EDEMA

What is edema?

Edema is an observable swelling from fluid accumulation in certain body tissues.

Edema most commonly occurs in the feet and legs, where it also is referred to as
peripheral edema. The swelling is the result of the accumulation of excess fluid under the
skin in the spaces within the tissues that are outside of the blood vessels. These spaces are
known as interstitial spaces or compartments.

The term anasarca refers to the severe, widespread accumulation of fluid in the various
tissues and cavities of the body.

Edema (American English), formerly known as dropsy or hydropsy, is the increase of

interstitial fluid in any organ — swelling. Generally, the amount of interstitial fluid is
determined by the balance of fluid homeostasis, and increased secretion of fluid into the
interstitium or impaired removal of this fluid may cause edema.

What is pitting edema and how does it differ from non-pitting edema?

Pitting edema can be demonstrated by applying pressure to, for example, the skin of a
swollen leg, by depressing the skin with a finger. If the pressing causes an indentation in
the skin that persists for some time after the release of the pressure, the edema is referred
to as pitting edema. Actually, any form of pressure, such as from the elastic part of socks,
can induce the pitting of this edema.

In non-pitting edema, which usually affects the legs or arms, pressure that is applied to
the skin does not result in a persistent indentation. Non-pitting edema can occur in certain
disorders of the lymphatic system such as lymphedema, which is a disturbance of the
lymphatic circulation that may occur after a radical mastectomy, or congenital
lymphedema. Another cause of non-pitting edema of the legs is called pretibial
myxedema, which is a swelling over the shins that occur in some patients with
hyperthyroidism. Non-pitting edema of the legs is difficult to treat. Diuretic medications
are generally not effective, although elevation of the legs periodically during the day and
compressive devices may reduce the swelling.

Assessment of Edema:

o The nurse palpates the edema, particularly if the area is taut, shiny skin noted.
o Edematous areas are palpated for consistency, temperature, shape, tenderness, and
mobility.
o The nurse presses a finger firmly against the edematous area for 5 seconds to
assess for pitting edema, that is, a residual indentation left by the finger’s pressure
when the fluid is displaced from the underlying tissue,
 o The depth of pitting is expressed in millimeters or centimeters. Because the
variation in rating scales is more accurate for the nurse to state the depth of pitting
rather than to rate it.
o Areas examined by the nurse for edema include over the sacrum (especially in
bed ridden clients), the feet, and ankles.

Signs and Symptoms:

o Swelling or puffiness of the tissue under your skin (subcutaneous tissue)

o Stretched or shiny skin
o Skin that retains a dimple after being pressed for several seconds
o Increased abdominal size (abdominal bloating)

Causes and symptoms:

Many ordinary factors can upset the balance of fluid in the body to cause edema,
including:
• Immobility. The leg muscles normally contract and compress blood vessels to
promote blood flow with walking or running. When these muscles are not
used, blood can collect in the veins, making it difficult for fluid to move from
tissues back into the vessels.
• Heat. Warm temperatures cause the blood vessels to expand, making it easier
for fluid to cross into surrounding tissues. High humidity also aggravates this
situation.
• Medications. Certain drugs, such as steroids, hormone replacements,
nonsteroidal anti-inflammatory drugs (NSAIDs), and some blood pressure
medications may affect how fast fluid leaves blood vessels.
• Intake of salty foods. The body needs a constant concentration of salt in its
tissues. When excess salt is taken in, the body dilutes it by retaining fluid.
• Menstruation and pregnancy. The changing levels of hormones affect the rate
at which fluid enters and leaves the tissues.

Some medical conditions may also cause edema, including:

• Heart failure. When the heart is unable to maintain adequate blood flow
throughout the circulatory system, the excess fluid pressure within the blood
vessels can cause shifts into the interstitial spaces. Left-sided heart failure can
cause pulmonary edema, as fluid shifts into the lungs. The patient may
develop rapid, shallow respirations, shortness of breath, and a cough. Right-
sided heart failure can cause pitting edema, a swelling in the tissue under the
skin of the lower legs and feet. Pressing this tissue with a finger tip leads to a
noticeable momentary indentation.
• Kidney disease. The decrease in sodium and water excretion can result in fluid
retention and overload.
 • Thyroid or liver disease. These conditions can change the concentration of
protein in the blood, affecting fluid movement in and out of the tissues. In
advanced liver disease, the liver is enlarged and fluid may build-up in the
abdomen.
• Malnutrition. Protein levels are decreased in the blood, and in an effort to
maintain a balance of concentrations, fluid shifts out of the vessels and causes
edema in tissue spaces.

Nursing Interventions:

Treatment of edema is based on the cause. Simple steps to lessen fluid build-up may
include:
• Reducing sodium intake. A high sodium level causes or aggravates fluid
retention.
• Maintaining proper weight. Being overweight slows body fluid circulation and
puts extra pressure on the veins.
• Exercise. Regular exercise stimulates circulation.
• Elevation of the legs. Placing the legs at least 12 in (30.5 cm) above the level
of the heart for 10-15 minutes, three to four times a day, stimulates excess
fluid re-entry into the circulatory system.
• Use of support stocking. Elastic stockings, available at most medical supply or
drug stores, will compress the leg vessels, promoting circulation and
decreasing pooling of fluid due to gravity.
• Massage. Massaging the body part can help to stimulate the release of excess
fluids, but should be avoided if the patient has blood clots in the veins.
• Travel breaks. Sitting for long periods will increase swelling in the feet and
ankles. Standing and/or walking at least every hour or two will help stimulate
blood flow.

Dietary changes, in addition to cutting back the amount of sodium eaten, may also help
reduce edema. Foods that worsen edema, such as alcohol, caffeine, sugar, dairy products,
soy sauce, animal protein, chocolate, olives, and pickles, should be avoided. Diuretic
herbs can also help relieve edema. One of the best herbs for this purpose is dandelion
(Taraxacum mongolicum), since, in addition to its diuretic action, it is a rich source of
potassium. (Diuretics flush potassium from the body and it must be replaced to avoid
potassium deficiency.) Hydrotherapy using daily contrast applications of hot and cold
(either compresses or immersion) may also be helpful.

Edema cannot be cured. The only way to treat edema is to treat the condition that is
causing it. The following are some things you can do to keep the swelling down:
• Put a pillow under your legs when you are lying down.
• Wear support stockings, which you can buy at most drugstores. Support
stockings put pressure on your legs and keep water from collecting in your
legs and ankles.
• Do not sit or stand for too long without moving.
• Follow your doctor's orders about limiting how much salt you eat.
Your doctor might want you to take a medicine called a diuretic, which is also called a
water pill.

It is important to see your doctor if you have edema. If it is not treated, your skin may
keep stretching, which can lead to other problems. Call your doctor right away if have
edema and you start to have trouble breathing. If you are pregnant and you notice edema,
call your doctor as soon as you can.

What Is It?

Edema is swelling of both legs from a buildup of extra fluid. Edema has many possible
causes:
• Prolonged standing or sitting, especially in hot weather, can cause excess fluid to
accumulate in the feet, ankles and lower legs.
• Tiny valves inside the veins of the legs can become weakened, causing a common
problem called venous insufficiency. This problem makes it more difficult for the veins to
pump blood back to the heart, and leads to varicose veins and buildup of fluid.
• Severe chronic (long-term) lung diseases, including emphysema and chronic
bronchitis, increase pressure in the blood vessels that lead from the heart to the lungs.
This pressure backs up in the heart. The higher pressure causes swelling in the legs and
feet.
• Congestive heart failure, a condition in which the heart can no longer pump efficiently,
causes fluid buildup in the lungs and other parts of the body. Swelling is often most
visible in the feet and ankles.
• Pregnancy can cause edema in the legs as the uterus puts pressure on the vena cava, a
major blood vessel that returns blood to the heart from the legs. Fluid retention during
pregnancy also can be caused by a more serious condition called pre-eclampsia.
• Low protein levels in the blood caused by malnutrition, kidney and liver disease can
cause edema. The proteins help to hold salt and water inside the blood vessels so fluid
does not leak out into the tissues. If a blood protein, called albumin, gets too low, fluid is
retained and edema occurs, especially in the feet, ankles and lower legs.

Symptoms:

• Symptoms vary according to the type of edema and its location. In general, the skin
above the swollen area will be stretched and shiny.

Prevention:

• The only way to prevent edema is to prevent the cause.

• Smoking is the main cause of chronic lung disease.
• Congestive heart failure most often is caused by coronary artery disease, high blood
pressure or drinking too much alcohol
• To avoid leg swelling on long trips, stand up and walk around often
• Ideally, you should get up once an hour
• Exercise your feet and lower legs while sitting. This will help the veins move blood
back toward the heart.

Treatment:

Treatment of edema focuses on correcting the cause of the fluid accumulation. A low-
salt diet usually helps. You also should avoid drinking too much fluid. If you are not short
of breath, elevate your legs above the level of your heart to keep swelling down. Your
doctor might suggest that you take a low dose of a diuretic (water pill).

For swollen ankles and feet caused by pregnancy, elevate your legs and avoid lying on
your back to help improve blood flow and decrease swelling.

If you have mild leg edema caused by venous insufficiency, elevate your legs
periodically and wear support (compression) stockings. Sometimes surgery is needed to
improve the flow of blood through the leg veins.

No matter what the cause of edema, any swollen area of the body should be protected
from pressure, injury and extreme temperatures. The skin over swollen legs becomes
more fragile over time. Cuts, scrapes and burns in areas that have edema take much
longer to heal and are more likely to get infected.

When to Call a Professional?

Call your doctor immediately if you have pain, redness or heat in a swollen area, an
open sore, shortness of breath or swelling of only one limb.

MIO

INTAKE AND OUTPUT

o THE CLIENTS I&O SHOULD BE MEASURED AND RECORDED FOR A 24

HR. PERIOD TO ASSESS FOR AN ACTUAL OR POTENTIAL IMBALANCE.

o A MINIMUM INTAKE OF 1,500 ML. IS ESSENTIAL TO BALANCE

URINARY OUTPUT AND THE BODY’S INSENSIBLE WATER LOSS.

o ALL LIQUIDS TAKEN BY MOUTH (e.g. soup, icecream, gelatin, juice and
water) AND LIQUIDS ADMINISTERED THROUGH TUBE FEEDINGS
(nasogastric or jejunostomy) AND PARENTALLY (IV fluids and blood) ARE
INCLUDED.
 o OUTPUT INCLUDES URINE, VOMITUS, DIARRHEA AND DRAINAGE
FROM TUBES SUCH AS GASTRIC SUCTION OR SURGICAL DRAINS.

THIRST
Thirst is the most common indicator of fluid volume deficit. The hypothalamus triggers a
thirst response when there is a decrease in ECF volume or an increase in plasma
osmolality.

FOOD INTAKE
Ingested food also helps maintain extracellular fluid volume. 1/3 of the body’s fluid needs
are met with ingested food. Electrolytes are also provided by food.

SKIN
Edema and skin turgor are two important indicators of fluid, electrolyte and acid-base
balance.

EDEMA
The main symptom of fluid volume excess is edema. It may be confined to a specific area
(localized) or occur throughout the body (generalized).
The skin is taut, shiny, smooth and pale in localized edema.
Pitting edema is rated on a four point scale as follows:

+0: no pitting
+1: 0 to ¼ inch pitting (mild)
+2: ¼ to ½ inch pitting (moderate)
+3: ½ to 1 inch pitting (severe)
+4: greater than 1 inch pitting (severe)

TURGOR
 Skin turgor refers ton the normal resiliency of the skin a reflection of hydration
status.
 When skin is pinched and released, it springs back to a normal position because
the cells and interstitial fluid exert outward pressure.
 Dehydration is the main cause of decreased skin turgor, which manifest as lax
skin turgor, which occurs in conjunction with edema.

BUCCAL (ORAL) CAVITY

The nurse should inspect the buccal cavity. With fluid volume deficit, saliva decreases
causing sticky, dry mucus membranes and dry, cracked lips.

EYES
The eyes should be inspected for sunkenness, dry conjunctiva, and decreased or absent
tearing, all signs of fluid volume deficit.
Puffy eyelids are signs of fluid volume excess.
Diagnostic Tests:
• Urinalysis
• Blood extraction

Urinalysis:
• Specific gravity - This test detects ion concentration of the urine. Small amounts
of protein or ketoacidosis tend to elevate results of the specific gravity. A very
high specific gravity means very concentrated urine, which may be caused by not
drinking enough fluid, loss of too much fluid (excessive vomiting, sweating, or
diarrhea), or substances (such as sugar or protein) in the urine. Very low specific
gravity means dilute urine, which may be caused by drinking too much fluid,
severe kidney disease, or the use of diuretics.
• Specific gravity -1.015-1.025
• pH - normally 4.8 to 7.5.
• Some foods (such as citrus fruit and dairy products) and medicines (such as
antacids) can affect urine pH. A high (alkaline) pH can be caused by severe
vomiting, a kidney disease, some urinary tract infections, and asthma. A low
(acidic) pH may be caused by severe lung disease (emphysema), uncontrolled
diabetes, aspirin overdose, severe diarrhea, dehydration, starvation, drinking too
much alcohol, or drinking antifreeze (ethylene glycol).

Serum osmolality:
Check the balance between the water and the chemicals dissolved in blood.
• Find out if severe dehydration or overhydration is present.
• Check to see if the hypothalamus is producing enough antidiuretic hormone
(ADH).
• Find the cause of seizures or coma. In severe cases, an imbalance between water
and electrolytes in the body can cause seizures or coma.
• Find out if certain poisons, such as rubbing alcohol (isopropanol), wood alcohol
(methanol), or antifreeze (ethylene glycol), have been drunk. Serum osmolality
can also help find out how much of these poisons are present in the blood.
Uric Acid:
• Check to see if kidney stones may be caused by high uric acid levels in the body.
• Find the cause of a high level of uric acid in the blood.

Blood Extraction:
• Sodium, blood urea nitrogen, and blood glucose levels.
-See if your kidneys are working normally.
-See if your kidney disease is getting worse.
-See if treatment of your kidney disease is working.
-See if severe dehydration is present. Dehydration generally causes BUN levels to
rise more than creatinine levels. This causes a high BUN-to-creatinine ratio.
Kidney disease or blockage of the flow of urine from your kidney causes both
BUN and creatinine levels to go up.
PHARMACOLOGICAL TREATMENT

KINDS OF DIURETICS:
o Furosemide (Lasix)
o Torsemide (Demedex)
o Butethamide (Bumex)
Those three blocks the sodium-potassium chloride transporter in the ascending loop of
Henle.

Diuretics that can combine to other agents:

1. Thiazide type diuretics such as:
o Hydrochlorthiazide (Hydrodiuril)
o Metolazone (Zaroxolyn)
Thiazide blocks the electroneutral sodium chloride transporter in the distal convoluted
tubule.

2. Potassium-sparing diuretic:
o Spironolactone (Aldactone)
o Triamterene(Dyrenium)
o Amiloride (Midamor)
o Acetazolamide (Diamox) - which counteracts the development of a high
concentration of bicarbonate (too much alkali) in the blood

Not all patients with edema will require drug treatment; in some patients, sufficient
sodium restriction (i.e., less than the amount excreted by the kidneys) and elevation of the
lower extremities above the level of the left atrium are effective. However, diuretics are
required in most patients in addition to nonpharmacologic treatments, especially
continued restriction of salt. The choice of diuretic, route of administration, and dosing
regimen will vary based on the underlying disease, its severity, and the urgency of the
problem.

HERBAL TREATMENT FOR EDEMA

o Parsley, taken either as an infusion or eaten raw (but not if pregnant), or dandelion
leaves, either drunk as a "coffee" or eaten in salad are both recommended. Cut
down on salt, eat lots vegetables, salads, and fruit, and drink fruit juices.
o Aromatherapy Lavender is very helpful.
o Massage and Acupressure Both of these can be beneficial.
o Effleurage is the most effective massage technique.