Pulmonary edema is a life-threatening condition where fluid accumulates in the lungs’ air sacs, leading to impaired gas exchange and breathing difficulty. It often develops suddenly and requires prompt nursing assessment and intervention.
There are two main forms of pulmonary edema: cardiogenic (due to heart problems like left-sided heart failure or myocardial infarction) and noncardiogenic (due to factors like lung injury, acute respiratory distress syndrome/ARDS, sepsis, or high altitude).
Understanding the causes and clinical cues of pulmonary edema helps nurses prioritize care and prevent respiratory failure in affected patients.
Assessment Findings
Subjective Cues (Patient may report):
- Increasing shortness of breath or a feeling of suffocation, especially when lying flat (orthopnea)
- Restlessness, anxiety, and a sense of impending doom due to difficulty breathing
- Fatigue and weakness with even mild activity
- Possible chest pain or tightness (if related to cardiac causes)
Objective Cues (Nurse may observe):
- Tachypnea (rapid breathing) and use of accessory muscles for breathing
- Crackles/rales upon lung auscultation, indicating fluid in alveoli
- Cough producing frothy, pink-tinged sputum (classic in acute cardiogenic pulmonary edema)
- Cyanosis or dusky skin from low oxygen levels; decreased O₂ saturation on pulse ox
- Signs of heart strain: rapid heart rate, elevated blood pressure (or low BP if in shock), jugular vein distension, and possibly peripheral edema (swelling in legs, seen in cardiogenic cases)
Diagnostic Tests
- Chest X-ray: Reveals fluid in the lung fields (e.g., hazy opacity, bat-wing pattern, or pleural effusions in cardiogenic edema).
- Arterial Blood Gases (ABGs): Show hypoxemia (low PaO₂) and possibly respiratory alkalosis initially, then acidosis as fatigue ensues.
- B-type Natriuretic Peptide (BNP): Elevated in cardiogenic pulmonary edema (helps distinguish heart failure-related fluid overload).
- Electrocardiogram (ECG): Performed to detect cardiac causes (e.g., myocardial infarction or arrhythmias precipitating pulmonary edema).
- Echocardiogram: Assesses heart function, ejection fraction, and valve issues contributing to fluid backup.
- Blood tests: Check for precipitating factors – e.g., cardiac enzymes (troponin) if MI suspected, thyroid levels, kidney function, and CBC to evaluate infection or anemia.
- Pulmonary artery catheterization (in ICU setting): An invasive test measuring cardiac pressures to definitively differentiate cardiogenic vs. noncardiogenic edema.
Brief Pathophysiology
In pulmonary edema, excess fluid leaks into the lung’s interstitial and alveolar spaces, disrupting normal gas exchange. In cardiogenic pulmonary edema, a failing left ventricle cannot effectively pump blood, causing pressure to rise in the pulmonary capillaries – this forces fluid out into the alveoli.
In noncardiogenic pulmonary edema, factors like inflammation or injury (e.g., ARDS, severe infection, inhalation of toxins) increase capillary permeability, allowing fluid to seep into lung tissue even without high pressure.
In both cases, the alveoli fill with fluid instead of air, leading to impaired oxygenation. Patients develop extreme shortness of breath and hypoxia. Without prompt intervention to remove the fluid and improve oxygenation, pulmonary edema can progress to respiratory failure and cardiac arrest.
Nursing Care Plans for Pulmonary Edema
Below are five (5) nursing care plans for patients with pulmonary edema. Each care plan includes a nursing diagnosis with related factors, expected evidence, targeted nursing interventions with rationales, and the desired outcomes.
Nursing Care Plan #1: Impaired Gas Exchange
Nursing Diagnosis Statement:
Impaired Gas Exchange related to alveolar fluid accumulation (alveolar-capillary membrane changes) secondary to pulmonary edema as evidenced by decreased oxygen saturation, dyspnea, and abnormal arterial blood gas levels.
Related Factors/Causes:
- Alveolar flooding with fluid
- Increased pulmonary capillary pressure (in cardiogenic causes)
- Inflammatory damage to alveolar membrane (in noncardiogenic causes)
- Altered pulmonary membrane permeability (e.g., due to toxins or infection)
Nursing Interventions and Rationales:
- Position the patient in a high-Fowler’s or semi-Fowler’s position.
Rationale: Upright positioning drops diaphragms and promotes maximal lung expansion, reducing the work of breathing and improving oxygenation. - Administer supplemental oxygen as prescribed (via nasal cannula, mask, or high-flow device).
Rationale: Increases the fraction of inspired oxygen to combat hypoxemia and improve tissue oxygen delivery. - Monitor oxygen saturation (SpO₂) continuously and obtain frequent ABGs.
Rationale: Allows early detection of declining gas exchange so interventions can be adjusted promptly (e.g., escalating O₂ support or ventilation assistance). - Auscultate breath sounds and assess respiratory rate/pattern at least hourly.
Rationale: Crackles, wheezes, or any decrease in breath sounds can indicate worsening fluid accumulation or atelectasis, guiding immediate intervention. - Assist with administration of prescribed diuretics (e.g., furosemide) and vasodilators.
Rationale: Diuretics help remove excess fluid from the circulation and lungs, while vasodilators (like nitroglycerin) reduce pulmonary congestion by decreasing preload and afterload, thereby improving gas exchange.
Desired Outcomes:
- The patient’s oxygen saturation will remain ≥ 95% (on appropriate oxygen therapy).
- Arterial blood gases will show improved oxygenation (PaO₂ within normal range) and resolution of acidosis.
- The patient will exhibit easier breathing with reduced dyspnea, and clear lung fields or diminished crackles on auscultation.
Nursing Care Plan #2: Decreased Cardiac Output
Nursing Diagnosis Statement:
Decreased Cardiac Output related to increased cardiac workload and pump failure secondary to pulmonary edema as evidenced by dyspnea, fatigue, weak peripheral pulses, and reduced tissue perfusion (e.g., delayed capillary refill).
Related Factors/Causes:
- Increased preload/afterload: Fluid volume overload and systemic hypertension forcing the heart to work harder
- Myocardial dysfunction: Damage to heart muscle (e.g., after myocardial infarction or in cardiomyopathy) weakening contractility
- Arrhythmias: Irregular heart rhythms (like atrial fibrillation) reducing cardiac output
- High pulmonary vascular resistance: Pulmonary edema itself increases pressure the right heart must pump against, straining the heart
Nursing Interventions and Rationales:
- Monitor vital signs and hemodynamic status frequently (blood pressure, heart rate, urine output, mentation).
Rationale: Hypotension, tachycardia, decreased urine output, or altered mental status can signal poor cardiac output and inadequate organ perfusion requiring urgent intervention. - Assess peripheral perfusion (skin color, temperature, pulses, capillary refill).
Rationale: Cool, clammy skin and weak pulses indicate diminished perfusion from a failing cardiac output, alerting the nurse to worsening heart failure. - Implement fluid restriction and strict intake/output (I&O) monitoring as ordered.
Rationale: Limiting fluids helps prevent fluid overload from worsening. Careful I&O tracking ensures diuresis is effective and alerts to fluid retention if output drops. - Administer prescribed cardiac medications such as diuretics, inotropes (e.g., dobutamine), or vasodilators (e.g., ACE inhibitors).
Rationale: Diuretics reduce circulating volume (preload), inotropes improve contractility, and vasodilators decrease resistance (afterload) – together these measures improve cardiac output and relieve pulmonary congestion. - Cluster nursing activities and encourage rest periods between care tasks.
Rationale: Spacing out activities minimizes oxygen demand and cardiac workload, preventing exhaustion and acute drops in cardiac output during exertion.
Desired Outcomes:
- The patient will maintain stable blood pressure and heart rate appropriate for activity level, indicating adequate cardiac output.
- Peripheral perfusion will improve, as evidenced by strong peripheral pulses, warm extremities, and alert mental status.
- The patient will report reduced fatigue and have sufficient energy for basic activities as cardiac output is optimized.
Nursing Care Plan #3: Activity Intolerance
Nursing Diagnosis Statement:
Activity Intolerance related to imbalance between oxygen supply and demand secondary to pulmonary edema as evidenced by dyspnea upon exertion, extreme fatigue, and inability to carry out normal activities without shortness of breath.
Related Factors/Causes:
- Reduced oxygen delivery to tissues due to fluid-filled alveoli and poor gas exchange
- Increased work of breathing even at rest, leaving little reserve for activity
- Decreased cardiac output leading to poor muscle perfusion during activity
- Generalized weakness and fatigue after an acute pulmonary edema episode or prolonged bed rest
Nursing Interventions and Rationales:
- Assess the patient’s activity tolerance (e.g., use a 0–10 scale for perceived exertion or observe how far they can walk before becoming dyspneic).
Rationale: Establishes a baseline and helps tailor activity plans. Early assessment can identify even minor changes in tolerance as pulmonary status improves or declines. - Plan care to include scheduled rest periods and pace activities (such as bathing, walking, therapy exercises).
Rationale: Intermittent rest prevents overexertion and allows the patient to complete essential tasks without precipitating severe dyspnea or hypoxia. - Assist with mobility and self-care as needed, gradually increasing activity as tolerated (e.g., sitting up, short walks in room).
Rationale: Helping with activities conserves the patient’s energy. Slow, progressive mobilization prevents deconditioning and builds endurance without overwhelming cardiopulmonary reserves. - Monitor vital signs before, during, and after activity (pulse, SpO₂, respiratory rate).
Rationale: An acute rise in heart rate, blood pressure changes, or drop in O₂ saturation during activity can indicate intolerance. Monitoring ensures patient safety and guides adjustments to the activity plan. - Educate on energy conservation techniques (sitting during tasks, using a shower chair, breaking activities into smaller steps).
Rationale: These techniques help the patient perform daily activities more efficiently and with less oxygen demand, promoting independence while ensuring safety.
Desired Outcomes:
- The patient will demonstrate improved activity tolerance, able to perform basic self-care or ambulate short distances without significant shortness of breath or fatigue.
- Vital signs will remain stable within acceptable ranges during activity, indicating adequate physiological response.
- The patient will verbalize and apply energy-saving strategies in daily routines to effectively manage fatigue.
Nursing Care Plan #4: Anxiety
Nursing Diagnosis Statement:
Anxiety related to respiratory distress and fear of suffocation secondary to pulmonary edema as evidenced by verbal expressions of worry (“I feel like I can’t breathe”), restlessness, and elevated respiratory rate.
Related Factors/Causes:
- Hypoxemia (low oxygen levels): Triggers feelings of air hunger and panic
- Sudden difficulty breathing: The acute onset of pulmonary edema can be terrifying for patients
- Uncertain prognosis and hospital environment: Fear of severe illness or death, monitors/alarm sounds, etc., can heighten anxiety
- Physical discomfort: Bubbly respirations, coughing, and chest tightness contribute to distress
Nursing Interventions and Rationales:
- Remain with the patient and maintain a calm, reassuring demeanor during acute episodes of breathlessness.
Rationale: The nurse’s presence and calm attitude can help reduce panic. Knowing someone is immediately available provides psychological comfort and safety. - Use therapeutic communication to acknowledge the patient’s fear and provide clear information about what is being done.
Rationale: Explaining treatments (e.g., “We are giving you oxygen to help you breathe easier”) demystifies the situation and can give the patient a sense of control and understanding, thereby reducing anxiety. - Teach and coach breathing techniques such as slow deep breathing or pursed-lip breathing if appropriate.
Rationale: These techniques can help the patient regulate breathing, prevent hyperventilation, and promote a sense of control over respirations, which in turn reduces panic. - Administer anti-anxiety medication or sedatives as prescribed (e.g., low-dose morphine or a benzodiazepine, if appropriate and not contraindicated).
Rationale: Medications like morphine can alleviate both dyspnea and anxiety in acute pulmonary edema by calming the patient and also causing mild vasodilation. This should be used cautiously under close monitoring due to respiratory depressant effects. - Involve family or support persons in the care when possible.
Rationale: Having a familiar presence can comfort the patient. Family can also assist in reassuring and distracting the patient from their difficulty breathing (as long as the family remains calm and supportive).
Desired Outcomes:
- The patient will report reduced anxiety, expressing feeling more at ease and in control of breathing.
- Observable signs of anxiety (restlessness, rapid breathing, panicked facial expression) will diminish.
- The patient will demonstrate use of effective coping techniques, such as controlled breathing or relaxation exercises, during episodes of respiratory distress.
Nursing Care Plan #5: Risk for Fluid Volume Excess
Nursing Diagnosis Statement:
Risk for Fluid Volume Excess related to compromised regulatory mechanisms secondary to cardiac dysfunction (heart failure) or renal dysfunction.
Note: This is a risk diagnosis, so no defining symptoms yet — preventive interventions are key.
Risk Factors:
- Compromised cardiac function: e.g., congestive heart failure leading to fluid retention
- Renal impairment: reduced kidney function causing decreased excretion of fluid
- Excessive fluid or sodium intake: dietary or IV fluids that could overwhelm circulation
- Medication effects: drugs like corticosteroids or mismanaged IV fluids that cause fluid retention
Nursing Interventions and Rationales:
- Monitor daily weights under the same conditions each day (e.g., same time, same scale).
Rationale: Sudden weight gain (e.g., >2 pounds in a day or 5 pounds in a week) is an early indicator of fluid retention that could precede recurrence of pulmonary edema. - Assess lung sounds and respiratory status regularly (even in the absence of current edema symptoms).
Rationale: New crackles or decreasing O₂ saturation may signal fluid re-accumulation in the lungs. Catching changes early allows for prompt intervention before full-blown edema recurs. - Maintain accurate intake and output records each shift.
Rationale: Ensures fluid balance is closely tracked. Detecting when intake consistently exceeds output can alert the team to impending fluid volume overload. - Adhere to fluid and sodium restrictions as ordered; educate the patient on these limits.
Rationale: Limiting oral fluids and dietary salt helps prevent excess fluid retention. Sodium restriction is crucial because sodium causes water retention, which can exacerbate pulmonary edema. - Administer diuretics prophylactically if prescribed (e.g., a daily low-dose diuretic regimen) and monitor electrolyte levels (potassium, sodium).
Rationale: Scheduled diuretics can prevent fluid accumulation. Monitoring electrolytes is important because diuresis can cause imbalances (like hypokalemia) which need correction to avoid cardiac complications.
Desired Outcomes:
- The patient will maintain a stable weight or lose weight if fluid overloaded, indicating no further fluid accumulation.
- No signs of fluid overload will be present on assessment – lungs remain clear on auscultation, no new edema in extremities, and blood pressure remains within normal range.
- The patient’s fluid balance will be optimized, with intake roughly equal to output and electrolytes remaining within normal limits.
Patient Education and Safety
Educating the patient (and family) is crucial to manage pulmonary edema and prevent future episodes. Key teaching and safety points include:
- Medication compliance: Instruct the patient to take heart failure medications (like diuretics, antihypertensives) exactly as prescribed. Explain that skipping doses can lead to fluid buildup or blood pressure rise that triggers pulmonary edema.
- Low-sodium diet: Teach the patient to follow a low-salt diet to help control fluid retention. Provide examples of high-sodium foods to avoid and encourage label reading. This diet can significantly reduce the workload on the heart.
- Fluid monitoring: If on fluid restriction, educate on spreading allowed fluids throughout the day and using measuring tools. Even if not strictly restricted, advise the patient to be mindful of excessive fluid intake (including soups and beverages).
- Daily weights at home: Instruct the patient to weigh themselves every morning after urination, using the same scale, and to report weight gains of 2-3 pounds in one day or 5+ pounds in a week to their provider. Sudden weight gain can be an early warning of fluid buildup.
- Recognizing early symptoms: Teach the patient and caregivers to recognize early signs of pulmonary edema or heart failure exacerbation — such as new onset of shortness of breath with activity or at night, increase in cough or sputum (especially frothy sputum), swelling in ankles, or unusual fatigue. Prompt recognition allows early medical intervention.
- Lifestyle modifications: Encourage smoking cessation (if applicable) since smoking can worsen lung function. If pulmonary edema was related to high altitude, advise gradual ascents or medication prophylaxis for future trips. Emphasize keeping up with vaccinations (flu, pneumonia) to prevent respiratory infections that could stress the lungs.
- When to seek help: Emphasize the importance of calling the doctor or emergency services if severe shortness of breath returns, if chest pain occurs, or if any symptom rapidly worsens. Ensure the patient and family understand this is a medical emergency and have an action plan in place.
- Safety with oxygen: If the patient is discharged on home oxygen, teach proper usage: no smoking around oxygen, how to check O₂ levels if they have a pulse oximeter, and how to maintain equipment. Also review energy-conservation techniques and keeping assistive devices (like a bedside commode or shower chair) to reduce exertion at home safely.
By reinforcing these education points, nurses empower patients to manage their condition, adhere to treatment, and reduce the risk of recurrence, all of which contributes to safer long-term outcomes.
FAQs
What is the priority nursing diagnosis for a patient with pulmonary edema?
The priority nursing diagnosis in acute pulmonary edema is often Impaired Gas Exchange. Because the lungs are filled with fluid, the patient can’t oxygenate properly – ensuring adequate breathing and oxygenation is the most critical focus. Other diagnoses (like Decreased Cardiac Output or Anxiety) are important but managing the patient’s gas exchange (through oxygen, positioning, and diuresis) takes precedence to prevent respiratory failure.
How should a nurse assess a patient with pulmonary edema?
The nurse should perform frequent, focused assessments including: monitoring vital signs (especially respiratory rate and O₂ saturation), auscultating lung sounds for crackles, observing for use of accessory muscles or cyanosis, and noting the patient’s mental status (anxiety or confusion can indicate hypoxia). It’s also important to assess for signs of worsening fluid status, such as jugular vein distension or new peripheral edema. Cardiac assessment (heart sounds, pulse quality) is also key since pulmonary edema often stems from heart issues.
What nursing interventions improve gas exchange in pulmonary edema?
Key interventions include positioning the patient upright (High Fowler’s position) to ease breathing, administering supplemental oxygen (to maintain saturation, aiming for SpO₂ > 95%), and giving rapid-acting diuretics as prescribed to remove excess fluid from the lungs. In severe cases, interventions escalate to noninvasive positive pressure ventilation (CPAP/BiPAP) or assisting with intubation and mechanical ventilation. Additionally, reducing the patient’s anxiety with calm reassurance or medications can prevent hyperventilation and further improve gas exchange efficiency.
Can pulmonary edema be prevented or managed at home?
Pulmonary edema can often be prevented from recurring by managing the underlying cause. For example, in heart failure patients, sticking to low-sodium diets, taking medications faithfully (like ACE inhibitors, beta-blockers, and diuretics), and monitoring daily weight can prevent fluid buildup. Avoiding known triggers (such as high altitude if you’ve had High-Altitude Pulmonary Edema before) is also important. While an acute pulmonary edema episode is a medical emergency that must be treated in the hospital, careful self-monitoring and early communication with healthcare providers (reporting symptoms like increasing shortness of breath or swelling) can catch fluid accumulation early and allow for adjustments in diuretics or other treatments at home before it progresses to a severe state.
Is pulmonary edema a life-threatening emergency?
Yes. Acute pulmonary edema is absolutely a medical emergency. When the lungs fill with fluid, the body can’t get enough oxygen, which can lead to respiratory failure and cardiac arrest if not promptly treated. Patients often need immediate interventions like high-flow oxygen, IV medications, and sometimes ventilatory support. Rapid recognition and action are crucial – that’s why nurses are trained to quickly identify signs like sudden extreme breathlessness, pink frothy sputum, and crackles in the lungs, and to respond by activating emergency protocols and treatment without delay.
Related Nursing Care Plans: (for further study and interlinking)
- Coronary Artery Disease Nursing Diagnosis – care plans for managing patients with coronary artery disease (a common cause of cardiogenic pulmonary edema)
- Decreased Cardiac Output – nursing diagnosis and interventions focusing on improving heart pump effectiveness
- Activity Intolerance – care strategies for patients with limited tolerance to exercise due to cardiac/respiratory issues
- Anxiety – nursing interventions to help patients cope with anxiety related to acute conditions
- Ineffective Tissue Perfusion – diagnosis addressing inadequate perfusion of tissues (relevant in shock or severe heart failure)
- Chest Pain – assessment and care plans for patients experiencing chest pain (e.g., during myocardial infarction or angina)
References
- Carpenito, L. J. (2022). Handbook of Nursing Diagnosis (16th ed.). Wolters Kluwer.
- Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2021). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.
- Hinkle, J. L., & Cheever, K. H. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer.
- Malek, R., & Soufi, S. (2024). Pulmonary Edema. In StatPearls [Internet]. StatPearls Publishing. (Updated 2023, April 7).
- American Heart Association. (2022). 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. Circulation, 145(18), e895–e1032. (Includes guidance on acute pulmonary edema management in heart failure).
