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?