A nurse is examining a client with cirrhosis of the liver and notes the presence of edema. The nurse determines that the indentation remains for several seconds and the skin swelling is obvious on inspection
How should the nurse quantify the severity of the finding? A) 1+ pitting edema
B) 2+ pitting edema
C) 3+ pitting edema
D) 5+ brawny edema
C
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The nurse should quantify the finding as 3+ pitting edema, since the indentation remains for several seconds and a skin swelling is obvious by general inspection. In case of 1+ pitting edema, there is a slight indentation (2 mm) with normal contours and the associated interstitial fluid volume is 30% above normal. 2+ pitting edema indicates that the indentation is deeper after pressing (4 mm) and lasts longer than a 1+, with fairly normal contours. In the case of 5+ brawny edema, there is no pitting; tissue palpates as firm or hard, and the skin surface appears shiny, warm, and moist.
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