Pulmonary edema is a condition in which the lungs fill with fluid. It’s also known as lung congestion, lung water, and pulmonary congestion. When pulmonary edema occurs, the body struggles to get enough oxygen and start to have shortness of breath.
It leads to impaired gas exchange and may cause respiratory failure. It is due to either failure of the left ventricle of the heart to remove blood adequately from the pulmonary circulation (cardiogenic pulmonary edema), or an injury to the lung parenchyma or vasculature of the lung (non-cardiogenic pulmonary edema).
Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump efficiently, blood can back up into the veins that take blood through the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs. This fluid reduces normal oxygen movement through the lungs. These two factors combine to cause shortness of breath.
Congestive heart failure that leads to pulmonary edema may be caused by: Heart attack, or any disease of the heart that weakens or stiffens the heart muscle (cardiomyopathy), Leaking or narrowed heart valves (mitral or aortic valves), Sudden, severe high blood pressure (hypertension).
Pulmonary edema may also be caused by: Certain medicines, High altitude exposure, Kidney failure, Narrowed arteries that bring blood to the kidneys, Lung damage caused by poisonous gas or severe infection, Major injury.
The most common symptom of pulmonary edema is difficulty breathing, but may include other symptoms such as coughing up blood (classically seen as pink, frothy sputum), excessive sweating, anxiety, and pale skin. Shortness of breath can manifest as orthopnea (inability to lie down flat due to breathlessness) and/or paroxysmal nocturnal dyspnea (episodes of severe sudden breathlessness at night). These are common presenting symptoms of chronic pulmonary edema due to left ventricular failure.
Nursing Care Plan for Pulmonary Edema
Assessment
Physical Examination
10 Nursing Diagnosis for Pulmonary Edema
1. Ineffective breathing pattern related to thick or excessive secretions, secondary to asthma characterized by; tachypnea, respiratory nostrils, increased pulse.
Subjective data: the client says "hard to breathe"
Objective data: dyspnea, takhypnea, using respiratory aids, shortness of breath, chest wall retraction.
2. Ineffective airway clearance is related to: intubation, ventilation, disease processes, weakness and fatigue.
Subjective data: complaining of shortness of breath
Objective data: cough (productive and non-productive), crackles, fever, hemopitysis and dyspnea.
3. Ineffective tissue perfusion related to disturbances of oxygen transport through alveolar and capillary membranes
Subjective data: the client says "tenderness in the chest"
Objective data: edema, decreased pulse, pale skin color, bradycardia, cold acral, cyanosis, decreased supply of O2, CRT less than 2 seconds, tachypnea.
4. Risk for injury related to decreased consciousness.
5. Activity intolerance related to imbalance in O2 supply with body needs.
Subjective data: the client says "feeling tired and feeling weak when doing activities"
Objective data: abnormal heart frequency response to activity, discomfort after activity, dyspnea after activity.
6. Excess fluid volume related to increased preload, decreased contractility and decreased cardiac output.
Subjective data: the client says "nervous", the client says "difficult urination".
Objective data: edema, electrolyte disturbances, changes in breathing patterns, decreased ventricular venous pressure, increased body weight, decreased urine production.
7. Constipation related to immobilization
Subjective data: the client says "cannot defecate, pain during defecation".
Objective data: hyperactive bowel sounds, general fatigue, deformed abdominal percussion, vomiting.
8. Imbalanced nutrition: less than body requirements related to vomiting, anorexia and indigestion.
Subjective data: the client says "feeling nauseous, lacking appetite"
Objective data: hyperactive bowel sounds, inability to digest food, complaining of sensational disturbances, pale mucous membranes, vomiting.
9. Decrease cardiac output related to changes in stroke volume
Subjective data: the client says "dizzy during light and heavy activities"
Objective data: vertigo, dyspnea, cyanosis, arrhythmias.
10. Anxiety related to hospitalization
Subjective data: the client says "fear of the new environment"
Objective data: clients appear anxious, scared, confused, stressed.
It leads to impaired gas exchange and may cause respiratory failure. It is due to either failure of the left ventricle of the heart to remove blood adequately from the pulmonary circulation (cardiogenic pulmonary edema), or an injury to the lung parenchyma or vasculature of the lung (non-cardiogenic pulmonary edema).
Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump efficiently, blood can back up into the veins that take blood through the lungs. As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs. This fluid reduces normal oxygen movement through the lungs. These two factors combine to cause shortness of breath.
Congestive heart failure that leads to pulmonary edema may be caused by: Heart attack, or any disease of the heart that weakens or stiffens the heart muscle (cardiomyopathy), Leaking or narrowed heart valves (mitral or aortic valves), Sudden, severe high blood pressure (hypertension).
Pulmonary edema may also be caused by: Certain medicines, High altitude exposure, Kidney failure, Narrowed arteries that bring blood to the kidneys, Lung damage caused by poisonous gas or severe infection, Major injury.
The most common symptom of pulmonary edema is difficulty breathing, but may include other symptoms such as coughing up blood (classically seen as pink, frothy sputum), excessive sweating, anxiety, and pale skin. Shortness of breath can manifest as orthopnea (inability to lie down flat due to breathlessness) and/or paroxysmal nocturnal dyspnea (episodes of severe sudden breathlessness at night). These are common presenting symptoms of chronic pulmonary edema due to left ventricular failure.
Nursing Care Plan for Pulmonary Edema
Assessment
- Patient identity - Age: infants and older adults tend to experience, compared to adolescents / young adults.
- Main complaints: shortness of breath, fatigue, rapid breathing and hypoxia.
- Current disease history: shortness of breath, cyanosis, coughing, cold sweat, anxiety, tachycardia, pale skin, and cold acral.
- Past medical history: predilection of systemic disease or systemic impact such as sepsis, pulmonary disease, such as pneumonia, pulmonary embolism, heart (left heart failure, heart valve disease), kidney.
- Activities of Daily Living
- Nutrition: shortness of breath will decrease appetite.
- Elimination: there can be a decrease in the amount of urine.
- Activity - rest: activity - rest can be disrupted due to shortness of breath.
- Personal hygiene: personal hygiene cannot be done independently.
- Psychosocial spirituality: Patients are restless, depressed, afraid, increased tension, smoking habits can cause heart failure which will later lead to pulmonary edema.
Physical Examination
- B1 (Breathing) : Shortness of breath, chest pressure, nasal passages, hyperventilation, coughing (productive / non-productive), large sputum, use of respiratory aids muscles, decreased SpO2, decreased PO2, increased PCO2, increased diaphragmatic breathing and abdominal breathing, increased respiratory rate, rheumatism at pulmonary visual field, pale skin, cyanosis.
- B2 (Blood) : Increased pulse, irregular heartbeat, additional heart sounds, lots of sweat, increased skin temperature, redness, cold and moist akral, CRT for more than 2 seconds, blood pressure increases.
- B3 (Brain) : Restlessness, decreased consciousness, seizures, decreased GCS, decreased reflexes.
- B4 (Bladder) : Urine production decreases, vesicle urine is soft.
- B5 (Bowel) : Sometimes nausea, vomiting, normal bowel sounds.
- B6 (Bone) : Weak, tired quickly, decreased muscle tone, reduced joint pain sensation.
10 Nursing Diagnosis for Pulmonary Edema
1. Ineffective breathing pattern related to thick or excessive secretions, secondary to asthma characterized by; tachypnea, respiratory nostrils, increased pulse.
Subjective data: the client says "hard to breathe"
Objective data: dyspnea, takhypnea, using respiratory aids, shortness of breath, chest wall retraction.
2. Ineffective airway clearance is related to: intubation, ventilation, disease processes, weakness and fatigue.
Subjective data: complaining of shortness of breath
Objective data: cough (productive and non-productive), crackles, fever, hemopitysis and dyspnea.
3. Ineffective tissue perfusion related to disturbances of oxygen transport through alveolar and capillary membranes
Subjective data: the client says "tenderness in the chest"
Objective data: edema, decreased pulse, pale skin color, bradycardia, cold acral, cyanosis, decreased supply of O2, CRT less than 2 seconds, tachypnea.
4. Risk for injury related to decreased consciousness.
5. Activity intolerance related to imbalance in O2 supply with body needs.
Subjective data: the client says "feeling tired and feeling weak when doing activities"
Objective data: abnormal heart frequency response to activity, discomfort after activity, dyspnea after activity.
6. Excess fluid volume related to increased preload, decreased contractility and decreased cardiac output.
Subjective data: the client says "nervous", the client says "difficult urination".
Objective data: edema, electrolyte disturbances, changes in breathing patterns, decreased ventricular venous pressure, increased body weight, decreased urine production.
7. Constipation related to immobilization
Subjective data: the client says "cannot defecate, pain during defecation".
Objective data: hyperactive bowel sounds, general fatigue, deformed abdominal percussion, vomiting.
8. Imbalanced nutrition: less than body requirements related to vomiting, anorexia and indigestion.
Subjective data: the client says "feeling nauseous, lacking appetite"
Objective data: hyperactive bowel sounds, inability to digest food, complaining of sensational disturbances, pale mucous membranes, vomiting.
9. Decrease cardiac output related to changes in stroke volume
Subjective data: the client says "dizzy during light and heavy activities"
Objective data: vertigo, dyspnea, cyanosis, arrhythmias.
10. Anxiety related to hospitalization
Subjective data: the client says "fear of the new environment"
Objective data: clients appear anxious, scared, confused, stressed.
