Correct Answers
What causes third spacing? - Answer: injury
surgery
fluid overload
cardiac failure
renal failure
alcoholism
malnourishment
How do you remove third space fluid in the abdomen? - Answer: Paracentesis
How do you remove third space fluid in the chest? - Answer: Thoracentesis
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,What is localized edema from? - Answer: traumatic injury, local inflammatory
processes or burns
What is generalized edema from? - Answer: throughout the body from cardiac,
renal, or liver failure
What are the classifications of +1 edema?
How long does it take the skin to return back to normal? - Answer: Mild pitting,
slight indentation, no perceptable swelling of the leg
1-6 seconds to return to normal
What are the classifications of +2 edema?
How long does it take the skin to return back to normal? - Answer: Moderate
pitting, indentation subsides rapidly
10-25 seconds to return to normal
What are the classifications of +3 edema?
How long does it take the skin to return back to normal? - Answer: Deep pitting,
indentation remains for a short time, leg looks swollen
1-2 minutes to return to normal
What are the classifications of +4 edema?
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, How long does it take the skin to return back to normal? - Answer: Very deep
pitting, indentation lasts a long time, leg is very swollen
Greater than 2 minutes to return to normal
How do you test for edema? - Answer: push down until a good blanch happens
and then count
do the same test on multiple sites
What else should the nurse do when a person has edema (especially in the legs)? -
Answer: take the time to feel for pedal pulses
are they easily palpable?
What is else is involved in the nursing assessment for edema? - Answer: skin tone,
color
nailbeds
hair placement
temperature of extremity, numbness/tingling
pain and changes in mobility AND especially if there is skin damage related to this
IS IT CHRONIC EDEMA R/T PT'S CONDITION
What are the causes of hypovolemia? - Answer: loss of fluid from anywhere
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