ANN STANONIS BSN, RN 1996 SURVEY OF METHODS OF EDEMA MEASUREMENT BY REGISTERED NURSES ABSTRACT The methods used to assess edema, an excessive amount of fluid in the body tissues, are varied. This descriptive, exploratory study used a researcher developed questionnaire to determine the assessment methods used by registered nurses providing bedside care in small to moderate sized Western Pennsylvania Hospitals. The information obtained will be utilized to encourage the establishment of nursing protocols for edema assessment in medical care facilities in order to achieve consistency and accuracy in assessment of edema. Thesis Nurs. 1996 S789e c.2 Stanonis, Ann. Evaluation and comparison of methods 1996. EVALUATION AND COMPARISON OF METHODS OF EDEMA MEASUREMENT BY REGISTERED NURSES by ANN STANONIS BSN, RN Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Approved by: (P , (fa- & ■ (jv'H . Chairperson, Thesis Committee Edinboro University of Pennsylvania bace Committee Member Date Committee Member c • 7- ACKNOWLEDGEMENTS First, 1 want to thank God for answering prayers, helping dreams come true, and giving me wonderful friends and family. Second, I wish to thank Margaret Catharine Davis, MSN, RN for her unfailing support, assistance, organization, and impetus to this project. This will never be forgotten. Third I wish to thank Professor Charles Manes of Thiel College for his assistance, support, and belief in me. Fourth, I wish to thank my family for their patience and support. Fifth, I wish to thank the employees of Clarion Career Center for their assistance, my Advisor Dr. Charlotte Paul, Dr. Keller and Dr. Beckman of my Committee, Professor Glen Rock of Clarion University, and Margaret Reid of Oil City I also wish to thank Anne Bookman for for their assistance with this project. bringing this project together so beautifully. May, 1996 AS ii TABLE OF CONTENTS ACKNOWLEDGEMENTS PAGE ii CHAPTER I II III INTRODUCTION Background of the Problem 1 Purpose of the Study 3 Statement of the Problem 4 Assumptions 4 Definition of Terms 5 Scope and Limitations 6 REVIEW OF THE LITERATURE 7 Introduction 7 The Conceptual Framework 21 METHODOLOGY . 23 Introduction . 23 Sample and Setting 23 Instrumentation . 24 Data Collection 26 Analysis of Data 27 IV PRESENTATION AND ANALYSIS OF DATA 30 V CONCLUSION 38 Summary 38 Discussion 39 Conclusions 42 Recommendations 42 LIST OF TABLES . 33 Table 1 - Method of Edema Assessment 33 Table 2 ■ Calculated Chi Square (Method) 35 Table 3 ■ Choice Factors for Assessment Methods 36 Table 4 - Calculated Chi Square (Choice) 37 REFERENCES 44 appendices 49 A. Edema Assessment Scales 49 B. Edema Assessment Scales 50 Edema Assessment Scales 51 C D. Agency Letter 52 E. Staff Nurse Cover Letter 53 F. Original Questionnaire 54 G. Revised Questionnaire 55 H. Final Questionnaire 56 Edema 1 CHAPTER I Introduction Background of the Problem An excessive amount of fluid in the body tissues is a symptom associated with various disease states and is commonly referred to as "edema." This symptom may be exhibited in a variety of individuals ranging from the severely ill to the relatively healthy. Diseases or disorders of many body systems, including cardiovascular, endocrine, hepatic, and renal, may exhibit evidence of edema. Furthermore, it may occur in drug reactions, malnutrition, burns, insect, snake, and animal bites. Physiological factors which lead to the formation of edema include (1) Plasma hydrostatic pressure changes in the capillaries ; (2) Plasma colloid osmotic pressure decreases; (3) Capillary permeability increases; (4) Sodium retention; and (5) Lymphatic drainage obstruction. As a result of these physiological factors, fluid leaks into the Edema 2 interstitial space and edema occurs. This fluid overload causes pressure on nerve endings and decreases blood flow, resulting in ischemia and pain in the affected tissue. The skin appears shiny, taut, and pale. The pulses in the affected areas begin to weaken. The tissues become less elastic and are easily injured. Organ function may be impaired and the cardiovascular system overloaded. The appearance of edema varies with the etiology, location, and the amount of fluid overload. The following terms which describe different types or appearances of edema are localized (not systemic), dependent (below heart level or lowest body part), pitting edema (an indent remains following applied pressure, non-pitting edema (does not indent to pressure), refractory (does not respond to treatment), and brawny (severe, rock hard, non-pitting edema). Because edema is a symptom of various pathological states, it is important to assess for its presence. If edema is found, the degree or amount must be determined in both the initial baseline assessment and the ongoing assessment. The importance of an ongoing assessment of the edema state is a high priority because continual assessment relates to the status and progress of the disease. Maxwell and Kleeman (1994) relate that the assessment of generalized edema is important in Edema 3 clinical practice, since it signals the presence of a number of important disease states including renal failure and congestive heart failure. It can be seen that this assessment needs to be consistent to obtain accurate data concerning the amount of fluid in the interstitial space. There are many methods utilized to assess edema. It is important to determine which method is preferred so the information may be utilized to encourage the establishment of nursing protocols in medical care facilities. This would also aid in achieving consistency of assessment of edema in medical facilities. Edema can occur in all parts of the body, internally as well as externally. The area of this research will be concerned with external edema and the assessment of such. Purpose of the Study The methods used to assess edema are varied. Many nurses feel that the assessment of edema is vague and imprecise. The purpose of this research is to determine which method is most frequently used by staff nurses to assess edema and Edema 4 the reason that method is utilized. Statement of the Problem The problem of this survey is to ascertain which method of edema assessment is most frequently utilized by nurses and why. The questions to be answered are: Is one method of edema assessment most frequently used by staff nurses? Are nurses more likely to chose a method of edema assessment based upon institutional policy, educational background, or peer influence? Assumptions The assumptions of this study consist of the following: 1. 2. 3. 4. It is assumed that nurses assess edema as a measurement of body function and as a symptom of disease. It is assumed that nurses use different methods to assess edema. It is assumed that all nurses have the same baseline knowledge of edema assessment. The standard used to verify this assumption would be the successful completion of the same State Board Examination. It is assumed that nurses will be honest with their answers. Edema 5 Definition of Terms The following terms are defined as they relate to this study: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Edema - an abnormal accumulation of fluid in the interstitial spaces of tissue. The source of the fluid is the blood plasma. Pitting Edema ■ phenomenon manifested by a small depression when one's finger is pressed over an edematous area. The "pit" gradually disappears following removal of the pressure of the finger. Non-pitting Edema - edema which leaves no indentation following applied pressure. The edema has coagulated in the tissue. The skin feels hard and rough. Nurses - registered nurses providing bedside care and assessments. Localized ■ edema which is restricted to a limited or definite region and is not systemic. Dependent Edema ■ the flow of excess fluid by gravity to the most dependent portion of the body. If standing, it will be found in feet and ankles. If lying down, it will be found in back and buttocks. Refractory Edema ■ edema which persists despite treatment with low sodium diet and diuretics. Brawny Edema ■ the type of edema in which the overlying skin is stretched taut and resembles a pig's skin with pronounced pores. It is hard to touch and pressure will not leave an indentation. It is often found with lymphatic obstruction. Intravascular - within blood vessels. Extravascular ■ outside a vessel. Edema 6 Scope and Limitations The focus of this study is the method used to measure edema by registered nurses providing bedside care in small to moderate sized health care agencies. Large teaching medical centers and facilities will be omitted because of the probability of established standards for edema assessment. The geographical scope of the study will include four acute care hospitals in Western Pennsylvania. Data collection was done by questionnaire. The convenience sample included registered nurses who reported to work during a two-week period. Edema 7 CHAPTER 2 Review of the Literature The purpose of this research is to determine which method of edema assessment is most frequently used by staff nurses and the basis for that decision. The review of literature which follows relates to the purpose of this research. In her book on nursing, Brown (1957) describes the following historical background of edema, which has long been a topic of medical interest: (1) Reference to edema is found in the Ebers Papyrus; (2)Hippocrates referred to three clinical forms of edema; (3) Hercules is shown on a Roman medical tablet drinking at a diuretic spring; (4) Digitalis, which comes from the foxglove plant, has diuretic properties described in 1785 by Withering in "An Account of the Foxglove"; (5) Paracelsus used calomel to treat edema; (6) Widal and Lemierre in 1903 reported the value of sodium restriction in the medical management of congestive heart failure patients; (7) In 1920 a medical study, by a chance observation, noted an unexpected diuresis following the administration of an organic mercurial compound being Edema 8 investigated as an antisyphilitic agent. Thus, the first mercurial diuretic, merbaphen, was introduced. According to Blacklow (1983), the lining of the capillaries is one cell layer thick, making the wall very thin. Large spaces or pores exist between the cells in the capillary membrane. Water, electrolytes, and protein shift freely through the capillary membrane in either direction. Blacklow (1983) states that the normal governing functions of the exchange of fluid between the intravascular (the blood) and extravascular fluid compartments are as follows: (1) Capillary permeability; (2) Capillary blood pressure or hydrostatic pressure; (3) Colloid osmotic pressure of plasma; (4) Colloid osmotic pressure of tissue fluids; and (5) Factors which influence formation and flow of lymph. The first factor which influences fluid and electrolytes shifts is capillary permeability. Capillaries become more permeable with the release of histamine by the tissue. This can be the result of allergic reactions. Bacterial infections cause the capillaries to have an increased porosity. Burns also damage the capillaries. As a result of any of these factors, plasma proteins leak into the interstitial fluid spaces and edema occurs. Edema 9 The second factor, plasma hydrostatic pressure, provides the force necessary to filter fluid through capillary walls, according to Blacklow (1983). The driving force comes from the heart. Capillary pressure is variable depending on total flow, venous outflow, arteriolar vasomotion, position or posture, and neurogenic influences. Blood, which may become dammed in the venous system, causes "back" pressure in the capillaries, thus raising the pressure. Increased pressure in the capillaries forces more fluid into the tissue resulting in edema. Congestive heart failure and venous obstruction can cause increased venous pressure. The third and fourth factors stated by Blacklow (1983) involve colloid osmotic pressures. Decreases in plasma colloid osmotic pressure results from diminished plasma protein concentration. Decreases in protein content will cause water to flow from the plasma into tissue spaces, thus causing edema. Malnutrition may cause this. The fifth factor described by Blacklow (1983) deals with formation and drainage of lymph. Blockage of lymphatics prevents the return of proteins to the circulation. He states that obstructed lymph flow is high in protein content. With Edema 10 the inadequate return of proteins to the circulation, the plasma colloid osmotic pressure will be decreased, thus causing edema. Cancer is one cause of lymphatic blockage. Blacklow (1983) also describes general mechanisms which affect the formation of edema. The mechanisms that deal with the regulation of water electrolyte balance are related to kidney function. The kidneys regulate the level of sodium ions in extracellular fluid Blacklow (1983). Kidney function depends on adequate blood flow. Inadequate blood flow, excess aldosterone, or diseased kidneys are factors which induce sodium retention and fluid retention, contributing to edema. In their book concerning fluid and electrolyte metabolism, Maxwell & Kleeman (1994) describe edema as "one of the most vexing problems to afflict patients". Edema is an important sign in medical and nursing assessments since it is found in major and minor illnesses. Maxwell and Kleeman (1994) define edema as an excessive accumulation of fluid within the interstitial space, that is, within the nonvascular portion of the extracellular fluid space causing swelling. The source of this fluid is the blood plasma or the circulating blood. Its composition is similar to Edema 11 that of plasma. Maxwell & Kleeman (1994) state that all edema is due to alterations of forces which govern the transcapillary movement of fluid. This phenomenon was researched by Starling in 1896. Edema may accumulate in any part of the body. Several authors discuss the location of edema. According to Rosdahl (1995), edema frequently occurs in loose tissues such as around the eyes. Edema occurs also in areas where return flow of blood is the slowest, as in fingers and ankles. Suddarth (1991) indicates that the location of edema is influenced by gravity. Fluids tend to collect bilaterally in lower body parts because of gravity. Thus the sacral area, the ankles, and feet are common locations for edema detection. Luckmann (1996) classifies edema with the following terms 1. 2. 3. 4. 5. 6. 7. Anasarca ■ severe generalized edema Ascites - excessive accumulation of fluid in the peritoneal cavity Pulmonary edema - excess fluid within the lung tissue Interstitial edema - excessive fluid in the interstitial space (common in heart failure) Hydrothorax - effusions of fluid in the pleural cavity causing lung collapse Hydropericardium - effusions of fluid in the pericardial cavity Pleural effusions - edema fluid in the pleural space (can occur without lung collapse) Maxwell & Kleeman (1994) describe edema as either localized or generalized. Edema which is restricted to a particular vascular area or organ, such as that found Edema 12 with inflammation or with insect bites is described as localized. When the potential for fluid to leave the vascular space throughout the body is present, generalized edema may occur. Metheny and Snively (1983) describe several types of edema seen in clinical practice including pitting edema, dependent edema, and refractory edema. Pitting edema is a phenomenon occurring when pressure is applied to the edematous area. Following removal of the pressure, an indent mark or depression is seen. Gradually the "pit" disappears. Metheny and Snively (1983) state that pitting edema is not evident until there is a 10% increase in the client's weight. Metheny and Snively (1983) describe dependent edema as the flow of excess fluid by gravity to the lowest part of the body. If the client is standing, the feet and ankles will swell. If lying down or sitting, the swelling will be in the sacral area and the buttocks. Luckmann (1996) states that edema which does not respond to diuretic therapy and salt-restricted diets is labelled 'refractory . Sundberg (1989), describing another type of edema not discussed by Methany and Snively (1983), states that edema may become so severe that pitting will not occur. This she labels as "non­ pitting" and describes the interstitial space as being so packed with fluid that Edema 13 pressure will not displace it. The tissue becomes rock hard to touch. If the swelling continues, coagulation occurs and the tissue becomes fibrotic producing edema known as brawny. The skin becomes roughened. The symptom of edema is considered to be an abnormal finding and is suggestive of disease. Accurate edema assessment aids in the determination of disease states, as well as evaluation of the progress of that disease. The Nurse's Reference Library (1983) describes the characteristics of edema as follows: (1) Pitting or non-pitting; (2) The location and extent of edema; (3) The degree of the pit (refers to the depth of the depression in the skin following pressure); and (4) Symmetry (unilateral or symmetrical). The techniques used to assess edema are inspection and palpation. With inspection the nurse observes body surfaces and develops a visual description of what is seen. Taking measurements to validate observations is important since it provides a baseline for future measurements and provides comparisons to normal. Observation also is important in edema assessment. The other technique used to assess edema is palpation in which the nurse feels with the fingers and hands. Diverse characteristics may be assessed by touch Edema 14 including temperature changes, textures, contours, and specifically with edema, pitting or non-pitting. The nursing process is a problem-solving approach used by nurses in providing care for clients. There are five phases to this process, with assessment being the first step. During the assessment phase of the nursing process, the initial assessment is accomplished with the first contact with the client. But assessment does not stop here. The nurse is responsible for ongoing assessment to determine effectiveness of care and to discover whether any new problems have arisen. Edema assessment follows the same principles of initial and ongoing assessment. But many questions arise when considering edema assessment. Are there methods of edema assessment which are better utilized for the initial assessment, and are there methods better utilized for on-going assessment? The review of literature reveals a lack of consistency and at times even vagueness in the information about edema assessment. Jones, Dunbar, & Jirovec (1982) state that the client's general appearance needs to be assessed as well as taking baseline measurements. Much can be determined about body hydration from the client's weight and vital signs. The client's Edema 15 weight needs to be compared to previous records. These authors also indicate that up to 10 pounds of fluid can accumulate before it is detectable as pitting edema. Carpenito (1995) and Sunyecz & Mirtallo (1993) indicate that in ongoing assessment of edema, a weight gain of two pounds a day is cause for concern, and they stress that recording daily weights is imperative in the ongoing assessment of edema. Beland & Passes (1981) discuss the accuracy of 24-hour intake and output records, stating that the chances of errors in measurement are great within the existing practices. Therefore, an ongoing record of the client's weight is probably the best single measurement of fluid status. For each pound of weight gained, about a pint of fluid is retained. To obtain an accurate weight, the client must be weighed at the same time each day, on the same scale, attired with the same amount of clothing. Suddarth (1991) indicates that weight gain occurs prior to clinical evidence of edema. Edema is a late sign of heart failure. Pitting edema is obvious only after retention of at least 4.5 kg (10 pounds) of fluid. Fluid is heavy; therefore, accumulation of water in the tissues causes weight gain. A gain of 2.2 pounds is equivalent to a gain of one liter of fluid. This finding is collaborated by many researchers such as Wolff, Weitzel, & Fuerst (1979); DeWit Edema 16 (1992); Sundberg (1989); Parys (1987); Letterer, Carew, Reid, & Woods (1992); Wright (1990); Rideout & Montemuro (1986); and Metheny & Snively (1983). Blacklow (1983) also indicates that relatively large amounts of fluid must accumulate in the extracellular fluid spaces before swelling is detected. Blacklow (1983) further states that a patient's body weight may increase nearly 10% before pitting edema occurs. Body weight can be used for initial assessment if a recent baseline body weight is available for comparison. Body weight is an accurate measurement of hydration status in an ongoing assessment. DeWit (1992) states the progress of edema (ongoing edema assessment) can be assessed by using a measuring tape to measure the circumference in inches or centimeters of the abdomen, thighs, ankles, calves, and feet. Marks should be placed on the skin to ensure that the exact same spot is measured each time. Quinlan (1984) states that edema should be assessed as to its nature, extent, and location in addition to assessing for pitting and measurement of a client s girth. When measuring the girth of an area, mark both sides (such as the abdomen) to make sure the measurements are taken at the same site each time. Note also whether the client is standing, sitting, or lying down. Edema 17 To determine the difference between "pitting" and "non-pitting" edema, firm finger pressure is exerted for five seconds over a bony prominence of the edematous With the release of the pressure, if an indentation appears, the edema is area. described as "pitting edema". The pit is formed by the movement of fluid away from the point of pressure to the adjacent tissue. The pitted area gradually refills as the fluid returns to the interstitial space. This fluid hinders cell nutrition as it increases the distance between the blood capillaries and the cells. Parts of the body with a large amount of edema exhibit tight, smooth, and shiny skin. This skin is easily injured. If, on the other hand, no indentation occurs, it is considered "non-pitting". The fluid cannot be moved into adjacent tissue by finger pressure. "Non-pitting" edema is found in conditions such as infections or trauma. The fluid collects and coagulates in tissue spaces. This coagulation prevents the movement of fluid to adjacent areas by pressure. The literature reviewed presents numerous scales to be utilized in the assessment of pitting edema. Most of the authors instruct the nurse gently but firmly to press a finger into the edematous area for 5 to 10 seconds. Estimating the Edema 18 depth of the depression or pit is the second step. The scale usually goes from 1 + to a 4+ with the 4+ being severe. Various scales are found in the literature regarding evaluation of pitting edema (Appendix A, B, C). However scales are not consistent. For example, they may refer to millimeters, centimeters, and parts of an inch to measure depth of the pit. 1 + to 4+ have diverse connotations to authors as well as to nurses using the scale. Other scales refer to the time in seconds and minutes for the pit to disappear. One scale correlates the depth of the pit with precise amounts of excess fluid volume. Grimes and Burns (1996), Canobbio (1990), and Berger and Williams (1992), have the most comprehensive and readily understood scales. Scherer and Timby (1995) state that there are no standard criteria for the numerical rating. The numbers refer to the examiner's subjective opinion and estimation, and therefore are not consistent or objective. It can be seen from the literature review, that many methods exist to assess edema, and the methods as well as the scales are not consistent. Even though there is a varied approach to edema assessment, the following authors feel that assessment is important. Billings & Stokes (1987) state that monitoring and frequent Edema 19 assessments of edema are significant to detect the early recognition of heart failure and pulmonary edema, which are serious disease states. In clinical practice, the assessment of generalized edema signals the presence of a number of important disease states, including renal failure and congestive heart failure (Maxwell & Kleeman (1994). Jones, Dunbar, & Jirovec (1982) state that, "Physical assessment of fluid and electrolyte dynamics can be invaluable in evaluating a client's fluid status". Porth (1994) states that effects of edema are determined by its location. Edema of brain, larynx, or lung is life threatening. Edema interferes with movement, limits motion, and can be disfiguring. At the tissue level, edema increases the distance for diffusion of oxygen, nutrients, and waste products. Edematous tissues are more susceptible to injury and pressure sores. In chronic edema, the stretching of tissue over a long period of time, makes correction or reversal difficult. Therefore, it is important to assess edema accurately, to monitor, and to treat these effects. Sundberg (1989) states that the degree of edema can be assessed by periodic measurement for size. Recording a series of measurements will indicate whether the Edema 20 condition is increasing, decreasing, or remaining the same. Berger & Williams (1992) note the degree of pitting generally correlates with the degree of fluid excess. When describing assessment, Bolander (1994) gives the following quotations from Florence Nightingale's "Notes on Nursing": The most important practical lesson that can be given to nurses is to teach them what to observe - how to observe - what symptoms indicate improvement - what the reverse ■ which are of importance - which are of none. Edema assessment fits into this description. It is important to observe edema and in doing so to see an increase or decrease in the state of edema which would reflect either a progression of illness or an improvement in health. In her book "The Nature of Nursing" (1966), Virginia Henderson states: The nurse who operates under a definition that specifies an area of independent, or an area of expertness, must assume responsibility for identifying problems, for continually validating her function, for improving her methods, and for measuring the effect of nursing care. The importance of assessment skills in general are implied in Henderson s words. Edema 21 The Conceptual Framework The conceptual or theoretical base of this study concerns the physiology of edema. In 1896 Starling first demonstrated that a disturbance in the balance between capillary filtration and resorption of fluid and electrolytes encouraged the formation of edema. Since his original studies with oncotic pressure of plasma proteins, research has shown that many factors such as capillary filtration, venous, and lymphatic pressure, muscular activity, cardiac output, aldosterone secretion, and renal function influence edema formation. These alterations in the internal environment directly affect the individual's physiologic functioning, and if severe enough, can cause death. Consequently, it is essential that the individual receive support during this period from the health care delivery system. All health care team members play an important role in the individual's care at this time, but much of the responsibility lies with the nurse because of proximity and the amount of time spent with the individual. Kinney et al. (1993) proposes a model of nursing responsibilities in relation to alterations in an individual's internal environment, which includes fluid and electrolyte imbalances. They state that nursing Edema 22 has the most frequent and extensive contact with the individual and, therefore, can detect changes in function. Their model of nursing responsibilities closely follows the nursing process and includes monitoring (assessing), interpreting, reporting and recording, intervening, and evaluating. They state that these responsibilities need to be consistent, frequent, and extensive. In the Kinney, et al, (1993) model these nursing responsibilities are implemented response to the external manifestations of internal alterations. External manifestations include physical appearance changes, physiological function changes, and behavioral changes. Edema is a classic example of this situation. The first responsibility of nurses is monitoring and assessing which must be done in a systematic, consistent manner. The other responsibilities follow in an orderly fashion, but the authors stress that all action must be based on accurate and sufficient data because to intervene inappropriately can threaten the stability of the individual. These responsibilities or functions must be performed periodically, accurately, and consistently and they provide the framework for delivering nursing care. Edema 23 CHAPTER 3 Methodology Introduction The purpose of this study is to determine which method of edema assessment is most frequently used by staff nurses and the reason for those choices. Sample and Setting The population for this study consisted of staff nurses who were employed in four acute care hospitals in Northwestern Pennsylvania with a bed complement of under 150 per hospital. A sample of convenience was nurses reporting to work during a utilized for this study and included all staff selected two-week period. The sample size selected was to be registered nurses who were licensed to practice nursing in Pennsylvania and available to participate in the study. Edema 24 Instrumentation Letters (Appendix D) soliciting permission to conduct this research were sent to the Directors of Nursing at the acute care hospitals within the area of this survey and permission was granted. The original copies of these letters are filed with the Department of Nursing, Edinboro University of Pennsylvania. A cover letter to each staff nurse was included with each questionnaire (Appendix E) to explain its purpose. Questionnaires (Appendix F, G, and H) in the form of a checklist were developed by the researcher based on the literature review of numerous assessment texts. The questionnaire (Appendix F) was evaluated for readability and content by a panel of experts including five faculty members of a local school of nursing, a Director of Nursing from a local hospital, and an education/staff development instructor. Based on their suggestions, the questionnaire (Appendix G) was revised to include the area of specialization of the nurse, the years of active service, and agency policy. At this time the study was refocused to include only Registered Nurses. Therefore, LPN was deleted from the questionnaire (Appendix G). A third revision to the questionnaire elicited the final version (Appendix Hi. Edema 25 Gender was added to the demographical data. Section II was expanded to reflect why a particular method was chosen. Further, the researcher was interested in the nurses' first choice of measurement. Polit & Hungler (1995) describe reliability of an instrument as the degree of consistency and accuracy with which it measures that which it is supposed to measure. The second evaluation of an instrument's quality is validity, which refers to the degree to which the instrument measures what it is intended to measure. Polit and Hungler (1995) define a pretest as a trial administration of a newly developed instrument to identify flaws. In order to test these concepts of the instrument developed for this research, a pretest was done. Six nurses not involved in the research completed the questionnaire. A minor change was made in the instrument (Appendix H) following the pretest to expand the demographic data to include the number of years worked in their specialty. All versions of the questionnaire can be seen in Appendix F, H, and H. Edema 26 Data Collection The data collection was performed using the developed questionnaire (Appendix H) which was distributed to the participating hospitals through the mail. Initially the researcher intended to provide self-addressed stamped envelopes for the nurses to return the questionnaires, but the Nursing Directors preferred to collect the questionnaires. A personal visit was made to three agencies to acquire the completed questionnaires. The fourth agency mailed them in bulk to the researcher. The nurses participating in the survey were to complete and return the questionnaires within two weeks. Verbal instructions concerning distribution and collection of the questionnaires, within the agencies were discussed with each Director of Nursing. A cover letter was included with each questionnaire to clarify how to complete the survey (Appendix E). personally to distribute the surveys. constraints, this was not feasible. The researcher s original intent was However, because of time and distance Because of the extent of preparation and distribution, two weeks were required to complete the survey at each facility. Data was collected between January 21, 1996 and February 21, 1996. Edema 27 Analysis of Data The statistical test used was one-way chi square chosen from Linton & Gallo (1975). Requirements for this test were one independent variable, three levels, an unequal number of subjects, and a between-subjects design. Sampling of convenience, which uses the most readily available persons as subjects for the study, was used. Polit & Hungler (1995) describe the chi square as a test of statistical significance utilized when categories of data are obtained. The collected information was prepared for computer analysis by coding the raw data and assembling it in categories. The categories of data were placed in contingency tables to describe the frequencies of cases falling in different classes. The chi square statistic was computed by comparing two sets of frequencies: those observed in the collected data and those expected, if there was no relationship between the variables. This statistical test aids in deciding whether a difference in proportions reflects a real experimental effect or a chance fluctuation. The values obtained when the chi square Edema 28 was computed were compared with a table of chi square values for various degrees of freedom and significance levels. The table was found in statistical texts. Linton and Gallo (1975) state that the value of chi square cannot be evaluated unless the number of degrees of freedom associated with it is known. The degree of freedom (df) was calculated based upon the number of rows and columns. According to Linton & Gallo (1975), if the computed chi square is greater than or equal to the tabled chi square, then the deviation of the observed frequencies from the expected frequencies is significant. If the computed chi square is less than the tabled chi square, then the deviation of the observed frequencies from the expected frequencies is not significant. Only if the difference between the expected and obtained frequencies is large enough, can a decision be made that a true population difference exists. Demographic information was elicited as a matter of interest for the researcher, since the only point of interest for this study was the method of edema assessment and why that choice was made. Demographic information included age groups, gender, nursing degree, year of graduation, years of active service, specialization. Edema 29 Registered nurses were evaluated as a single group yielding preferred assessment methods and the reason for the choice. Since each sample was measured under one condition, it was a between subjects design. The tool yielded frequency data, which adapted well to the chi square statistical test. Edema 30 CHAPTER IV PRESENTATION AND ANALYSIS OF DATA The researcher conducted this study over a four-week period. Over this time span, data was collected from two hospitals simultaneously during the first two weeks. This process was repeated for the last two hospitals during the third and fourth week. The Director of Nursing of each hospital arranged for distribution of the questionnaire to the nurses reporting to work during the identified two-week period. The completed questionnaires were collected by the agency personnel and returned by mail and by hand to the researcher. Four hundred questionnaires were distributed to the four agencies. The total returned completed questionnaires numbered 293, or 73% of the total distribution. Some nurses answered more than one response to the research questions, thus invalidating those questionnaires. A total of 166 of the returned questionnaires could be included, which was 57% of the total returned and 42% of the number distributed. included on the questionnaire. This data did not enter into the Demographic data was i research and was included only as personal interest of the researcher. The following summary of the collected demographic data describes the population surveyed. In the age category the Edema 31 number of respondents in the 36-45 range consisted of 42.2% of the total population. The number in the 26-35 range consisted of 26%; the number in the 46-55 range consisted of 18%; and the number in the 19-25 range consisted of 12%. The number in the 56-65 range contained the lowest percentage of respondents at 1.8% of the total. The gender category results were as the researcher expected. Females still outnumber males in the nursing profession. The male respondents were 3.6% of the total sampled population. The highest degree obtained by the sampled population was the next category. This category also contained unexpected findings for the researcher. Four respondents' highest degree was a Master of Science in Nursing and consisted of 2.4% of the total population. The Diploma category of nursing degree consisted of 39.6/o of the total population. The Bachelor of Science in Nursing was the next largest group consisting of 32% of the total population. The Associate Degree in Nursing was 26% of the total population. There were no respondents in the "other" category. The next demographic category consisted of the year of graduation. The range in this category was 1951 to 1995. Another category was the years of active practice. This range consisted of 1 to 45 years with a mean of 22 years of active service. Edema 32 Area of specialization was the last category and was confusing for many respondents, as they had worked in a variety of units. Also the researcher had no category for the maternity group of nurses. These nurses added their own category on the questionnaire. Percentages could not be accurately calculated in this category as nurses answered in more than one area. The responses from highest to lowest rank were Medical, Surgical, Cardiac, Intensive Care, and Maternity. The demographic data yielded expected and unexpected results for the researcher. The questionnaire was unclear in the specialization category. The tool should have directed respondents to check only the current area of specialization. This flaw was not identified in the pretest. The nurses who responded that their choice of edema assessment method was related to policy also responded that their area of employment was Intensive Care. The first research question to be addressed. Is one method of edema assessment most frequently used by staff nurses? Edema 33 TABLE I Method of Edema Assessment Number of Questionnaires Reviewed (N-166) METHOD RESPONSES IN EACH CATEGORY Depth 110 Time 23 Tape 13 None 20 The first method of edema assessment was estimating the depth of the pit and using a scale of 1 + to 4+. This category received 110 responses and was 66% of the total and the highest category. The second method of edema assessment was the use of time measurement in minutes and seconds for the pit to disappear. There were 23 respondents in this category or 14% of the total. The use of a tape measure to assess abdominal girth, circumference of the thigh, calf, and ankle was the third method. It received 13 responses which was 8% of the total. The fourth category was labeled as none of the above. If it was checked, there was to be an explanation of the methodology used. Of 20 such responses, there was no further clarification. This was 12% of the total responses. Edema 34 The chi square for each method was calculated (Table 2) with three degrees of freedom. The first method of edema assessment, estimating the depth of the pit, received a score of 113.07, (df value = 11.345) which shows significant difference at the .01 level (see Table 2). The next method of edema assessment, determining the time in seconds and minutes for the pit to disappear, received the score of 8.25 (df value = 7.815) which was significant at the .05 level. The third method of edema assessment, using a tape measure to assess circumference changes, received the score of 19.57 (df= 11.345) which was significant at the .01 level. The last category of edema assessment methods, which was none of the above, received a score of 11.14, (df=7.815 ■ 11.345) which was significant at the .05 level. It is evident that nurses' primary choice of edema assessment is estimating the depth of the pit following applied pressure. Cell frequencies as discrepant as these would occur by chance less than 5% of the time. Estimating the depth of the pit, was the most frequent response to the research question. Edema 35 TABLE 2 Calculated Chi Square METHOD CHI SQUARE Depth 113.06 Time 8.25 Tape 19.57 None 11.14 .01 = 11.345 df-3 .05 = 7.815 The second research question to be addressed: Are nurses more likely to choose a method of edema assessment based upon institutional policy, educational background, or peer influence? The first category, institutional policy, had 19 responses, contributing 11% of the total responses. Of those 19, no one identified the agency policy as the questionnaire requested. Educational background was chosen by 124 respondents which was 75% of the total responses. They indicated that their basic nursing education influenced their choice of edema assessment method The third choice was peer influence. This received 23 responses, or 14% of the total responses. Edema 36 TABLE 3 Choice Factors For Assessment Methods Number of Questionnaires Reviewed (N = 166) CHOICE FACTORS RESPONSES IN EACH CATEGORY Institutional Policy Educational Background Peer Influence 19 124 23 The chi square was calculated on the second research question with two degrees of freedom. The first choice was related to institutional policy and received a score of 23.85 (df = 9.210) which was significant at the .01 level. The second choice, relating to educational preparation, received a score of 85.23 (df=9.210) which was significant at the .01 level. Peer influence received a score of 18.89 (df=9.210) which was also significant at the .01 level. Clearly, most nurses identified educational preparation as the basis for their choice. Edema 37 TABLE 4 Calculated Chi Square CHI SQUARE CHOICE FACTOR Institutional Policy 23.85 Educational Background 85.23 Peer Influence df = 2 18.89 .01=9.210 .05 = 5.992 Edema 38 CHAPTER V CONCLUSION Summary The focus of this study was surveying methods of edema assessment to determine which one was used most frequently by registered nurses and the reason for that choice. The literature review included historical background of edema, pathophysiology of edema, and the location and types of edema. The edema assessment methods were inconsistent and varied according to authors. Of primary importance was the relationship between edema assessments and disease states. The conceptual framework evolved around Starling's original research and is evidenced in the Kinney Model as it relates to nursing practice. Four hundred questionnaires were sent out with a return of 293 of which 166 were valid. Some nurses answered more than one response on the questionnaire, thus negating it. Edema 39 Demographic data was elicited as well as the two research questions of edema assessment methods used by registered nurses and the reason for their choice. The data showed the majority of nurses selected the edema assessment method of estimating the depth of the pit. The majority of nurses identified their educational preparation as the primary influence upon their choice of method used to assess edema. Discussion This study was initiated as a result of the researcher listening to nurses report their edema findings and noting that wide variations occurred. These inconsistencies were of concern since an accurate reflection of a patient's status could not be gleaned if based upon conflicting information. Additionally, there were no standards of practice identified in the agencies. This researcher assumed that nurses assess edema as a measurement of body function and as a symptom of disease. This was on the verified by the fact that all nurses indicated a choice of edema assessment study questionnaire. Through assessment methods were diverse, nurses displayed Edema 40 knowledge of edema assessment. This study investigated whether nurses use one method of edema assessment most frequently. The edema assessment methods were chosen from the literature review. Just as the researcher found inconsistencies in nurses reporting edema findings, there were inconsistencies found in edema assessment scales in the literature review. The edema assessment methods survey included measurement of the depth of the pit using a scale of 1+ to 4+, with 4+ being the most severe; using time measurements in seconds and minutes for the pit to disappear; and using a tape measure to assess abdominal girth, circumference of the thigh, calf, and ankle. the fourth category was none of the above. This study showed a significant difference in nurses' choice of edema assessment methods. The first method of estimating the depth of pit using a scale of 1 + to 4+ received the highest number of responses, indicating this as the method preferred by the majority of nurses. The number of responses was significantly higher than any of the other responses with very little possibility of such responses occurring by chance. This method of using 1+ to 4+ was found most frequently in the literature review (Appendix A, B, C). The values for 1+ to 4+ are inconsistent Edema 41 and vary with the authors describing the scale. The second area of investigation of this study dealt with the factors that influence nurses' choice of edema assessment methods. These factors were elicited from numerous discussions with many nurses and include institutional policy, educational background, and peer influence. These factors were adapted to the questionnaire to collect the data. With the first factor, institutional policy, the researcher hoped to gain information about policies being utilized to assess edema. The nurses who responded to this factor did not comment on their policy as the questionnaire requested. Educational background was chosen by the majority of nurses to guide them in their choice. This information shows that many nurses rely on knowledge gained during their basic nursing education to choose a method to assess edema. A significant difference can be seen between this factor and the other two factors. This study showed a significant difference in nurses' choice of edema measurement methods as well as in the reasons for choosing that method, research, publicity, and education are needed to toe edema assessed consistently and accurately. Edema 42 Conclusions Within the limitations of this study, the following conclusions can be drawn: 1. Nurses choose estimating the depth of the pit following applied pressure as the most frequently used edema assessment method. 2. Nurses rely upon their educational preparation as the basis for their choice of edema assessment methods. 3. There is no standard method for reporting edema assessment in the participating hospitals. 4. There is a lack of awareness regarding the inconsistencies in edema assessment methods. Edema 43 Recommendations It is recommended that: 1. Policies be developed that are very specific for edema assessment. 2. Policies include the entire institution and not a specific unit. 3. Education be provided for the nursing staff regarding edema assessment expectations. 4. Further study be undertaken to determine the best method for initial assessment versus ongoing assessment of edema. 5. The questionnaire be revised for clarity if used again. It should clearly state that only one response be given for each research question and the demographic section. Edema 44 REFERENCES Beland, I.L., & Passos J.Y. (1981). Clinical nursing: Pathophysiological and psychosocial approaches (4th ed.). New York: Macmillan Publishing Co., Inc. Berger, K.J. & Williams, M.B. (eds) (1992). Fundamentals of nursing. Norwalk, CT: Appleton & Lange. Billings, D.M. & Stokes, L.G. (1987). Medical-surgical Nursing (2nd ed.). St. Louis: The C.V. Mosby Company. Blacklow, R.S. (1983). MacBryde's signs and symptoms: Applied pathologic physiology and clinical interpretation (6th ed.). Philadelphia: J.B. Lippincott Company. Bolander, V.B. (1994). Sorensen and Luckmann's basic nursing: A physiologic approach (3rd ed.). Philadelphia: W.B. Saunders Company. Brown, A.F. (1957). Medical nursing (3rd ed.). Philadelphia: W.B. Saunders Company. Canobbio, M.M. (1990). Cardiovascular disorders. St. Louis: The C.V. Mosby Company. Carpenito, L.J. (1995). Nursing diagnosis: Application to clinical practice (6th ed.). Philadelphia: J. B. Lippincott Company. Edema 45 Cole, G. (Ed.). (1991) Basic nursing skills and concepts. St. Louis: Mosby- Year Book. DeWit, S.C. (1992). Keane's essentials of medical-surgical nursing (3rd ed) Philadelphia: W.B. Saunders Company. Erb, G., Kozier, B., & Bufalino, P. (1989). Introduction to nursing. Redwood City, Ca: Addison-Wesley Publishing Company. Grimes, J., & Burns, E. (1996). Health assessment in nursing practice (4th ed.). Boston: Little and Brown. Henderson, V. (1966). The nature of nursing. New York: The Macmillan Co. Jones, D.A., Dunbar, C.F., & Jirovec, M.M. (1982). Medical surgical nursing: A conceptual approach (2nd Ed.). New York: McGraw-Hill Book Company. Kinney, M„ Packa, D., & Dunbar, S. (1993). AACN's Clinical reference for critical-care nursing (2nd ed.). St. Louis: C.V. Mosby. Kozier, B„ Erb, G., Blais, K„ Johnson, J., & Temple, J. (1993). Addison-. Wesley nursing (4th ed.). Redwood City, CA: A Division of the Benjamin/Cummings Publishing Com pany, Inc. Edema46 Letterer, R.A., Carew, B„ Reid, M., & Woods, P. (1992). Learning to live with congestive heart failure. Nursing, May, 34-41. Linton, M., Gallo, P.S., & Logan, C.A. (1975). The practical statistician. Monterey, CA: Brooks/Cole Publishing Company. Luckmann, J. (1996). Luckmann's care principles and practice of medical- surgical nursing. (A.L. Polaski & S.E. Tatro, Eds.). Philadelphia: W.B. Saunders Company. Maxwell, M.H., & Kleeman, C.R. (1994). Clinical disorders of fluid and electrolytes (5th ed.). New York: McGraw-Hill, Inc. Metheny, N.M., & Snively, W.D. (1983). The nurse's handbook of fluid balance (4th ed.). Philadelphia: J.B. Lippincott Company. Nurse's Reference Library. (1986). Nursing 86 books: Signs and symptoms. Springhouse, PA: Springhouse Corporation. Nurse's Reference Library. (1983). Nursing 83 books: Assessment. Springhouse, PA: Intermed Communications, Inc. Parys, E.V. (1987). February 1987, 42.49. Assessing the failure state of the heart. Nursing, Edema 47 Polit, D.F., & Hungler, B.P. (1995). Nursing research (5th ed.). Philadelphia: J.B. Lippincott Company. Porth, C.M. (1994). Pathophysiology: Concepts of altered heath states (4th ed.). Philadelphia: J.B. Lippincott Company. Potter, P.A. & Perry, A.G. (1990). Clinical nursing skills and techniques (2nd ed.). St. Louis: The C.V. Mosby Company. Quinlan, M. (1984). Edema: What really causes it; how to control it. R.N., April 1984, 55-57. Rideout, E., & Montemuro, M. (1986). Hope, morale, and adaptation in patients with chronic heart failure. Journal of advanced nursing, (2nd ed.). (4), 429- 438. Rosdahl, C.B. (1995). The textbook of basic nursing (6th ed.). Philadelphia: J.B. Lippincott Company. Scherer, J.C., & Timby, B.K. (1995). Introductory medical-surgical nursing (6th ed.). Philadelphia: J.B. Lippincott Company. Seidel, H.M., Ball, J.W., Gains, J.E., & Benedict, G.W. (1995). Mosby's guide to physical examination (3rd ed.). St. Louis: Mosby-Year Book, Inc. Edema 48 Starling, E.H. (1896). On the absorption of fluids from the connective tissue spaces. Journal of physiology 19: 312. Suddarth, D.S. (1991). The Lippincott manual of nursing practice (5th ed.). Philadelphia: J.B. Lippincott Company. Sundberg, M.C. (1989). Fundamentals of nursing (2nd ed). Boston: Jones & Bartlett Publishers, Inc. Sunyecz, L., & Miratallo, J.M. (1993). Sodium imbalance in a patient receiving total parenteral nutrition. Clinical pharmacology, 12, (2), 138-149. Wolff, L„ Weitzel, M.H., & Fuerst, E.V. (1979). Fundamentals of nursing (6th ed.). Philadelphia: J. B. Lippincott Company. Wright, S. (1990). Pathophysiology of congestive heart failure. Jou.rna.Lof cardiovascular nursing, 4, (3), 1-16. ( I Edema 49 APPENDIX A I1 I I EDEMA ASSESSMENT SCALE 1 + = 2 millimeters (mm) 3+ 6 mm 2+ = 4mm 4+ = 8mm DeWit (1992); Seidel, Ball, Dains, & Benedict (1991); and Cannobio (1990). EDEMA ASSESSMENT SCALE 2+ = 1 centimeter (cm) 3+ = 3cm 2+ = 2cm 4+ = 4cm Potter & Perry (1990); and Nurse's Reference Library (1986). EDEMA ASSESSMENT SCALE 1 + = shallow pit 3+ 2+ = moderate pit 4+ = generalized, very deep pitting deep indentation Metheny & Snively (1983); Cole (1991); Sundberg (1984); and Quinlan (1984). EDEMA ASSESSMENT SCALE 1 + = 0-1/4 inch (in.) (mild) 2+ = 1/4 in. ■ 1/2 in. (moderate) 3+ = 1/2 in. ■ 1 in. (severe) The Nurse's Reference Library (1983); and Suddarth (1991). Edema 50 APPENDIX B EDEMA ASSESSMENT SCALE 1+ = Barely detectable 3+ 2+ = Less than 5mm 4+ = more than 10mm 5mm to 10mm Kozier et al. (1993); and Erb, Kozier, & Bufalino (1989). EDEMA ASSESSMENT SCALE TIME 0 ■ No pitting 1+ - Trace 2+ - Moderate, disappears in 10 15 seconds 3+ - Deep, disappears in 1-2 minutes 4+ - Very deep, disappears in 5 minutes Grimes and Burns (1996 EXTENT 1 + - Shallow Pit 2+ ■ Deep Pit 3+ ■ signs of pitting dependent part of body (limb 1-1/2 times normal) 4+ - Generalized deep pitted edema accompanied by ascites Edema 51 f APPENDIX C EDEMA ASSESSMENT SCALE SCALE 1+ 2+ 3+ 4+ ■ • • Trace Mild Moderate Severe DEGREE Slight 0-0.6cm (0-1/4 in.) 0.6-1.3cm (1/4-1/2 in.) 1.3-2.5cm (1/2-1 in.) RESPONSE Rapid 10-15 Seconds 1- 2 Minutes 2- 5 Minutes Canobbioo (1990) EDEMA ASSESSMENT SCALE TESTING SCALE +1 +2 +3 +4 (+4 edema takes at least 30 seconds to rebound.) Berger & Williams (1992) DEPTH 1mm 2mm 3mm 4mm and beyond EXCESS FLUID VOLUME 5-7 lbs. 10-15 lbs. 20 lbs. > 20 lbs. Edema 52 APPENDIX D Ann Stanonis Box 11 Star Route Cooperstown, PA 16317 Dear As a graduate student of Edinboro University of Pennsylvania, I am working on a Thesis. The purpose of my research is to evaluate and compare the methods used by registered nurses to assess edema in Western Pennsylvania Hospitals. My hope is to use your agency as one of the hospitals to be utilized in my study. permission from you is required prior to initiating any research activities. Written Your name and your agency's name will be held in the strictest of confidence. No participant or institution will be identified in the study. The information obtained will be viewed by myself and by my advisor only. I require anonymous information for the study. I plan to collect my data through the use of a questionnaire which I have included, for your perusal. It is my hope, once permission has been obtained, to present the questionnaire to Registered Nurses providing bedside care at report time. I am interested in all three shifts of nurses. I plan to do my data collection in January, February, 1996 with the specific dates to be discussed with you at a later date, following written permission. I will make the results of my study available to you upon request. If you have any questions please do not hesitate to call me either at work (814) 226-5857 or at home (814) 374-4250. Thank you for your consideration of the issue and hope to hear from you. Sincerely, Ann Stanonis RN, BSN Edinboro University of Pennsylvania Master of Science in Nursing Program Edema 53 APPENDIX E Dear Staff Nurse: I am a registered nurse enrolled as a graduate student at Edinboro University of Pennsylvania. I am required to write a Thesis to complete the requirements for a Master of Science in Nursing Degree. The subject of my Thesis is the assessment of edema. My interest is in you, the nurse providing bedside nursing care, as you assess patients on a daily basis. I am interested in your first method used upon detecting edema in your patients. By returning the questionnaire, you are giving your consent to participate. It is my hope that you would help me with my research by completing the following questionnaire. Thank you in advance for your participation. Sincerely, Ann Stanonis RN, BSN Edinboro University of Pennsylvania Master of Science in Nursing Program Edema 54 APPENDIX F EDEMA ASSESSMENT QUESTIONNAIRE 1. Demographical Data A. Please indicate appropriate age group: 19-25 26-35 36-45 II. 46-55 56-65 other B. Please indicate highest degree obtained: LPN Master Diploma other RN BSN C. Please indicate year of graduation from basic nursing program. Edema Assessment Please indicate which method you use to measure edema: A. Estimating depth of pit following pressure for 5 seconds. Use of scale similar to the following range: 1 + = 1 cm 2+ = 2 cm 3+ = 3 cm 4+ = 4 cm Timing B. the seconds and minutes for the pit to return to normal. Use C. of tape measure to assess abdominal girth, circumferences of thigh, calf, and ankle. Edema 55 APPENDIX G EDEMA ASSESSMENT QUESTIONNAIRE I. _____ ADN BSN Diploma RN Demographical Data A. Indicate appropriate age obtained: group: Indicate highest degree 19-25 26-35 36-45 26-55 56-65 other B. MSN other (Please Specify) C. D. E. Indicate year of graduation from basic nursing Indicate years of active practice as a nurse Indicate area of specialization: 1. 2. 3. 4. II. Special Cardiac General General program Intensive Care Floor Med Surgical Edema Assessment Indicate if the method you use is related to an agency policy: A. Yes No Indicate which method you first use to measure edema: B. B. Estimating depth of pit following pressure for 5 seconds. Use of scale similar to following range: 1+ = 1 cm 2+ = 2 cm 3+ = 3 cm 4+ = 4 cm C. Timing the s normal. D. Use of tape measure to assess abdominal girth, circumferences of thigh, calf, and ankle. Edema 56 APPENDIX H EDEMA ASSESSMENT QUESTIONNAIRE I. Demographic Data A. B. Indicate appropriate age group: 19-25 26-35 36-45 46-55 56-65 other Sex: Male Female C. Indicate highest degree obtained: BSN Diploma RN MSN Other (please specify) D. Indicate year of graduation from basic nursing program: E. Indicate years of active practice as a nurse: F. Indicate specialization you work in and how many years of experience in this unit: Special Intensive Care years years Floor Cardiac years General Med years General Surgical ADN Edema 57 II. Edema Assessment A. 1. Indicate if the method you use is related to an agency policy: Yes No If it is an agency policy what do you have to use? 2. Indicate if the method you use is related to your basic nursing education: Yes No 3. Indicate if the method you use is related to peer influence (your co-worker). yes B. No Based on the following criteria indicate which method you would first use to measure edema: Estimating depth of pit following pressure for five seconds. Use of scale similar to following range: 1 + = 1 cm 2 + = 2 cm 3 + = 3 cm 4+ = 4 cm Timing the seconds and minutes for the pit to return to normal. Use of tape measure to assess abdominal girth, circumferences of thigh, calf, and ankle. None of the above. What do you use?