Pulmonary edema is an accumulation of fluid in the alveoli of the lungs that causes disturbances in gas exchange. Cardiogenic and noncardiogenic pulmonary edema are the two main types of this condition.
Cardiogenic: Blood that enters through veins from the lungs cannot be pumped out by the left heart ventricle. A sudden increase in the fluid pressure of the pulmonary capillaries leads to the development of volume-overload pulmonary edema. This is observed in conditions such as acute myocarditis, congestive heart failure, myocardial infarction, and dysrhythmias.
Noncardiogenic (unrelated to the heart): Lung damage results in increased pulmonary vascular permeability, which causes fluid to migrate into the lung compartments. Acute respiratory distress syndrome (ARDS), pneumonia, inhalation injuries, or indirect causes such as sepsis, shock, acute pancreatitis, or rapid descent from a high altitude may cause this type of pulmonary edema.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Gas Exchange
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
Nursing Process
Comprehensive assessment and monitoring by nurses are essential for earlier detection and management of pulmonary edema. Effective history-taking will identify complex comorbidities, medication nonadherence, and lifestyle risk factors that place the client at risk for pulmonary edema.
The involvement of other health team members, such as internists, cardiologists, and pulmonologists, is advised for timely intervention, as pulmonary edema can be a complication of multiorgan involvement.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to pulmonary edema.
Review of Health History
1. Assess the patient’s general symptoms.
The following symptoms of pulmonary edema depend on whether the cause is cardiogenic or noncardiogenic:
- Signs of both cardiogenic and noncardiogenic pulmonary edema include:
- Tachypnea
- Rales or crackles on lung auscultation
- Progressive dyspnea
- Signs of cardiogenic pulmonary edema include:
- Hypoxemia from fluid overload
- Cough with frothy pink sputum
- S3 gallop or murmurs on heart auscultation
- Elevated jugular vein pressure
- Peripheral edema
- Signs of non-cardiogenic pulmonary edema include:
- Infection symptoms, such as fever
- Productive cough
- Dyspnea
2. Review the patient’s cardiovascular history.
Identify heart conditions that may cause cardiogenic pulmonary edema. Congestive heart failure is the most prevalent cause of cardiogenic pulmonary edema. Other causative conditions are:
- Arrhythmias like atrial fibrillation
- Cardiomyopathy
- Myocardial infarction
- Hypertension
- Myocarditis
- Pericardial effusion
- Heart valve defects
- Coronary artery disease
3. Review the patient’s medical history.
Noncardiogenic pulmonary edema leads to fluid buildup in the lungs. Possible causes include:
- Acute respiratory distress syndrome (ARDS)
- Lung infection
- Pulmonary embolism
- Sepsis
- Trauma
- Pancreatitis
- Multiple blood transfusions
- Inhalation injuries
In general, the mechanisms causing edema can arise from any array of conditions disrupting fluid balance, such as:
- Kidney disease
- Thyroid disease
- Liver conditions
- Excessive iron buildup (hemochromatosis)
- Protein buildup (amyloidosis)
4. Review the medication list.
Aspirin and illegal drugs (like heroin and cocaine) are just a few of the substances that are known to cause pulmonary edema.
5. Track the patient’s smoking history.
Chemicals in fire and tobacco smoke harm the membrane that separates the capillaries from the air sacs, increasing lung permeability and fluid buildup.
6. Ask about the patient’s lifestyle and occupation.
Mountain climbers, hikers, skiers, and other people who travel at high altitudes but do not acclimate to the change in elevation are at risk for high-altitude pulmonary edema (HAPE).
7. Take caution with drowning incidents.
During near drowning, water disrupts the alveolar-capillary membrane, increasing the permeability and risk for fluid shifts.
Physical Assessment
1. Assess the ABCs.
Check the ABCs (airway, breathing, and circulation). Pulmonary edema can quickly become life-threatening if not recognized.
2. Monitor the vital signs.
Assess vital signs frequently. Findings may reveal:
- Alterations in blood pressure
- Rapid pulse rate
- Increased respiratory rate
- Decreased oxygen saturation
3. Assess the respiratory status.
The clinical characteristics of both cardiogenic and noncardiogenic pulmonary edema are:
- Progressive dyspnea
- Rapid breathing (tachypnea)
- Presence of rales (or crackles) upon auscultation
4. Assess the cardiovascular status.
Fluid accumulation in the lungs can cause the following signs:
- Peripheral edema
- Increased jugular vein pressure
- S3/S4 heart sounds upon auscultation
- Cough with pink, frothy sputum
5. Note the general appearance.
Pulmonary edema commonly causes restlessness and anxiety due to dyspnea and a feeling of suffocation.
6. Track the blood transfusion record.
Check for a recent history of blood transfusions and any past complications. A large volume or rapid infusion of blood products can cause noncardiogenic pulmonary edema, which leads to transfusion-associated circulatory overload.
Diagnostic Procedures
1. Quickly obtain an ECG.
Electrocardiography can quickly diagnose myocardial infarction or identify dysrhythmias as underlying causes.
2. Obtain samples for lab testing.
The following laboratory tests may be performed to determine a possible cause:
- Systemic etiologies:
- Complete blood count
- Metabolic panel
- Kidney function
- Thyroid function
- Heart problems:
- Brain-type natriuretic peptide (BNP)
- Troponin
- Serum albumin
- Toxic ingestion:
- Serum electrolyte levels
- Renal function
- Serum osmolarity
- Toxicology screening
- Acute pancreatitis:
- Lipase levels
- Amylase levels
3. Prepare the patient for a chest X-ray.
The characteristics of pulmonary edema include:
- Cardiogenic:
- Pleural effusions
- Kerley B septal lines
- Peribronchial cuffing
- Central edema
- Increased heart size
- Noncardiogenic:
- Patchy and peripheral edema
- Air bronchograms
- Ground-glass opacities/consolidation
4. Monitor ABGs.
Arterial blood gas testing is utilized to monitor for hypoxemia and hypercapnia.
5. Examine the heart.
Echocardiography identifies valvular defects and left ventricular systolic dysfunction.
6. Consider modern techniques.
Modern diagnostic techniques can efficiently diagnose pulmonary edema:
- Lung ultrasound: This noninvasive test does not involve radiation exposure and detects the buildup of extravascular lung water before the onset of symptoms.
- Pulmonary artery catheterization: This test is the gold standard for determining the cause of pulmonary edema and is an invasive procedure that monitors systemic vascular resistance, cardiac output, and filling pressures.
- Transpulmonary thermodilution: This invasive procedure is utilized when patients are already undergoing significant thoracic, cardiac, or vascular procedures.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with pulmonary edema.
Manage the Pulmonary Edema
1. Manage the underlying cause.
Treatment of the underlying pathologic condition and symptom relief are the goals of care for patients with pulmonary edema.
2. Administer supplemental oxygen.
Oxygen is the first line of treatment for acute pulmonary edema. Oxygen via a nasal cannula or mask should alleviate symptoms of dyspnea. Continuously monitor the oxygen saturation while on oxygen therapy.
3. Improve ventilation.
If oxygenation worsens despite oxygen therapy, non-invasive or invasive ventilation support may be necessary. When initiated early, non-invasive measures such as CPAP or BiPAP reduce the need for intubation and mechanical ventilation.
4. Administer medications as ordered.
Treatment options may include one or more of the following drugs, depending on the severity and cause of the pulmonary edema:
- Diuretics
- Vasodilators
- Nitroglycerin
- Calcium channel blockers
- Clevidipine
- Nifedipine (prophylaxis and treatment for HAPE)
- Inotropes
- Morphine
5. Treating HAPE.
The first line of treatment for high-altitude pulmonary edema (HAPE) is applying oxygen. If a portable hyperbaric chamber is available, this can imitate moving to a lower elevation.
Prevent Accumulation of Fluid in the Lungs
1. Manage the comorbidities.
Adherence to treatment regimens is crucial to prevent the development of pulmonary edema. Control blood sugar levels in diabetes. Maintain the blood pressure within the desired range. Participate in exercise for heart health and weight loss.
2. Recommend avoiding risky activities.
Avoiding drug use or high altitudes can help prevent further lung damage. Mountain climbers should ascend gradually and can discuss taking medications like acetazolamide or nifedipine before climbing to prevent HAPE.
3. Encourage smoking cessation.
Enlighten the patient on the effects of smoking. Introduce smoking cessation programs if the patient is interested in quitting.
4. Guide the patient in creating a meal plan.
Whole grains, fruits, and vegetables should make up a significant portion of a balanced, heart-healthy diet. It is recommended that added sugars, salt, and saturated and trans fats be reduced.
5. Transfuse blood with caution.
Monitor for blood transfusion reactions. Transfusion-related acute lung injury (TRALI) causes noncardiogenic pulmonary edema and is the leading cause of death from transfusion.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for pulmonary edema, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for pulmonary edema.
Anxiety
Anxiety associated with pulmonary edema can be caused by changes in health status and the threat of death.
Nursing Diagnosis: Anxiety
Related to:
- Stress from a change in health status
- Fear of respiratory instability
- Decreased carbon dioxide in the blood
As evidenced by:
- Verbalization of apprehension
- Expression of health concerns
- Distress
- Increased tension
- Gasping for air
- Hyperventilation
- Restlessness
- Dizziness
- Lightheadedness
- Diaphoresis
Expected outcomes:
- Patient will be able to express their feelings of anxiety related to pulmonary edema.
- Patient will be able to manifest a regular breathing pattern and rhythm.
- Patient will report feeling in control of their health status.
Assessment:
1. Assess the patient’s anxiety level.
Particularly for patients with a severe heart condition in cardiogenic pulmonary edema, intense anxiety level poses a significant risk of acute pulmonary edema.
2. Check for signs of hyperventilation.
Anxiety can cause hyperventilation which leads to the excessive output of CO2. This will further exacerbate symptoms related to pulmonary edema.
3. Observe nonverbal cues of anxiety.
Monitor for restlessness, irritability, decreased cooperation, and preoccupation as signs of impending anxiety.
Interventions:
1. Ensure the patient is well-informed.
Ensuring the patient is well-informed of their treatment plan, prognosis, and understanding of ventilation keeps them involved in their care and may relieve anxiety.
2. Involve the family.
Encourage support systems to provide diversions and direct the focus off of breathing.
3. Instruct on breathing techniques.
Coach the patient to take slower, deeper breaths, abdominal breaths, or pursed-lip breathing to maximize comfort and control.
4. Administer morphine as ordered.
Morphine can be administered to treat anxiety and dyspnea from pulmonary edema. Administer cautiously so as not to depress the respiratory system.
Impaired Gas Exchange
Impaired gas exchange associated with pulmonary edema can be caused by fluid collection preventing oxygenation.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Fluid collection in the lungs
- Fluid shifts in the lung compartments
- Cardiac conditions such as heart failure
- Non-cardiogenic conditions such as pneumonia
- High altitudes
As evidenced by:
- Irregular breathing pattern
- Changes in the rate and depth of respirations
- Dyspnea
- Restlessness
- Irritability
- Confusion
- Productive cough
- Use of accessory muscles
- Alterations in ABGs
- Abnormal chest X-ray
- Adventitious breath sounds
Expected outcomes:
- Patient will be able to attain oxygen saturation of 95-100%.
- Patient will demonstrate clear breath sounds.
- Patient will demonstrate the ability to clear their airway.
Assessment:
1. Identify the causative factors.
Reduced gas exchange from pulmonary edema can progress to ARDS. A non-cardiogenic process brought on by injury to the lung or a cardiogenic process brought on by an inability to remove enough blood from the lungs must be identified for appropriate treatment.
2. Monitor the patient’s respiratory status.
Evaluate the respiratory rate, depth, pattern, and O2 saturation. Symptoms of pulmonary edema can progress rapidly.
3. Auscultate the breath sounds.
Adventitious breath sounds like crackles, wheezing, or bubbling can be heard. Fine crackles heard on inspiration are specific to cardiogenic pulmonary edema.
5. Review imaging results.
Hallmarks of cardiogenic pulmonary edema are central edema, pleural effusions, and an enlarged heart. In noncardiogenic pulmonary edema, edema is patchy and peripheral, with ground-glass opacities and consolidations.
Interventions:
1. Elevate the head of the bed or place the patient on their side.
For optimal breathing and to avoid obstruction from secretions, turn the patient on their side or raise the head of the bed.
2. Apply oxygen.
Supplemental oxygen is often required to maintain oxygen saturation.
3. Regularly check the ABGs.
ABGs show progress or deterioration in the lung’s ability to exchange oxygen and CO2.
4. Cautiously use diuretics as prescribed.
The most frequently prescribed drug is furosemide. Diuretics continue to be the cornerstone of pulmonary edema treatment. Although higher doses are linked to temporary renal impairment, they are also linked to a more significant improvement in dyspnea.
5. Give vasodilators with diuretics as adjuvant therapy.
The recommended vasodilator is IV nitroglycerin, which reduces lung congestion and preload.
6. Administer prophylactic medication as ordered.
High-altitude pulmonary edema is prevented and treated with nifedipine. Nifedipine is only used as a prophylaxis in high-risk individuals. It is also given under circumstances such as rapid rate of ascent, intense physical exercise, and recent respiratory tract infection.
7. Provide inotropes as prescribed.
Inotropes such as dobutamine and dopamine are administered to treat pulmonary edema with tissue hypoperfusion.
Impaired Spontaneous Ventilation
Impaired spontaneous ventilation associated with pulmonary edema is caused by respiratory muscle fatigue and uncontrolled secretions.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Anxiety
- Respiratory muscle fatigue
- Impaired inspiration and expiration mechanisms in pulmonary edema
- Uncontrolled secretions
As evidenced by:
- Dyspnea
- Restlessness
- Tachycardia
- Accessory muscle use
Expected outcomes:
- Patient will demonstrate a regular respiratory rate and rhythm.
- Patient will maintain an oxygen saturation of 95-100%.
- Patient will maintain clear breath sounds.
- Patient will demonstrate an ability to wean off the ventilator.
Assessment:
1. Monitor for impending respiratory failure.
Worsening ventilation manifests as shallow, apneic breathing (respiratory muscle fatigue) and mental confusion.
2. Observe for other respiratory symptoms.
Irregular breathing, gasping for air, and use of accessory muscles are symptoms of impaired spontaneous ventilation that require immediate attention.
3. Assess ABGs.
ABGs evaluate the degree of hypoxemia and hypercapnia requiring ventilatory support.
Interventions:
1. Ensure endotracheal placement.
After assisting with intubation, ensure the ET tube is correctly placed by monitoring symmetric chest expansion, breath sound auscultation, and X-ray confirmation.
2. Suction as needed.
Suction PRN to clear the airway of secretions. Suction at the lowest level and shortest duration possible.
3. Monitor settings.
Ventilator settings such as FiO2, tidal volume, and peak inspiratory pressure should be monitored frequently.
4. Consult with respiratory therapists.
Respiratory therapists administer respiratory drugs, treatments, assist with intubation, and adjust ventilator settings.
Ineffective Airway Clearance
Pulmonary edema is the buildup of fluid in the lungs that obstructs oxygenation and ventilation.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Smoking
- Fluid in alveoli
- Sepsis
- Cardiomyopathies
As evidenced by:
- Dyspnea
- Hypoxemia
- Anxiety
- Rales/crackles
- Restlessness
- Productive cough
Expected outcomes:
- Patient will maintain a patent airway.
- Patient will manifest clear lung sounds.
Assessment:
1. Assess quality, rate, pattern, and depth of respirations.
Changes in respiration may be indicative of respiratory compromise. Dyspnea and tachypnea are observed with pulmonary edema.
2. Monitor breath sounds.
Pulmonary edema often presents with crackles or rales.
3. Assess for a cough.
Cardiogenic pulmonary edema may cause a cough with frothy pink sputum due to hypoxemia. Noncardiogenic causes may also cause a productive cough.
Interventions:
1. Initiate oxygen therapy.
Begin with supplemental oxygen via nasal cannula or mask. If oxygenation worsens, consider noninvasive ventilation measures before progressing to intubation and mechanical ventilation.
2. Elevate the head of the bed.
This promotes lung expansion, helps reduce venous return to the heart, and alleviates pulmonary congestion.
3. Administer diuretics.
Diuretic therapy is a mainstay treatment to alleviate dyspnea from fluid overload.
4. Utilize vasodilators.
In addition to diuretics, vasodilators like IV nitroglycerin are utilized to treat pulmonary congestion.
Ineffective Breathing Pattern
Shortness of breath caused by abnormal fluid buildup results in inspiration and/or expiration that does not provide adequate ventilation.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Cardiac conditions (CHF, MI, CAD, etc.)
- High altitudes
- Lung infections
- Anxiety
- Fluid buildup in the lungs
As evidenced by
- Dyspnea
- Tachypnea
- Hypoxemia
- Anxiety
Expected outcomes
- Patient will report feeling comfortable when breathing.
- Patient will manifest a respiratory rate within normal limits.
- Patient will demonstrate ABGs within normal limits.
Assessment:
1. Monitor the respiratory rate and pattern.
Pulmonary edema causes dyspnea and tachypnea. Monitor for an increase in respiratory rate, accessory muscle use, or respiratory fatigue.
2. Observe restlessness and anxiety.
Difficulty breathing can cause panic in most people, which may further worsen the ability to breathe effectively.
3. Evaluate radiographic tests.
Chest X-rays are often obtained first to assess for pulmonary edema. CT scans and echocardiography may also offer diagnostic findings.
Interventions:
1. Administer oxygen as prescribed.
Supplemental oxygen is implemented immediately to alleviate dyspnea and prevent hypoxemia.
2. Continuously monitor SpO2.
Continuous oxygen saturation monitoring is necessary to identify hypoxemia and prevent worsening in condition.
3. Provide emotional support, especially during dyspneic episodes.
A supportive environment can reduce anxiety and oxygen demand.
4. Monitor hemodynamic stability.
Acute respiratory distress syndrome or cardiac collapse can occur with pulmonary edema. Monitor for ventilatory failure, acidosis, or hypotension that requires immediate intervention.
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