A nurse caring for a 9-year-old notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation
Due to these physical findings, the nurse would be most concerned with assessing: 1. Skin integrity, especially in the lower extremities.
2. Urine output.
3. Level of consciousness.
4. Range of motion and ankle mobility.
2
Rationale:
1. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.
2. Dependent, pitting edema, especially in the lower extremities, can be a symptom of kidney and cardiac disorders. Decreases in urine output also can indicate compromise in the renal and cardiac systems.
3. Changes in level of consciousness, if present, more than likely would be a later effect in this situation.
4. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.
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