Edema Nursing Care Plan: 2 Sample Plans and Interventions

Edema is swelling caused by extra fluid trapped in the body's tissues, often in the feet, ankles, legs, or around the eyes. Common causes include heart failure, kidney disease, liver disease, low protein, and sitting or standing too long. Your priorities are finding the cause, managing fluid balance, and protecting the swollen skin.

A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation

Each care plan below follows the nursing process (ADPIE).

CARE PLAN 1 · NURSING DIAGNOSIS

Excess Fluid Volume

Related to

Sodium and water retention
Heart, kidney, or liver problems
Low albumin from poor nutrition or liver disease

As evidenced by

Pitting edema in the legs or feet
Weight gain over a short time
Intake greater than output
Crackles in the lungs or shortness of breath with severe fluid overload

PLANNING · EXPECTED OUTCOMES

Short-term goals

Edema decreases by at least 1 grade within 48 hours
Client loses weight toward their dry weight as ordered

Long-term goals

Client keeps a stable weight and manages fluid and sodium intake at home

ASSESSMENT

Daily weight, same scale and time
Strict intake and output
Edema location and grade using a pitting scale
Lung sounds and breathing
Sodium, potassium, albumin, BUN, and creatinine

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Give diuretics as ordered and monitor potassium	Diuretics remove extra fluid but can cause low potassium.
Restrict sodium and fluids as ordered	Less sodium means the body holds on to less water.
Elevate swollen legs above the level of the heart when resting, unless contraindicated	Elevation helps fluid return to the circulation.
Teach to avoid sitting or standing still for long periods	Movement helps the leg muscles pump fluid back to the heart.

EVALUATION

Edema grade is decreasing
Weight is moving toward goal
Intake and output are balanced
Lungs remain clear

CARE PLAN 2 · NURSING DIAGNOSIS

Risk for Impaired Skin Integrity

Risk factors

Stretched, fragile skin over swollen areas
Poor circulation to swollen tissue
Limited mobility

PLANNING · EXPECTED OUTCOMES

Short-term goals

Skin over swollen areas stays intact throughout the hospital stay

Long-term goals

Client keeps skin intact and moisturized at home

ASSESSMENT

Skin over edematous areas for redness, blisters, weeping, or breakdown
Pressure points and areas under devices
Shoes and socks for tightness

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Handle swollen limbs gently and avoid tight clothing or straps	Stretched skin tears and breaks down easily.
Reposition and pad bony areas at least every 2 hours	This relieves pressure on fragile tissue.
Keep skin clean, dry, and moisturized	Healthy, moisturized skin resists cracking.
Apply compression stockings only as ordered	Compression helps some edema, but it can harm clients with poor arterial blood flow.

EVALUATION

Skin remains intact with no new redness or blisters
Client states how to protect swollen skin

Practice this in This vs That

Compare edema from heart failure, kidney disease, and venous problems side by side.

Play This vs That

Quick answers

How is pitting edema graded?

Press a finger into the swollen area and see how deep the dent is and how long it lasts. Scales usually go from 1+ (slight, quick to rebound) to 4+ (deep, slow to rebound), per facility policy.

Which is the best way to track fluid changes in a client with edema?

Daily weights. Weight shows fluid gain or loss faster and more reliably than looking at the swelling.

For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.