Nursing care
Pulse grading scale and pitting edema scale: what each grade means at the bedside
Written and reviewed by Nicole Ramirez, BSN, RN, CMSRN · 4 min read · Updated November 2026
Short answer
On the pulse grading scale used in the Open RN Nursing Skills text, 0 is absent, 1 is decreased, 2 is normal and 3 is increased or bounding. Pitting edema is graded 1+ to 4+, from a barely visible dent that rebounds at once to a deep pit that takes many seconds to fill. Compare both sides and record the trend.
Pulse amplitude grades
Pulse grading describes how strong the pulse feels under your fingers, separate from rate and rhythm. Open RN grades amplitude from 0 to 3, so a pulse charted as 2 means within normal range. Other references use a four-point version, so always record which scale your unit uses.
| Grade | Meaning | Nursing response |
|---|---|---|
| 0 | Absent | Check with Doppler; if not heard and new, report immediately |
| 1 | Decreased, weak or thready | Compare with the other side and with prior findings; check color, warmth, refill |
| 2 | Within normal range | Document and compare bilaterally |
| 3 | Increased, bounding | Look for causes such as hyperthyroidism or another hypermetabolic state |
Feel paired pulses at the same time where safe, but palpate carotid pulses one side at a time to avoid reducing blood flow to the brain. MSD Manuals adds that obesity or heavy musculature can make peripheral pulses hard to feel, which is a reason to use Doppler before calling a pulse absent.
Pitting edema grades by depth and rebound
Press firmly over a bony area such as the tibia for a few seconds, then watch the pit. Grading combines how deep the dent is and how long the skin takes to rebound. The table uses the criteria reported in a 2026 edema grading study.
| Grade | Approximate depth | Rebound time |
|---|---|---|
| 0 | No pit | None |
| 1+ | About 2 mm | Immediate, within 1 second |
| 2+ | About 4 mm | 1 to 10 seconds |
| 3+ | About 6 mm | 10 to 20 seconds |
| 4+ | About 8 mm | More than 30 seconds |
Open RN describes 4+ as a deep depression taking more than 20 seconds to rebound, so the cut points differ by source. Note the level the swelling reaches, such as ankle or mid-shin, because that is easier to compare between nurses than a single number.
Worked example: documenting a hypothetical patient
Hypothetical practice patient: a 72-year-old with heart failure has gained weight over three days. Both dorsalis pedis pulses feel weaker than the radial pulses but are equal to each other. Pressing over the shins leaves a pit that takes about 15 seconds to fill on both sides, reaching mid-calf.
Worked example
- Pulse strength: weaker than expected but present on both feet = 1 on the 0 to 3 scale
- Symmetry: equal right and left, so no single-limb blockage suggested
- Edema depth and rebound: about 15 seconds falls in the 10 to 20 second band = 3+
- Distribution: bilateral, to mid-calf, with recent weight gain
- Chart: pedal pulses 1 bilaterally; 3+ pitting edema to mid-calf bilaterally
Open RN notes that sudden weight change is a likely sign of fluid volume overload, so the weight trend backs up the edema finding. Swelling can also be hard to see in larger patients, which makes daily weights the more reliable measure.
Where these scales mislead
MSD Manuals states plainly that pitting edema is graded 1 to 4 but there is no agreed definition for the grades. Two nurses can call the same leg 2+ and 3+. What carries more meaning is symmetry, the level reached, and whether it is changing across shifts.
Symmetry is also the key to the exam. Bilateral, painless, dependent pitting edema fits fluid overload or right heart failure, while one swollen, red, warm or tender leg suggests an inflammatory cause or a possible deep vein thrombosis, which Open RN lists as a finding to report. A pulse of 1 in one foot only, with a cool pale limb, is more urgent than 1 in both feet with warm skin.
Sources and further reading
Open RN Nursing Skills 2e: 9.3 Cardiovascular Assessment. Pulse amplitude graded 0 to 3, bilateral comparison except carotid, Doppler for nonpalpable pulses and reporting, pitting edema 1+ to 4+ with 4+ over 20 seconds, edema hard to see in larger patients, weight change and fluid overload, unilateral swelling and DVT.
MSD Manual Professional Version: Cardiovascular Examination. No agreed definition for pitting edema grades, pulses hard to feel with obesity or muscularity, bounding pulse in hypermetabolic states, unilateral tender or red edema suggests inflammatory cause.
Lower limb edema detection and grading classification using deep learning (Frontiers in Medicine, 2026). Edema grading table with indentation depths of 2, 4, 6 and 8 mm and rebound times by grade.
MSD Manual Professional Version: Edema. Right heart failure and fluid overload cause symmetric, dependent, painless pitting edema.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our fundamentals practice questions are the closest set to what this page covers.
Common questions
What does a 2+ pulse mean?
A pulse graded 2 or 2+ is a normal-strength pulse on the common scales. On the Open RN 0 to 3 scale, 2 is within normal range, 1 is decreased and 3 is bounding. Always check which scale your facility charts.
How is pitting edema graded?
Press over a bony area such as the shin, then grade by how deep the pit is and how long it takes to rebound, from 1+ (barely visible, immediate rebound) to 4+ (deep pit, slow rebound). Exact cut points vary between sources.
What is 3+ pitting edema?
A moderately deep pit, about 6 mm in one published grading, that takes roughly 10 to 20 seconds to fill. Record its level on the limb and whether both sides are affected.
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