Identification of edema in a nursing examination
Identification and examination of edema. Inflammatory swelling
Edema are detected visually, palpatory, by measurementvolume of limbs, their fragments and weighing the body. The presence of edema is indicated by the puffiness of the face, puffiness of the eyelids, swollen eyes, an increase in the volume of the whole body or its individual parts. Especially often, edema is localized on the lower limbs.
Puffiness symmetrical parts, body partstestifies to generalized edema (cardiac, renal, hypoproteinemic, etc.). Asymmetric edema is characteristic for local processes - violation of local blood and lymph circulation, trophic, as well as for inflammation, trauma. Examining the body, you need to pay attention to the available on the skin prints from the folds of clothing, shoes, belt, buttons, rubber socks, bed.
Edema are manifested by swelling, pallor,cyanotic or reddening of the skin. With significant swelling, the skin is strongly stretched, becomes pale, shiny, there are cracks through which oozing muddy, pale edematous fluid. Significant edema smooths the natural fossa and occlusions, bony projections (eg, ankles) "sink" in soft tissues, there may be scars on the legs and abdomen. With massive swelling, the abdomen increases due to the accumulation of fluid in the abdominal cavity (ascites).
Inflammatory swelling more often it is asymmetric, more limited, itaccompanied by redness of the skin, pain, increased local temperature. Any swelling is easier and more significant where there is loose fiber: eyelids, face, genitals, and lower limbs.
Palpation swelling Identify or confirm withcompression of the index or thumb in places where the skin and subcutaneous tissue has a dense surface: the rear of the foot and hand, ankles, tibia, sacrum. This manipulation can also be performed in any place where tissue swelling is seen or suspected.
With compression finger gently plunges into the fabric until it feelshard surface. After weaning the finger, if there is no swelling, the tissues are instantly straightened, if there is swelling, the hole remains for 1-2 minutes, then it disappears. With old swelling, the skin and subcutaneous tissue are compacted and pits can not be.
Having removed a finger from the skin, you need to make a sliding motion1-2 fingers over the site of compression. This method confirms the presence of a fossa and even a slight indentation and unevenness, which happens with minor swelling. If, during compression, the finger feels the test, and the fossa is not visible or there is a barely noticeable trace of pressure, this is called pastoznost, which indicates a slight swelling of the tissues.
AT places. Where under the skin and soft tissues there is no hardbases, edema can be detected by seizure of the skin-fat fold and squeezing it between the fingers. Long-lasting dents indicate swelling of the tissues.
Palpable skin in the presence of edema cold, painless. Only with inflammatory edema it is hot to the touch. If the eye is supposed to be swollen, and if the finger does not form a fossa, then it is supposed:
• chronic edema,
• false swelling.
False swelling occurs with myxedema and scleroderma.
Edema can be detected by measuring the circumference of the limbson symmetrical sites, measurement of a circle of a stomach, a thorax. This is especially important for dynamic observation. Edema is revealed when a person is systematically weighed.