Edema Nursing Diagnosis and Care Plan

Edema Nursing Care Plans Diagnosis and Interventions

Edema NCLEX Review and Nursing Care Plans

Edema, also known as fluid retention or hydropsy, is a condition in which fluid accumulates in the body’s tissues, most commonly affecting the extremities and infrequently in other regions of the body such as the face and abdomen.

Reducing the patient’s salt intake and taking medications to flush out excess fluid can help ease the symptoms associated with edema. However, the underlying disease must be treated independently from the edema.

Signs and Symptoms of Edema

  • Inflamed tissue can be seen in the affected area (e.g., swelling beneath the skin, particularly in the arms and legs)
  • Having skin that is stretched or glossy/shiny
  • Noticeable depression in the skin when the swollen area is slightly pressed with the finger
  • Abdominal distention
  • Patients with pulmonary edema may have breathing or coughing problems

Anyone experiencing shortness of breath, strained or painful breathing, or chest pain must see a doctor right away since these are possible signs of pulmonary edema.

If there is persistent swelling and soreness in the legs after sitting for an extended period, don’t hesitate to call your doctor. Swelling accompanied by pain in the lower extremities can signify a blood clot in the vein (deep vein thrombosis).

Causes of Edema

Mild edema may be caused by:

  • Symptoms and indications of premenstrual syndrome are present.
  • Excessive amounts of salty foods
  • Remaining in one position or sitting for an extended period
  • Pregnancy
  • Edema can also occur as a side effect of certain drugs, including NSAIDs, Steroids and Estrogens, medications for high blood pressure, and several diabetic drugs.

In some instances, edema may indicate the presence of a more significant underlying condition/medical issue.

Some disorders and circumstances can lead to edema, such as:

  • Congestive heart failure. Congestive heart failure is a condition in which one or both of the bottom chambers of the heart is unable to adequately pump blood. Edema can develop in the legs and ankles due to the accumulation of blood in these locations. Another indication of congestive heart failure is abdominal swelling. In some cases, the illness can lead to fluid accumulation in the lungs or pulmonary edema, which can cause shortness of breath.
  • Damage to the kidneys. Nephrotic syndrome can occur if the kidneys’ blood vessels are damaged. Patients with this condition tend to exhibit deficiencies in blood protein (albumin) which contributes to fluid buildup and edema.
  • Kidney disease. Fluid and sodium levels in the bloodstream might rise due to renal disease; thus, resulting in edema. Edema in the legs and eyes is more common in people with renal disease than in the general population.
  • Leg veins that are weak or have been damaged. Those who have chronic venous insufficiency (CVI) may have leg swelling due to a weakened or damaged one-way valve in their leg veins. Symptoms such as discomfort and swelling in the veins of one leg may suggest the presence of a blood clot (deep vein thrombosis) in the veins of that leg. If this happens, seek medical attention right away.
  • Cirrhosis. Due to liver disease or damage such as cirrhosis, fluid may build in the abdominal cavity (also known as ascites) and in the legs.
  • Inefficient lymphatic system. The body’s lymphatic system aids in the removal of extra fluid from tissues. If this system is compromised (either as a result of cancer surgery), the development of edema is likely to occur. One possible cause is the damage of the lymph nodes and lymph veins that drain the affected area.
  • Severe and long-term protein insufficiency. Severe protein deficiency can lead to fluid retention and swelling if it persists for an extended period.

Risk Factors for Edema

Due to the fetus and placenta fluid requirements, pregnant women store more sodium and water than usual. Consequently, they have a greater likelihood of developing edema.

An increased likelihood of developing edema can also be caused by conditions such as liver disease, congestive heart failure (CHF), or kidney disease.

In addition, surgery can occasionally clog a lymph node, resulting in swelling in the leg or arm, which is usually limited to one side of the body.

Some medications may also increase the chance of developing edema, and these may include:

  • NSAIDs
  • steroids
  • estrogen-containing drugs
  • antihypertensives or medications for high blood pressure
  • anti-diabetes drugs

Diagnosis of Edema

  • Physical exam – an initial assessment of the patient’s physical health and medical history can help the healthcare team diagnose edema and possible cause/s. Usually, edema may be diagnosed based on this information alone.
  • Radiographic imaging such as X-rays
  • Ultrasounds
  • Magnetic resonance imaging (MRIs)
  • Blood tests
  • Urine examination

Treatment of Edema

  1. Mild edema is usually self-limiting. Proper repositioning, such as elevating the legs with mild edema, may resolve it.
  2. Medications. Urine-increasing medications (diuretics) may be prescribed to treat more severe edema. Prolonged treatment typically focuses on removing or decreasing swelling. However, if certain medications induce edema, the physician may have to adjust the dosage and may necessitate finding an alternate medication that does not cause swelling.
  3. Treatment of the underlying cause. Emphysema and chronic bronchitis are two examples of lung disorders that can induce swelling, and patients with these conditions are strongly advised to quit smoking.

Prevention of Edema

Swelling caused by health issues, such as congestive heart failure (CHF), renal disease, or liver disease, cannot be treated but can only be adequately managed. Doctors may counsel their patients to get regular exercise and cut back on the salt intake to prevent edema. The following actions can be done to prevent the formation of edema:

  • If the legs are swollen, consider wearing support stockings.
  • Try to stay as active as possible. Do not sit or stand for long periods without getting up and moving around.
  • Raise the legs while sitting or lying down.
  • Reduce sodium consumption.

Edema Nursing Diagnosis

Nursing Care Plan for Edema 1

Nursing Diagnosis: Fluid Volume Excess related to excessive fluid buildup in the extracellular fluid space, secondary to edema as evidenced by increased diastolic pressure in the pulmonary artery, oliguria, changes in specific gravity, blood pressure, electrolytes, and respiratory pattern. 

Desired Outcome: The patient will express his or her understanding of the factors that lead to fluid overload and will verbalize the appropriate actions required to remedy the situation.

Nursing Interventions for EdemaRationale
Analyze the patient’s medical history to determine what might be causing the fluid imbalance.  Health care providers can utilize this information to aid them through the decision-making process or to actively manage their patients. Reviewing the patient’s medical history may reveal increased fluid or sodium intake.
Closely monitor the patient’s fluid intake and output.Fluid shifting may result in dehydration, even if the total amount of fluid consumed is sufficient. This must be noted since dehydration reduces sodium levels, which in return promotes fluid retention.
Evaluate the patient for the presence of edema. Check the ankles, sacrum, and tibia for any signs of pitting.Edema is caused by excess fluid collection in the extravascular regions.
There are four grades of edema, ranging from ‘trace,’ meaning scarcely noticeable, to 4, meaning severe edema.
After pushing one’s finger against the affected area and then removing it afterward, one may easily identify pitting edema by the depression left behind. A measuring tape can assess the degree or extent of edema in an individual’s arm or leg.
As instructed by a healthcare professional, have the patient ingest sodium in moderation.Limiting sodium intake not only helps reduce fluid retention but also helps in preventing excess fluid exacerbation.
Explain why anti-embolism stockings (also known as TED stockings) or bandages are essential and advocate their use.As a result of using these aids, venous blood flow is improved, and fluid retention in the arms and legs is reduced. Instead of allowing more fluid to pool and worsen swelling, it regulates the amount of edema and keeps the skin from expanding.
Increase the patient and family members’ understanding of excessive fluid volume and its contributing factors.Problems can only be dealt with effectively if the patient and their significant others have the right information at their disposal.

Nursing Care Plan for Edema 2

Desired Outcomes:

  • The patient will have a reduced risk for impaired physical mobility as he/she takes preventative precautions.
  • The patient will engage in physical activity on his/her own or within the confines of the disease.
Nursing Interventions for EdemaRationale
Evaluate the patient’s capacity to carry out daily tasks (or ADLs) safely and efficiently.  
0 – indicates total independence.
1 – Necessitates the employment of equipment, tools, or devices
2 – Requires the involvement, supervision, or instruction of a third party or another individual.
3 – Requires the assistance of another person and/or a piece of equipment.
4 – Is reliant on others and does not engage in any kind of activity.
Assess whether the patient can function at the highest level or whether he/she requires support. Because of their inability to move about, suspected patients suffering from edema may find it difficult to carry out regular activities as their condition worsens. Hence, the ability to intervene quickly is made feasible through prompt evaluation.  
Provide a supportive and safe atmosphere for the patient by lowering the bed, putting up the bed rails, and keeping critical items close by.  By implementing these safety measures, the likelihood of the patient tripping and falling is decreased.
Assist the patient’s range of motion by performing passive or active assistive ROM exercises.Maintaining a healthy level of physical activity increases muscle mass, stamina, and strength. Additionally, it promotes circulation, which helps drain away excess fluids.
Plan activities, posture modifications, and exercises with the patient or significant other.The patient can gain a sense of control or autonomy over his/her care.
Provide the patient with early mobility assistance. Assistance with hanging legs, moving, chair sitting, and walking is required in the initial adjustment.A variety of edema-related conditions can cause prolonged immobility. By performing these procedures, the functional activity of the patients is preserved.
Educate and encourage the patient to engage in progressive activities.Setting smaller, more manageable goals can boost the patient’s self-esteem and alleviate feelings of inadequacy.

Nursing Care Plan for Edema 3

Nursing Diagnosis: Risk for Impaired Skin Integrity related to the onset of skin breakdown, secondary to edema, as evidenced by skin appearing to be stretched, presence of tenderness, discomfort, pitting, and swelling at the site of injury.

Desired Outcome: The patient will maintain optimal skin integrity within the confines of the condition.

Nursing Interventions for EdemaRationale
Evaluate the skin’s overall state and condition, including its color, texture, and temperature.The condition of the skin may serve as the starting point for prospective treatment options in the management and identification of risk for impaired skin integrity in edematous patients.
Encourage the patient to walk or move around when he/she is capable.Being physically active helps boost blood circulation and drainage of fluids.
Keep the patient’s skin healthy, clean, and moisturized, especially in regions where bones are close to the surface (bony prominence).Edema can be exacerbated by injury or infection. For this reason, proper skincare is essential, as it makes the skin more resistant to damage/injury.
Ensure that the patient receives appropriate nourishment and hydration.When the body isn’t getting enough water, it holds on to the fluid that it already has; because of this, swelling or edema may be exacerbated. Likewise, maintaining elasticity, moisture, and suppleness of the skin are all critical to preventing the skin from the negative effects of pressure and friction.
Promote leg elevation in the patient and avoid placing them in a passive position for extended periods.Elevating the legs above the heart level can help alleviate edema in the lower extremities.

Nursing Care Plan for Edema 4

Nursing Diagnosis: Risk for Ineffective Tissue Perfusion related to inhibition or disruption of venous blood flow, secondary to edema

Desired Outcomes:

  • The patient will recognize factors that increase blood flow.
  • The patient will demonstrate tolerance for physical exertion.
Nursing Interventions for EdemaRationale
Ineffective Tissue Perfusion (Peripheral):
Determine whether there are symptoms of diminished tissue perfusion.Signs and symptoms may be linked to a variety of different conditions. Hence, it is necessary to evaluate the defining aspects of ineffective tissue perfusion in order to provide a benchmark for future comparisons.
Encourage ROM exercises that are both active and passive.Venous stasis and circulatory impairment can be prevented by regular physical activity.
Assist the patient in readjusting their position.By carefully transferring the patient from a supine posture to a sitting or standing position, the risk of orthostatic BP variations can be reduced. Fluctuations in blood pressure are more common among patients over 65 because their bodies do not respond physiologically to changes in position because of factors such as dehydration, blood loss, or medical problems and drugs taken in combination.
Place the patient in a semi-to Fowler’s high position.Improved alveolar gas exchange is achieved when the patient is positioned upright in the case of pulmonary edema.
For patients with venous insufficiency: 
Educate and instruct the patient in recognizing and reporting any unusual or concerning signs or symptoms (e.g., tenderness, pain, or swelling in the calf) to the nurse on duty.Chronic venous insufficiency (CVI) is characterized by increased pressure in the veins, resulting in the formation of leg edema. A pre-evaluation allows for a more expedited start to treatment.
Recommend a weight loss plan for obese patients.Obesity has been linked to an increased risk of developing CVI or chronic venous insufficiency.

Nursing Care Plan for Edema 5

Nursing Diagnosis: Acute Pain related to sudden swelling of extremities, secondary to edema as evidenced by expressions of sensitivity, pain, discomfort, presence of tenderness, and history or presence of ruptured popliteal cyst (Baker’s cyst). 

Desired Outcome: The patient will express alleviation of pain as shown by an increase in or normalization of everyday routines.

Nursing Interventions for EdemaRationale
Assess the patient’s source of pain in all its facets. Observe the pain’s onset, persistence, and its nature and severity.Only the person experiencing the pain can provide the most accurate description of its intensity. By asking the patient questions about his/her pain, the nurse can create effective methods of pain management
Ask the patient as to what may be contributing to his/her pain (e.g., provoking factors).Patients with swelling or edema complain of discomfort. Identification of effective pain management strategies begins with evaluating the triggering variables.
Determine the source of pain by having the patient point to the area that is causing them discomfort/pain.In the case of children, this is especially important because they may not be able to appropriately express their pain.
Offer pain relief options to the patient before the condition worsens.  The pain may increase in direct proportion to severe swelling; hence, providing the patient with pain reduction treatments like analgesics can lessen his/her suffering and provide some measure of comfort or ease.
Provide the patient complementary or alternative pain management options such as:
-CBT techniques like guided imagery
-Cutaneous stimulation
-Heat and cold applications
-Acupressure
-Massage
CBT techniques aim to alleviate pain by modifying the brain’s perception. Meanwhile, the application of cutaneous stimulation can provide temporary pain relief. In order to work, tactile stimulation must be provided to the patient in order for their attention to be diverted away from negative sensations.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

Nursing Stat Facts
Nursing Stat Facts

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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