive sodium intake
- Ineffective medication self-management
- Deviations affecting fluid elimination
- Compromised regulatory mechanism
As evidenced by:
- Adventitious breath sounds
- Altered blood pressure
- Altered urine specific gravity
- Intake exceeds output
- Jugular vein distension
- Oliguria
- Edema
- Pulmonary congestion
- Weight gain over a short period
Expected outcomes:
- Patient will demonstrate a reduction of edema through physical examination.
- Patient will maintain clear lung sounds and the absence of symptoms of respiratory distress.
Assessment:
1. Assess causative factors of edema.
Edema may be caused by several factors including an underlying medical condition, allergic reaction to a medication, or temporary water retention. Identifying the causative factor enables the healthcare team to formulate the most appropriate interventions and prevent further complications.
2. Monitor the patient’s intake and output.
Imbalanced fluid intake and urine output can indicate acute kidney injury or chronic renal failure and may cause complications like cardiac problems and pulmonary edema.
3. Assess lung sounds and respiratory patterns.
Excess fluid can cause pulmonary edema and respiratory distress. This is a serious condition that requires immediate intervention.
4. Assess laboratory studies for any abnormalities.
Fluid overload and edema can occur due to kidney injury. Laboratory tests such as urinalysis, BUN, and creatinine levels can indicate impaired kidney function.
Interventions:
1. Administer medications.
Diuretics are provided to patients with edema and excess fluid accumulation to aid in fluid elimination by increasing urine output.
2. Restrict fluids as ordered.
Fluid restriction can decrease cardiac workload in patients with edema and fluid overload. Patients with congestive heart failure, for example, are often on fluid restrictions.
3. Encourage a low-sodium diet.
Educate patients that large amounts of sodium cause the body to retain water in an attempt to dilute it which causes fluid overload. Instruct on ways to lower sodium intake.
4. Weigh daily.
Daily weights can assess the effectiveness of diuretic therapy. Educate patients with conditions such as CHF that if they notice a weight gain of 5 lbs in a week or 2 lbs overnight, they should contact their doctor.
Ineffective Health Maintenance
Ineffective health maintenance of acute and chronic conditions can result in edema. Edema can be effectively treated and managed in compliance with prescribed treatment regimens.
Nursing Diagnosis: Ineffective Health Maintenance
Related to:
- Conflict between cultural beliefs and health practices
- Conflict between health behaviors and social norms
- Inadequate health resources
- Inadequate support system
- Inadequate trust in health care professionals
- Deficient knowledge
As evidenced by:
- Failure to take action that prevents health problem
- Inadequate commitment to a plan of action
- Inadequate interest in improving health
- Inadequate knowledge about basic health practices
- Ineffective choices in daily living for meeting health goals
Expected outcomes:
- Patient will verbalize understanding of health maintenance goals and adhere to the treatment regimen.
- Patient will demonstrate an improvement in health conditions and in turn, edema.
Assessment:
1. Assess risk factors.
By identifying potential risk factors such as healthcare values, cultural beliefs, and prior decision-making, the nurse can proactively implement care to prevent complications.
2. Determine the patient’s capabilities.
Preventing and treating edema requires lifestyle modifications as well as strict treatment adherence. Assess the patient’s abilities to adhere to medications, meal planning, and appointment follow-up.
Interventions:
1. Involve support systems.
If available, involve family and other support persons in understanding the causes and prevention of edema.
2. Ensure the patient understands their disease process.
Edema is often a result of uncontrolled medical conditions such as cirrhosis, kidney disease, or heart failure. Educate the patient on the importance of managing these chronic conditions.
3. Refer to appropriate community and social services.
The involvement of a social worker or case manager may be necessary to provide routine follow-up. Disease management programs can provide ongoing education and monitoring to reduce readmissions and produce better health outcomes.
Risk for Impaired Skin Integrity
Patients with edema are at risk for impaired skin integrity. As fluid accumulates under the skin, it will appear tight and shiny. Skin can lose its integrity if edema persists, making it susceptible to injuries and possible infection.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Edema
- Inflammatory process
- Disease condition
- Decreased tissue perfusion
- Alteration in skin turgor
As evidenced by:
A risk diagnosis is not evidenced by any signs and symptoms, as the problem has not occurred yet and the nursing interventions will be directed at the prevention of symptoms.
Expected outcomes:
- Patient will verbalize understanding of risk factors and demonstrate interventions that prevent impaired skin integrity.
- Patient will not experience impaired skin integrity.
Assessment:
1. Perform a complete skin assessment.
Routine skin assessments help determine progression and appropriate interventions for patient care. Monitor for impaired skin integrity such as redness, nonblanchable skin, and open wounds.
2. Assess pitting edema.
Severe edema can be documented as pitting on a scale of 1+-4+ which is assessed by the depth of indentation in the skin without rebound when applying pressure.
Interventions:
1. Keep the skin clean and dry.
To reduce the risk of skin damage, the affected area must be kept clean and dry. Provide daily skin hygiene to patients who are bed bound and incontinence care as necessary.
2. Elevate edematous extremities.
Elevate edematous extremities above the level of the heart several times per day to ease swelling.
3. Apply compression stockings.
Compression stockings can prevent fluid build-up in the legs and ankles and improve circulation.
4. Educate on positioning.
Pregnancy, long periods of standing or sitting such as when flying can result in lower leg edema. Remind patients to elevate lower legs periodically.
Risk for Unstable Blood Pressure
Edema occurs due to excessive fluid retained in the body’s tissues. This extra fluid can increase the patient’s blood pressure and force the heart to work harder to compensate. As fluid retention worsens and decreased cardiac output develops and hypotension can occur.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Edema
- Disease process
- Fluid retention
- Fluid shifts
- Thyroid disorders
- Diuretic administration
- Medication side effects
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will maintain blood pressure within normal parameters.
- Patient will adhere to their medication regimen.
Assessment:
1. Assess and monitor the patient’s blood pressure.
Patients with edema often exhibit alterations in blood pressure due to excess fluid in the body. Hypertension initially occurs, followed by hypotension as cardiac failure or decreased cardiac output ensues.
2. Assess causative factors contributing to the patient’s edema and unstable blood pressure.
Various factors and medical conditions like cardiac issues, kidney disease, Cushing syndrome, hormonal changes, and other metabolic changes can result in edema and blood pressure alterations. Identifying these factors can ensure proper treatment to manage symptoms.
3. Review results of cardiovascular imaging tests.
Review the results of ECG and echocardiography. These tests can detect arrhythmias, heart failure, or other cardiac abnormalities contributing to fluid overload and unstable blood pressure.
Interventions:
1. Perform medication teaching.
Antidepressants, NSAIDs, and steroids may be a necessary part of the patient’s treatment plan, but carry side effects of edema and hypertension. Instruct the patient to monitor their blood pressure on these medications. Discontinuation or alternatives may be necessary.
2. Administer antidiuretic therapy cautiously.
Diuretics are a mainstay for treating edema but can carry risks such as hypotension as the body’s circulating volume decreases. The nurse must closely monitor the patient’s blood pressure during administration.
3. Educate on a heart-healthy diet.
Dietary modifications, including sodium, fat, and cholesterol limitations, are indicated for patients with edema and hypertension, as this can help manage fluid retention and reduce their overall risk of cardiovascular disease.
4. Encourage the use of compression stockings.
Compression stockings are often indicated for patients with edema to the lower extremities as they can help increase venous return, promote blood flow, and manage unstable blood pressure.
References
- Edema. Cleveland Clinic. May 17, 2022. https://my.clevelandclinic.org/health/diseases/12564-edema
- Edema. Mayo Clinic. December 1, 2020. https://www.mayoclinic.org/diseases-conditions/edema/diagnosis-treatment/drc-20366532
- Edema – Diagnosis and treatment – Mayo Clinic. (2023, July 28). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved February 2024, from https://www.mayoclinic.org/diseases-conditions/edema/diagnosis-treatment/drc-20366532
- Edema: Causes, symptoms & treatment. (2022, May 17). Cleveland Clinic. Retrieved February 2024, from https://my.clevelandclinic.org/health/diseases/12564-edema
- Goyal, A., Cusick, A. S., & Bhutta, B. S. (2023, August 17). Peripheral edema – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved February 2024, from https://www.ncbi.nlm.nih.gov/books/NBK554452/
- InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Causes and signs of edema. 2008 Nov 5 [Updated 2016 Dec 30]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279409/
- Lent-Schochet, D., & Jialal, I. (2023, May 1). Physiology, edema – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved February 2024, from https://www.ncbi.nlm.nih.gov/books/NBK537065/
- Patient education: Edema (swelling) (Beyond the Basics). Richard H Sterns, MD. UpToDate. November 23, 2021. https://www.uptodate.com/contents/edema-swelling-beyond-the-basics/print
- Trayes, K. P., Studdiford, J. S., Pickle, S., & Tully, A. S. (2013). Edema: diagnosis and management. American family physician, 88(2), 102–110. https://www.aafp.org/pubs/afp/issues/2013/0715/p102.html
