Wednesday, January 27, 2016

Edema and Home Health

Edema and Home Health
By Ralph Santos, Center4PT Services, Inc.
January 2016

In the home health setting we often encounter cases of edema which typically occur in the bilateral lower extremities.  This edema can often deter the patient’s ability to perform their activities of daily living (ADLs), can cause a decreased active range of motion (AROM), can contribute to pain or discomfort, can negatively affect our clients emotional well being, can disrupt our clients circadian rhythms, can induce harmful stress levels and so much more.  As home health therapists we need to understand what are the causes of the edema, how to properly assess and document the edema and how to properly treat the edema.

Causes of edema.  Edema or swelling is the accumulation of fluids in the tissues which can be attributed to either a systemic cause.  The organs that generally contribute to the systemic related edema are the liver, the heart and the kidneys which can be related to excessive sodium levels.  Another cause of edema related to the liver and the kidneys can be a decrease in albumin levels. 

Pitting Edema versus Non Pitting Edema.  Edema is often measured by two subjective tests:  (1) how deep is the space on the limb after you release pressure with a finger and (2) how long will it take for the limb to return to its resting state.  Pitting edema can be seen by applying pressure with ones fingers to the affected limb or in many of my patient’s case, by removing their shoe or socks and looking for what appears to be a tourniquet or indentation caused by the shoe or sock.  In non pitting edema, the skin does not indent and one of the major causes for non pitting edema can be the diagnosis of lymphedema which affects the lymph system.  My own experience is that with lymphedema the cause is related to breast cancer with a subsequent mastectomy, lymph node surgery, radiation therapy and or an increased stress level.  Other reasons for non-pitting edema may be a low thyroid level or a deep vein thrombosis (DVT).

Here is a scale that I found in the 2015 Corridor Group Therapy Quickflips:

Edema Score
Depth of Pitting
Response time to Refill
0.6 cm (0-1/4 in)
10-15 Seconds
0.6 – 1.3 cm (1/4 in – ½ in)
1-2 Minutes
1.3 – 2.5 cm (1/2 in – 1 in)
2-5 Minutes

I can honestly say that assessing edema can be quite subjective but this scale and others like the:

1.  O’Sullivan, S.B. and Schmitz T.J. (Eds.). (2007). Physical rehabilitation: assessment and treatment (5th ed.). Philadelphia: F. A. Davis Company. p.659

2.  Hogan, M (2007) Medical-Surgical Nursing (2nd ed.). Salt Lake City: Prentice Hall

3.  Brunner L. (1982).The Lippincott Manual of Nursing Practice. (3rd ed.). Lippincott Williams and Wilkins, Philadelphia. p.36

are other options, with the bottom line being that we as home health therapists need to be consistent when documenting edema.

How to treat edema?  The conservative edema reduction strategies can include: 

(1) Teach and encourage active range of motion exercises (AROM) to help with circulation and assist the heart in pumping excess fluid.

(2)  Elevating the affected limb above the level of the heart.  I usually tell my patients to elevate their limb(s) when going to sleep since we spend half of our lives in bed.  I also tell my patients to avoid dependent positions during the day using chairs with arm rests, splints and other external devices for positioning.

(3)  A very superficial massage where you elevate the limb above the heart and massage the fluids back towards the heart may be helpful.  When I was going to school, this was often referred to as a retrograde massage and when I got my certification in lymphedema, I learned that the lymph system is very superficial and a light massage is often very effective.

(4)  Compression via TED Hoses or other garments.  These garments provide a certain amount of MM Hg (millimeter of mercury) and are often prescribed by a physician.  The only problem with these garments is the actual donning/doffing process but otherwise it will help with preventing fluid from collecting in the tissue.

(5) Skin Hydration.  I always tell my patient’s to keep their skin clean and well moisturized.  I usually recommend an aloe vera based lotion during the summer months and a butter based lotion during the winter months.  I myself stay away from thick oil based lotions such as A&D, unless there is a certain medical reason to use said lotions.

(6) Salt.  Reducing the amount of foods that contain sodium is essential.  A television dinner, a microwavable noodle soup, and other foods that our patients consume due to ease of preparation contain a ton of sodium and this will only contribute to their edema battles. 

Finally, the physicians will often look at other treatments such as using diuretics which have their own pros and cons.  My thought is that we as home health therapists need to be cognizant of the causes of edema, how to properly assess/document edema, and how to teach our patients to incorporate conservative edema reduction strategies. 

1.  Therapy Quikflips, The Corridor Guide for Home Health Therapists. 2015.

As a clinician and active owner of the Center4PT Services, Inc., I believe that client care is the utmost priority with our company being on the leading edge with its customer care!  We are home health staffing agency that partners up with skilled home health agencies and hospice agencies in the Los Angeles County to provide skilled Physical Therapy, Occupational Therapy, Speech Therapy and Social Work Services for homebound clients.  Our mission is to be the leading provider of in-the-home Therapy Services in the Greater Los Angeles area by providing Timely, Quality, Efficient, & Competent Therapy Services to all of the Clients that we Serve!

Our focus is on the rehabilitation of our clients and ensuring that our clients get better and progress towards independence!  We know that through hard work and through perseverance our clients get better, stronger faster!  We also realize that in today's medical model we have to do more with less with often medical insurers authorizing less visits and demanding more functional results.  We have made many adaptations to include using on line resources for our clients and making those vital phone calls to ensure that our clients indeed are making gains with our staff.

I cannot stress enough how important it is for our staff to be competent and compassionate towards each other and towards our clients.  If you are looking for a solid home health company with lots of experience and lots of support, then the Center4PT Services, Inc. is your new home!

(626) 683-9959 Office                                                               Email:

(626) 683-9969 Fax                                                                   Website: