Edema is swelling caused by extra fluid trapped in the spaces between the body’s cells. The main NANDA-I nursing diagnosis is Excessive Fluid Volume when the body is holding too much fluid, as in heart failure, kidney disease, or liver disease. Common companion diagnoses are Risk for Impaired Skin Integrity because swollen skin is stretched and fragile, Decreased Activity Tolerance when fluid makes the client short of breath and tired, and Inadequate Health Knowledge when the client does not know how to manage sodium, weights, and medicines at home. Nursing care centers on finding and treating the cause, daily weights, intake and output, lung and skin checks, safe diuretic care, positioning, and teaching.
At a glance
- What it is
- A build-up of fluid in the tissues. It is a sign, not a disease, so the nurse always asks what is causing it. Pitting edema leaves a dent when pressed; non-pitting edema, as in lymphedema, does not.
- Who gets it
- Clients with heart failure, kidney disease or nephrotic syndrome, cirrhosis, venous insufficiency, a blood clot, low protein or malnutrition, preeclampsia, or a recent surgery or injury; clients who sit or stand for long periods; and clients taking drugs that cause swelling, such as some calcium channel blockers, NSAIDs, corticosteroids, and pioglitazone.
- Key signs
- Swelling of the feet, ankles, legs, hands, face, or sacrum; tight, shiny skin; pitting; rings or shoes that no longer fit; sudden weight gain; puffy eyes; and shortness of breath, crackles, or neck vein distention when fluid backs up into the lungs.
- Nursing focus
- Weigh daily on the same scale, keep strict intake and output, grade the edema the same way each shift, listen to the lungs, protect the skin, give diuretics safely and watch electrolytes, and teach the sodium and fluid limits the provider sets.
- Act now
- Escalate new or worsening shortness of breath, crackles, or pink frothy sputum; swelling of the lips, tongue, or throat; a single swollen, warm, painful calf; chest pain; a sudden drop in urine output; or new swelling with high blood pressure or headache in pregnancy.
Pathophysiology
Fluid moves out of the capillaries into the tissues and back again all day. Pressure inside the vessels pushes fluid out, proteins in the blood (mainly albumin) pull it back in, and the lymph system carries away what is left over. Edema forms when one of these goes wrong and more fluid leaves the vessels than can be returned.
- Higher pressure inside the vessels — heart failure, kidney failure, and sodium retention raise the volume and pressure in the veins. A blood clot or weak vein valves (venous insufficiency) raise pressure in one limb. Gravity adds to this, which is why swelling collects in the feet and ankles of a client who is up, and over the sacrum of a client in bed.
- Too little protein in the blood — when albumin is low, as in cirrhosis, nephrotic syndrome, or severe malnutrition, the blood cannot hold fluid in the vessels. Swelling is often widespread and can include ascites.
- Leaky capillaries — inflammation, infection, burns, sepsis, and allergic reactions let fluid and protein escape. Swelling with redness, warmth, and pain suggests infection, such as cellulitis.
- Blocked lymph flow — surgery, lymph node removal, radiation, or tumor can block lymph drainage. Lymphedema is usually firm and non-pitting and does not go down much with elevation.
- Medicines — dihydropyridine calcium channel blockers such as amlodipine, NSAIDs, corticosteroids, estrogens, pioglitazone, and gabapentin or pregabalin can all cause or worsen swelling.
Grading pitting edema
Press firmly over a bony area, such as the top of the foot, the inner ankle, or the shin, for a few seconds, then let go. Grading gives you something to chart and compare between shifts. Scales differ between textbooks and facilities, so use the one your facility uses. A common version:
| Grade | Depth of the dent | How fast it fills back in |
|---|---|---|
| 1+ | Slight, about 2 mm | Disappears almost at once |
| 2+ | About 4 mm | Within several seconds |
| 3+ | About 6 mm | Up to about a minute |
| 4+ | About 8 mm or deeper | Several minutes |
Nursing assessment
Subjective data
- When the swelling started, where it is, whether it is on one side or both, and whether it goes down overnight or with the legs up
- Shoes, rings, or waistbands that feel tight; recent weight gain the client has noticed at home
- Shortness of breath with activity or when lying flat, waking up short of breath at night, and how many pillows the client sleeps on
- Pain, heaviness, aching, itching, or tightness in the swollen area
- History of heart, kidney, liver, or vein disease, blood clots, cancer treatment, lymph node surgery, or pregnancy
- All medicines, including over-the-counter pain relievers, and whether diuretics are being taken as prescribed
- Usual diet, especially salty, canned, processed, and restaurant foods, and how much fluid the client drinks
Objective data
- Daily weight on the same scale, at the same time, with similar clothing, compared with the client’s dry or usual weight
- Location, pitting grade, and symmetry of the edema; calf or limb measurements at a marked spot when ordered
- Sacral and back swelling in a client who is in bed
- Lung sounds (crackles), breathing rate and effort, oxygen saturation, and neck vein distention
- Blood pressure, heart rate and rhythm, and an S3 heart sound if you are trained to listen for it
- Intake and output, and urine color and amount
- Skin color, temperature, and condition over swollen areas: shiny, tight, cracked, weeping, red, or broken
- Pulses and capillary refill in the swollen limb
- Lab and test results the provider orders, such as electrolytes, kidney function, albumin, liver tests, BNP, urinalysis, and an ultrasound of the leg veins
Nursing diagnoses used with edema
- Excessive Fluid Volume — the main diagnosis when the body is holding too much fluid, with edema, weight gain, and often crackles or shortness of breath
- Risk for Impaired Skin Integrity — swollen, stretched skin that is still intact but breaks down easily
- Impaired Skin Integrity — when the skin over the edema has already cracked, blistered, weeps fluid, or has a wound
- Decreased Activity Tolerance — fluid overload makes everyday activity tiring and causes shortness of breath
- Impaired Gas Exchange — when fluid in the lungs lowers oxygen levels
- Ineffective Peripheral Tissue Perfusion — when edema occurs with poor blood flow to a limb
- Risk for Electrolyte Imbalance — during diuretic therapy
- Inadequate Health Knowledge — the client does not know how to manage sodium, fluid, weights, or medicines at home
Worked care plans
Four plans in the same ADPIE shape. The scenario is a 74-year-old woman with heart failure with reduced ejection fraction, admitted with swelling of both legs and shortness of breath. She says her diuretic ran out 8 days ago and she ate ham and canned soup at a family gathering. Her weight is 71.4 kg; her usual weight at home is 68.6 kg. She has 3+ pitting edema of both feet and lower legs and 1+ over the sacrum. Her skin on the shins is tight and shiny but intact. She has crackles in both lung bases and gets short of breath walking to the bathroom. She sleeps on three pillows. Blood pressure is 148/86, heart rate 98, respiratory rate 22, and oxygen saturation 93% on room air. Her potassium, sodium, and creatinine are within the lab’s normal ranges. The provider orders IV furosemide, a sodium-restricted diet and a fluid restriction at the amounts the provider sets, daily weights, strict intake and output, a daily basic metabolic panel, oxygen to keep saturation in the ordered range, and cardiac rehabilitation and dietitian consults.
1. Excessive Fluid Volume
Problem-focusedSubjective: “My shoes don’t fit and my legs feel heavy.” “I get winded just walking to the bathroom.” “I ran out of my water pill last week.”
Objective: Weight 71.4 kg, up 2.8 kg from her usual 68.6 kg; 3+ pitting edema of both lower legs; 1+ sacral edema; crackles in both bases; neck vein distention when sitting at 45 degrees; BP 148/86; RR 22; SpO2 93% on room air.
Excessive Fluid Volume related to excessive sodium intake and interrupted diuretic therapy, associated with heart failure, as evidenced by weight gain over a short period, 3+ bilateral pitting edema, crackles, jugular vein distention, and dyspnea.
- Client’s weight moves toward her usual weight of 68.6 kg by discharge
- Leg edema decreases by at least one grade and crackles clear within 72 hours
- Oxygen saturation stays in the ordered range on room air before discharge
- Weigh her every morning before breakfast, after she voids, on the same scale with similar clothing, and compare with the day before
- Keep strict intake and output; spread the ordered fluid limit across the day and tell her how much she has left
- Give the ordered IV furosemide, then check urine output, blood pressure, and how she feels; report little or no response
- Review the daily electrolytes and kidney function, and report potassium, sodium, or creatinine outside the range the provider sets; watch for muscle cramps, weakness, and new irregular heartbeats
- Listen to lung sounds and check edema grade, neck veins, and breathing every shift and as needed
- Raise the head of the bed for breathing, and raise her legs on pillows when she is sitting, if her breathing allows
- Serve the ordered sodium-restricted diet and remove salty snacks brought from home, with her agreement
By day 3 her weight was 68.9 kg, leg edema was 1+, sacral edema was gone, and crackles had cleared. Saturation was 96% on room air and she slept on one pillow. Electrolytes stayed within the ordered ranges. Goal met.
2. Risk for Impaired Skin Integrity
Risk diagnosisSubjective: “My legs itch and feel tight.” “I mostly sit in my recliner all day at home.”
Objective: Tight, shiny, dry skin over both shins; 3+ pitting edema; 1+ sacral edema; skin intact with no redness over the heels or sacrum; spends most of the day sitting; reduced mobility because of shortness of breath.
Risk for Impaired Skin Integrity related to excessive fluid volume in the tissues, dry skin, pressure over bony prominences, and decreased physical mobility.
- Skin over the legs, heels, and sacrum stays intact throughout the stay
- Client changes position, or asks for help to, at the intervals the care plan sets
- Inspect the legs, heels, sacrum, and skin folds every shift and with each position change; use the facility’s pressure injury risk tool
- Help her change position on the schedule the care plan sets; float the heels and use a pressure-redistributing surface if indicated
- Wash with mild soap and warm water, pat dry, and apply a fragrance-free moisturizer to dry skin, not between the toes
- Avoid tape on swollen skin; use soft dressings or wraps if anything must be secured, and check under devices such as oxygen tubing and socks
- Ask the provider about compression before using it. It is not started without an order, because it can harm clients with poor arterial blood flow and may not be safe while heart failure is not controlled
- Report any blister, weeping skin, crack, or redness that does not fade so a wound plan can begin early
Her skin stayed intact through discharge, with no redness over the heels or sacrum. She repositioned herself in bed and in the chair when reminded and described why she should not sit all day in the recliner at home. Goal met.
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NCLEX Readiness Diagnostic
Fifty questions with a written rationale on every option, scored by section so you can see which content area is weakest. Sent as a PDF.
3. Decreased Activity Tolerance
Problem-focusedSubjective: “I have to stop and catch my breath halfway to the bathroom.” “I’m too tired to shower.”
Objective: Walking 6 m to the bathroom raised heart rate from 98 to 118 and respiratory rate from 22 to 30, and saturation fell from 93% to 89%; she needed to sit down to rest; heavy, swollen legs.
Decreased Activity Tolerance related to an imbalance between oxygen supply and demand and physical deconditioning, associated with heart failure, as evidenced by exertional dyspnea, an abnormal heart rate and oxygen saturation response to activity, and reported fatigue.
- Client walks to the bathroom and back with vital signs staying within the limits the care team sets, by day 3
- Client takes part in bathing and dressing with rest breaks before discharge
- Check heart rate, blood pressure, breathing, and saturation before, during, and after activity; stop and rest if she has chest pain, dizziness, severe shortness of breath, or a drop in saturation below the ordered range
- Cluster care and plan rest periods between activities, such as resting before and after bathing
- Increase activity a little each day as tolerated: sitting in a chair, then short walks in the room, then the hallway
- Provide a shower chair, a bedside commode at night, and items within reach to save energy
- Watch for dizziness when she stands, because diuresis can lower blood pressure; have her sit on the edge of the bed first and rise slowly
- Work with the physical therapist and cardiac rehabilitation team on a walking plan for home
On day 3 she walked to the bathroom and back without stopping. Heart rate rose from 82 to 96 and saturation stayed at 95% or above. She washed her upper body at the sink with one rest break. Goal met; cardiac rehabilitation referral placed for after discharge.
4. Inadequate Health Knowledge
Problem-focusedSubjective: “I don’t add salt, so I thought I was fine.” “I didn’t know weighing myself mattered.” “I didn’t call because I thought I could wait until my appointment.”
Objective: Does not own a scale; ran out of her diuretic and did not request a refill; could not name high-sodium foods beyond table salt; no written heart failure action plan.
Inadequate Health Knowledge related to insufficient information about heart failure self-management as evidenced by inaccurate statements about sodium in food, not monitoring weight, and lapse in taking a prescribed diuretic.
- Client explains how and when to weigh herself and the weight gain her provider wants reported, before discharge
- Client chooses lower-sodium options from a sample menu and reads the sodium line on three food labels
- Client and daughter state a plan for refills and for who to call with symptoms
- Ask what she already knows and what matters most to her, and include her daughter, who shops and cooks
- Teach daily weights: same time each morning after voiding, before eating, same scale, written in a log; give the weight gain limit her provider sets for calling
- With the dietitian, show which foods hide sodium, such as canned soup, deli meat, ham, frozen meals, bread, cheese, and restaurant food, and how to read the label
- Explain what the diuretic does, when to take it, why not to stop it, and how to arrange refills before it runs out
- Review a written heart failure zone plan: what is normal, what needs a call to the provider, and what needs 911
- Use teach-back and large-print materials, and confirm she has a working scale at home before discharge
Before discharge she showed how she would weigh herself and record it, stated the weight gain her provider wants reported, picked lower-sodium choices from the menu, and named canned soup and ham as high in sodium. Her daughter set up automatic refills. Goal met.
Interventions and rationales
Client and family teaching
- Weigh yourself every morning after you urinate and before you eat, on the same scale, and write it down. Call your provider if your weight goes up by the amount they told you to watch for
- Follow the sodium limit your provider or dietitian gives you. Read the sodium line on food labels and limit canned, frozen, deli, and restaurant foods
- If you have a fluid limit, measure your drinks and count soups, ice, and gelatin as fluid
- Take your water pill exactly as prescribed, usually in the morning so you are not up all night. Do not stop it on your own, and refill it before it runs out
- Ask your provider or pharmacist before taking over-the-counter pain relievers such as ibuprofen or naproxen
- Raise your legs when you sit, avoid sitting or standing still for long periods, and walk as your care team advises
- Check your feet and legs every day for cracks, blisters, redness, or weeping. Keep the skin clean and moisturized, and wear shoes that fit
- Wear compression stockings only if your provider prescribes them, and put them on in the morning before swelling builds
- Call your provider for weight gain, more swelling, more shortness of breath, needing more pillows to sleep, or less urine
- Call 911 for severe shortness of breath, chest pain, pink frothy sputum, swelling of the lips, tongue, or throat, or fainting
NurseStudyPrep.com
You’ve read the care plan. Now answer one.
A priority item in the NCLEX format. On Prep, every option gets a written rationale — including the three that are wrong.
The nurse receives report on four clients with swelling. Which client should the nurse see first?
Why B. Swelling of the tongue with a hoarse voice after starting an ACE inhibitor suggests angioedema, which can close the airway. Airway comes first: the nurse stays with the client, calls for help, and prepares for airway support. Option A is expected dependent edema in heart failure that needs monitoring. Option C is chronic and unchanged. Option D is a known, non-urgent side effect of amlodipine. Prep also explains why each wrong option looks reasonable.
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Frequently asked questions
What is the nursing diagnosis for edema?
The NANDA-I label most often used is Excessive Fluid Volume. A typical statement is “Excessive Fluid Volume related to excessive sodium intake as evidenced by edema, weight gain over a short period, and crackles.” Risk for Impaired Skin Integrity, Decreased Activity Tolerance, and Inadequate Health Knowledge are common companion diagnoses.
Is “edema” itself a nursing diagnosis?
No. Edema is a sign, and it belongs in the “as evidenced by” part of the statement. The nursing diagnosis describes the client’s response, such as Excessive Fluid Volume, and the cause, such as heart failure, is written as an associated condition.
What is the nursing diagnosis for bilateral lower extremity edema?
Swelling of both legs usually comes from a body-wide cause, so Excessive Fluid Volume is the usual choice, with Risk for Impaired Skin Integrity for the stretched skin. If the swelling is from venous insufficiency rather than fluid overload, Ineffective Peripheral Tissue Perfusion may fit better.
What is the difference between pitting and non-pitting edema?
Pitting edema leaves a dent after you press on it and is typical of fluid overload, heart failure, and venous problems. Non-pitting edema stays firm and does not dent, and is seen with lymphedema and some thyroid conditions.
Should you always elevate a swollen leg?
Usually, but not always. Elevation helps venous and dependent edema. It may be limited in clients with poor arterial blood flow, and a single swollen, painful leg should be reported before any treatment because it may be a blood clot.
When is edema an emergency?
Call for help right away for swelling of the lips, tongue, or throat; edema with severe shortness of breath, crackles, or pink frothy sputum; a sudden swollen, painful calf; or new swelling with high blood pressure, headache, or vision changes in pregnancy.
References
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification, 2024–2026. Thieme.
- Heidenreich, P. A., Bozkurt, B., Aguilar, D., et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure. Circulation, 2022;145(18):e895–e1032.
- Trayes, K. P., Studdiford, J. S., Pickle, S., & Tully, A. S. Edema: diagnosis and management. American Family Physician, 2013;88(2):102–110.
- Hinkle, J. L., Cheever, K. H., & Overbaugh, K. J. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer, 2022.
- Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (13th ed.). Elsevier, 2023.
- Silvestri, L. A. Saunders Comprehensive Review for the NCLEX-RN Examination. Elsevier, 2023.
Edema grading scales, weight gain limits for calling the provider, sodium and fluid restrictions, diuretic orders, electrolyte targets, oxygen saturation targets, and compression orders vary by client, by provider, and by facility. Follow the provider’s orders and your own institution’s policies and protocols. This page supports study and does not replace course instruction or clinical judgment.
