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Edema

Nursing Administrative Manual

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] 

Tags
Edema
Edema Assessment
Long-Term Care
Nursing Documentation
Resident Care Plan
CMS compliance
SOM Guidelines
nursing home policy
Section E. Nursing Administration Manual
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