Edema

Edema 

Effective Date: [Original NPP Date] 

Revised Date: [Current Date] 

Standard: 

Edema will be documented when present. 

Policy: 

Edema is monitored by the licensed nurse and findings documented in the nurse’s notes. The physician and responsible party are notified when indicated. 

Procedure: 

How to Assess for Edema: 

• To assess pitting edema, press firmly for 5-10 seconds over a bony surface, such as the subcutaneous part of the tibia, fibula, sacrum, or sternum. 

• Remove your finger and note how long the depression remains. 

Edema Scale: 

Use the following edema scale consistent with the nursing administration assessment’s scale: 

• 0 o No pitting edema 

• +1 o Mild pitting edema, 2mm depression that disappears rapidly 

• +2 o Moderate pitting edema, 4mm depression that disappears in 10-15 seconds 

• +3 o Moderately severe pitting edema, 6mm depression that may last more than 1 minute 

• +4 o Severe pitting edema, 8mm depression that can last more than 2 minutes 

Documentation: 

• Findings are documented in nurse’s notes, including the location and scale of the edema. 

• The resident's care plan is updated as needed to reflect changes in the resident’s condition and any interventions initiated. 

• The physician and responsible party are notified promptly when significant edema is noted or if there are any changes in the resident’s condition related to edema. 

References: 

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. [Link to current CMS SOM] 

• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]