Pulmonary Edema Nursing Care Plans Diagnosis and Interventions
Pulmonary edema NCLEX Review and Nursing Care Plans
Pulmonary edema, also known as pulmonary congestion, is a lung condition that involves the accumulation of fluids in the lungs.
Difficulty of breathing is one of the classic signs of pulmonary edema. Acute pulmonary edema is considered a medical emergency and can be fatal but can also respond to treatment quickly if it is diagnosed early.
Signs and Symptoms of Pulmonary Edema
- Acute or sudden pulmonary edema:
- Dyspnea (difficulty of breathing) – worsened when lying down or with activity
- Cold, clammy skin
- Gasping for breath
- Feeling suffocated or drowning
- Productive cough – frothy sputum (may be blood-tinged)
- Tachycardia (fast heartbeat; may be irregular)
- Cyanosis (e.g. blue tinged lips)
- Chronic or long-term pulmonary edema:
(In addition to the signs and symptoms of above)
- Rapid weight gain
- Edema on the lower extremities
- Difficulty of walking uphill
Causes of Pulmonary Edema
There are two types of pulmonary edema in terms of causation: cardiogenic and non-cardiogenic.
- Cardiogenic Pulmonary Edema: The most common cause of pulmonary edema is heart disease, such as acute myocardial infarction, congestive heart failure (CHF), coronary artery disease (CAD), cardiomyopathy, heart valve problems, and hypertension (which enlarges the heart). Cardiogenic pulmonary edema occurs when the heart is unable to pump out the normal blood volume from the lungs due to a dysfunction in the left ventricle. This puts more pressure to the left atrium of the heart. When there is an increased left atrial pressure, the hydrostatic pressure in the capillaries of the lungs are retrogradely elevated. The fluid is pushed into the pulmonary air sacs, which results to difficulty of breathing.
- Non-Cardiogenic Pulmonary Edema: If there is no left ventricular dysfunction despite the fluid accumulation in the lungs, the pulmonary edema might be non-cardiogenic, or not caused by any problems in the heart. This may result from acute respiratory distress syndrome (ARDS), pneumonia, sepsis, viral infections (hantavirus and dengue virus), severe bleeding, brain injury (neurogenic), fluid overload, acute asthma, thromboembolism, lung surgery, trauma (e.g. post-intubation), or drug use (e.g. cytokines and heroin). Non-cardiogenic pulmonary edema may also be due to smoke inhalation, near drowning, high altitude or physical exertion, such as exercise, swimming and diving (swimming-induced or immersion pulmonary edema).
Complications of Pulmonary Edema
- Edema of the abdominal cavity and lower extremities. If left untreated, pulmonary edema can further increase the pulmonary arterial pressure. This condition is called pulmonary hypertension. When this occurs, the right ventricle of the heart fails, causing the pressure in the right atrium to further elevate. This will eventually cause swelling in the abdomen and lower extremities.
- Pleural Effusion. The increased pressure in the pulmonary circulation may lead to the accumulation of fluid in the pleural cavity which surrounds the lungs.
- Liver congestion and swelling. There can be increased pressure in the hepatic portal system, causing the liver to be congested and swollen, thereby unable to detoxify the blood as normal.
Diagnostic Tests for Pulmonary Edema
- Pulse oximetry – to measure the oxygen level in the blood
- Chest X-ray
- Blood tests – including arterial blood gas analysis, full blood count, biochemistry, and thyroid function.
- Electrocardiogram (ECG) – to determine if it is cardiogenic
- Cardiac catheterization and coronary angiogram – insertion of a very thin and long catheter usually through the arm or neck, which the doctor can use to get a better visualization of the heart (a dye is usually injected), as well as to measure the pressure in the different chambers of the heart, and to possibly open a blocked artery.
Treatments for Pulmonary Edema
- Oxygen therapy: The priority is to give oxygen to reverse the hypoxia or the deprivation of oxygen supply in the body. Severe hypoxia may require the use of mechanical ventilation to provide positive airway pressure.
- diuretics: To decrease the fluid that has accumulated in the heart and lungs, diuretics such as furosemide (Lasix) are usually administered.
- Anti-hypertensives: Hypertension may eventually lead to pulmonary edema. Blood pressure medications include beta blockers (e.g. bisoprolol) and ACE inhibitors (e.g. ramipril).
- Preload reducers and afterload reducers: Medications such as nitroglycerin may be used to decrease the pressure going into the heart.
- Anti-cholesterol drugs: For cardiogenic pulmonary edema, anti-cholesterol drugs might be prescribed to reduce the LDL or bad cholesterol that clog up the cardiac arteries.
- Antivirals or antibiotics: Bacteria and viruses are common underlying causes of the non-cardiogenic pulmonary edema.
Nursing Diagnosis for Pulmonary Edema
Nursing Care Plan for Pulmonary Edema 1
Nursing Diagnosis: Impaired Gas Exchange related to pulmonary edema as evidenced by shortness of breath, SpO2 level of 85%, productive cough, and frothy phlegm
Desired Outcome: The patient will maintain optimal gas exchange as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96% on room air (88-92% if patient has COPD) and verbalize ease of breathing.
|Nursing Interventions Pulmonary Edema||Rationales|
|Assess the patient’s vital signs, especially the oxygen saturation and characteristics of respirations at least every 4 hours. Also, monitor the results of ABG analysis.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.|
ABG Analysis: To check if there is an increase in PaCO2 and a decrease in PaO2, which are the signs of hypoxemia and respiratory acidosis.
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Administer the prescribed medications: diuretics antihypertensives, pressure reducers, and/or antibiotic/ antiviral medications.||Administer the prescribed medications: diuretics antihypertensives, pressure reducers, and/or antibiotic/ antiviral medications. |
diuretics: To decrease the fluid that has accumulated in the heart and lungs, diuretics such as furosemide (Lasix) are usually administered.
Anti-hypertensives: Hypertension may eventually lead to pulmonary edema.
Preload reducers and afterload reducers: Medications such as nitroglycerin may be used to decrease the pressure going into the heart.
Anti-cholesterol drugs: For cardiogenic pulmonary edema, anti-cholesterol drugs might be prescribed to reduce the LDL or bad cholesterol that clog up the cardiac arteries.
Antivirals or antibiotics: Bacteria and viruses are common underlying causes of the non-cardiogenic pulmonary edema.
|Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position.||Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.|
|Turn the patient at least every 2 hours. Encourage to mobilize as tolerated.||To prevent the complications of immobility such as thromboembolism that may worsen the pulmonary edema.|
Nursing Care Plan for Pulmonary Edema 2
Nursing Diagnosis: Ineffective Breathing Pattern related to pulmonary edema as evidenced by shortness of breath, SpO2 level of 85%, productive cough, and blood-tinged frothy phlegm
Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96% on room air (88-92% if patient has COPD), and verbalize ease of breathing.
|Nursing Interventions Pulmonary Edema||Rationales|
|Assess the patient’s vital signs and characteristics of respirations at least every 4 hours||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range of 88 to 92%.|
|Administer the prescribed medications (e.g. bronchodilators or combination inhalers / nebulizers) and antibiotic/antiviral medications.||Bronchodilators: To dilate or relax the muscles on the airways.|
Antibiotics or antivirals: To treat the underlying infection.
|Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position||Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.|
|Perform chest physiotherapy such as percussion and vibration, if not contraindicated. Nebulization using sodium chloride (NaCl) may also be done, as ordered by the physician. Steam inhalation may also be performed. Suction as required.||To facilitate clearance of thick airway secretions.|
Nursing Care Plan for Pulmonary Edema 3
Excess Fluid Volume
Nursing Diagnosis: Excess Fluid Volume related to impaired regulatory mechanism secondary to pulmonary edema and heart failure as evidenced by orthopnea, presence of S3 heart sound, presence of adventitious breath sounds, oliguria, edema, jugular venous distension, positive hepatojugular reflux, alterations in blood pressure, weight gain over a short period of time, and pulmonary congestion.
- The patient will demonstrate stabilized fluid volume with balanced intake and output, clear breath sounds, normal vital signs, stable weight, and absence of edema.
- The patient will verbalize an understanding of individual dietary and fluid restrictions.
|Nursing Interventions Pulmonary Edema||Rationale|
|Monitor the patient’s urine output. Note the amount and color, as well as the time of the day when diuresis occurs.||Urine production may be sparse and concentrated during the day primarily because of diminished renal perfusion. Because recumbency encourages diuresis, thereby increasing urine output at night or while on bedrest|
|Monitor the patient’s 24-hr intake and input and output (I&O) balance.||Diuretic therapy can cause a lot of fluid loss in a short period of time, creating circulating hypovolemia despite the presence of edema and ascites in patients with advanced heart failure or congestive heart failure.|
|Maintain the patient in bedrest or chair rest in a semi-Fowler’s position during the acute phase of the disease.||Recumbency elevates the glomerular filtration rate and decreases the production of ADH, thereby improving diuresis.|
|If fluids are restricted due to medical reasons, create a fluid intake regimen. If feasible, incorporate beverage preferences. As part of your fluid intake, give frequent mouth care and ice chips.||Involving the patient in the counseling process can help them feel more at ease. It can also give them a sense of control and promote collaboration despite restrictions.|
|Monitor the patient’s weight daily. Monitor also serum electrolyte levels (i.e., serum potassium, sodium, chloride, and magnesium) as well as blood urea nitrogen and creatinine levels on a regular basis.||A rise in body weight suggests a fluid volume excess, which is a sensitive sign of fluid balance. Changes in edema or its remission in response to therapy must be documented. A 5-pound gain in weight represents about 2 liters of fluid. Diuretics, on the other hand, can cause rapid and excessive body fluid changes as well as weight loss.|
|Evaluate if the patient exhibits jugular venous distension (i.e., distended neck and peripheral vessels). Assess for body areas with localized edema and characterize whether it is pitting or non-pitting. Note also for the presence of generalized body edema (anasarca).||Venous engorgement and edema are signs of excessive fluid retention. As heart failure (HF) worsens, peripheral edema occurs in the feet and ankles, or dependent areas, and progresses upward. Pitting edema can only be visible after fluid retention of about 10 lbs. Right-sided HF causes increased vascular congestion, which leads to systemic tissue edema.|
|Allow the patient to frequently switch positions. When seated, elevate the patient’s feet. Inspect the skin. Keep the skin surface dry and give cushioning as needed.||Edema, reduced circulation, changed dietary intake, and prolonged immobilization or bedrest are all cumulative stressors that compromise skin integrity and necessitate regular monitoring and preventive treatments.|
|Examine for the presence of edema in the extremities. If the client is dyspneic, do not elevate the legs.||Reduced systemic blood pressure due to aldosterone stimulation, which induces enhanced salt reabsorption in the renal tubules. A low-sodium diet helps avoid sodium retention, which reduces water retention. Fluid restriction can be used to reduce fluid consumption and hence reduce excess fluid volume.|
|Examine the patient’s breath sounds, noting any changes such as decreased sounds and presence of adventitious breath sounds (e.g., crackles and wheezes). Presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, and persistent cough should also be noted.||Pulmonary congestion is frequently caused by an excess of fluid volume. Acute left-sided pulmonary edema can cause symptoms of pulmonary edema. Respiratory symptoms such as dyspnea, cough, and orthopnea may appear later in right-sided HF, but they are more difficult to cure. Fluid travels within the alveolar septum when pulmonary capillary hydrostatic pressure exceeds oncotic pressure, as demonstrated by crackles on auscultation.|
|Examine complaints of sudden acute dyspnea and air hunger, the need to sit up straight, a feeling of suffocation, panic, or impending doom.||It differs from orthopnea paroxysmal nocturnal dyspnea in that it develops considerably more quickly and requires immediate action. It may suggest the development of problems (pulmonary edema and/or embolus).|
|Monitor frothy sputum production.||Sputum that is frothy and pink-tinged indicates that the patient is developing pulmonary edema.|
|Obtain the patient’s medical history in order to determine the likely origin of the fluid disturbance.||Increased fluid or sodium consumption, as well as weakened regulating mechanisms, are all possibilities.|
|Monitor the patient’s blood pressure and central venous pressure (CVP), if available.||Hypertension and a high CVP indicate fluid overload. This could indicate the onset or worsening of pulmonary congestion secondary to heart failure.|
|Evaluate the patient’s bowel sounds. Note for complaints of nausea, anorexia, constipation, and abdominal distension.||Visceral congestion, which develops as HF progresses, might impair gastrointestinal function.|
|Small, frequent, and readily digestible meals should be provided to the patient.||Reduced gastric motility might make digestion and absorption more difficult. Small, frequent meals may help with digestion and absorption of nutrients. avoid abdominal ache.|
|As specified, take a measurement of the patient’s abdominal girth.||Fluid may migrate into the peritoneal cavity as right-sided HF progresses. resulting in an increase in abdominal girth (ascites).|
|Palpate your stomach. Take note of reports of pain in the right upper quadrant or tenderness.||As HF progresses, venous congestion occurs, leading to abdominal distention, engorged liver (hepatomegaly), and discomfort. This can decrease or prolong medication absorption by altering liver function and impairing drug metabolism.|
|Increased tiredness, hypotension, and muscular cramps should be noted.||These are symptoms of potassium and sodium deficiency, which can lead to serious health problems. These may occur as a result of fluid changes and the use of diuretics|
|Determine the amount of urine produced in response to diuretic medication.||The focus is on monitoring the diuretic’s response rather than the amount of urine passed.|
|Determine whether an indwelling urinary catheter is required.||Excess fluid diuresis is the mainstay of treatment.|
|Encourage the patient to express their feelings about restrictions.||Anxiety, which is an energy drain that can contribute to weariness, can be reduced by expressing feelings.|
|Check for crackles in the breath sounds every 2 hours.||Fluid travels within the alveolar septum when pulmonary capillary hydrostatic pressure exceeds oncotic pressure, as demonstrated by crackles on auscultation.|
|Follow a low-sodium diet and/or limit your fluid intake.||The patient feels thirsty because his or her body is dehydrated. Without increasing fluid consumption, oral care might help relieve the discomfort.|
|Keep an eye on the patient’s chest x-ray.||Changes that indicate the clearance of pulmonary congestion are revealed.|
Nursing Care Plan for Pulmonary Edema 4
Anxiety Related to Difficulty of Breathing
Nursing Diagnosis: Anxiety related to breathlessness from inadequate oxygenation secondary to pulmonary edema.
- The patient will distinguish strategies to decrease the feeling of anxiety.
- The patient will demonstrate enhanced concentration.
- The patient will cope with anxiety through establishing coping patterns.
|Nursing Interventions Pulmonary Edema||Rationale|
|Maintain a calm and tranquil demeanor when interacting with patients.||A calm environment and approach may reduce anxiety levels, and the patient’s heart work may be reduced as a result.|
|As needed, acquaint patients with the environment and new experiences or individuals.||The patient’s comfort can be enhanced by being aware of his or her surroundings, which can help to reduce worry. Anxiety can quickly escalate to panic if the patient feels vulnerable and incapable of managing immediate cues. When a patient’s anxiety levels drop, so does his or her cardiac output.|
|During the acute stage of disease, give oxygen to the patient.||Oxygen treatment reduces the amount of work required to breathe and improves comfort.|
|Encourage physical comfort and psychological assistance when the patient is anxious.||The presence of a family member can be reassuring; pet visiting or animal-assisted therapy can also be beneficial.|
|Use basic language and short statements when communicating with the patient.||Patients suffering from moderate to severe anxiety may be unable to comprehend anything else than straightforward, clear, and quick instructions.|
|Teach techniques to control anxiety and avoid anxiety-provoking circumstances after the patient is at ease.||Factors such as noise, extreme discussion, and equipment near the patient might cause anxiety to the patient and may further lead to panic. Anxiety can become terrifying for both the patient and others as it grows.|
|Assist in the identification of elements that cause anxiety.||Talking about anxiety-inducing situations and thoughts can help the patient see things more clearly and recognize anxiety-related elements.|
|Assist the patient in identifying anxiety triggers that may require intervention.||The patient may reconsider the threat or come up with new ways to deal with it after gaining understanding.|
|Examine for depression, which frequently occurs alongside or as a result of worry.||Depression and anxiety symptoms are present in roughly one-third of heart failure patients. Studies have uncovered evidence that people with heart failure had “much greater” incidence of depression and anxiety disorders than the general population.|
|Allow the patient to express anxious sensations and, if possible, evaluate anxiety-provoking situations.||Talking about anxiety-inducing situations and thoughts can help the patient see things more clearly and recognize anxiety-related elements.|
|Assist the patient in learning new techniques for lowering anxiety (e.g., relaxation and deep breathing exercises, positive visualization, and reassuring self-statements).||The patient can control anxiety in a variety of ways by learning new coping methods.|
|Reassurance that isn’t warranted may cause needless anxiety.||For the worried person, reassurance is ineffective.|
|When feasible, intervene to eliminate sources of anxiety.||Anxiety is a normal reaction to actual or perceived danger; after the threat has passed, the response will cease.|
|Use non-medical terminology and slow, calm discourse to explain all actions, procedures, and difficulties involving the patient. When possible, do this ahead of time and confirm the patient’s knowledge.||Patients who get pre-admission patient education report less anxiety and mental distress, as well as improved coping skills, because they know what to expect. Anxiety is exacerbated by uncertainty and a lack of predictability.|
|Educate the patient and his or her family about the signs and symptoms of anxiety.||If the patient and family can recognize worried responses, they will be able to intervene sooner than they would otherwise.|
|Teach patients to imagine or fantasize about being free of worry or pain, having a positive experience with the scenario, resolving conflict, or having a positive outcome from the surgery.||Guided imagery has been shown to be effective in lowering anxiety.|
Nursing Care Plan for Pulmonary Edema 5
Nursing Diagnosis: Fatigue related to an imbalance between oxygen supply and demand secondary to pulmonary edema as possibly evidenced by limited range of motion and weakness.
Desired Outcome: The patient will demonstrate and report an enhanced sense of energy.
|Nursing Interventions Pulmonary Edema||Rationale|
|Examine the patient’s medication regimen.||It is important to review the drugs administered to the patient as some pharmaceutical agents can cause or worsen fatigue.|
|Examine the patient’s vital signs.||To determine the fluid state and cardiopulmonary response to activity.|
|Determine whether sleep difficulties exist and how severe they are.||Sleep deprivation has the potential to cause fatigue.|
|Obtain descriptions of the client’s weariness.||To assist in determining how it will affect the client’s life.|
|Inquire about the client’s level of weariness.||To figure out the patient’s extent of fatigability.|
|Keep track of your everyday energy trends.||It’s useful for figuring out the pattern or timing of activities.|
|With the client, set realistic activity goals and encourage progressive movement.||Increases the patient’s motivation to achieve the best possible results.|
|Plan interventions to allow for proper relaxation intervals for each patient.||Adequate relaxation intervals must be set in order to include as many people as possible.|
|Assist with self-care and ambulation requirements.||To save energy for other purposes.|
|Excessive heat and humidity should be avoided.||Excessive heat and humidity may have a negative impact on one’s level of energy.|
|Teach the client how to keep track of their reactions to activity and any major signs or symptoms.||Indicates the need to change the level of exercise.|
|Measures to improve overall health are encouraged.||This can promote the patient’s energy.|
|As needed, administer supplemental oxygen.||Hypoxemia limits the amount of oxygen available for cellular uptakes, contributing to weariness.|
|Assist the client in identifying healthy coping strategies.||Improves self-esteem and promotes a sense of control.|
More Nursing Diagnosis for Pulmonary Edema
- Activity Intolerance
- Anxiety related to Acute Pulmonary Edema
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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