After assisting a patient to turn in bed, the nurse notes that the patient's leg has indentations that clearly show where the leg was supported by the nurse's hand. How would the nurse document this finding?
1. Pitting edema
2. Loss of skin elasticity
3. Increased skin turgor
4. Reduced sensation
1
Rationale 1: If pressure leaves an indentation in the skin, pitting edema is present. Edema is caused by the accumulation of fluid in the intercellular spaces. Pitting edema is generally evaluated on a 4-point scale.
Rationale 2: Loss of skin elasticity causes the skin to lack firmness, but the skin does not indent when compressed.
Rationale 3: Skin turgor is assessed by pinching the skin to determine how quickly it returns to its normal shape.
Rationale 4: The nurse would have to conduct additional assessments to determine if sensation is reduced.
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