Nursing Diagnosis, Care Plan, and Interventions for Pulmonary Edema-A Student’s Guide
Pulmonary edema is the accumulation of fluid in the lungs, characterized by shortness of breath and coughing. It occurs when there isn’t enough blood flow to provide for the exchange of oxygen. The causes include heart failure or severe shock.
There are two main kinds of pulmonary edema:
Cardiogenic pulmonary edema – caused by heart failure, in which the heart is unable to pump enough blood through the lungs
Cardiogenic pulmonary edema can be further classified into Acute or sub-acute (occurs suddenly, usually requiring emergency measures), Chronic (long-term fluid overload within the lungs)
Non-cardiogenic pulmonary edema is caused by other medical conditions that disrupt blood flow through the lung lymphatic vessels, such as pneumonia or anaphylaxis.
Non-cardiogenic pulmonary edema can be classified as Acute or subacute (occurs suddenly and usually requires emergency measures), such as drowning, anaphylactic shock, and severe allergic reaction.
This article aims to guide nursing students on Pulmonary Edema; it’ll focus on aspects such as the signs& symptoms, nursing diagnosis, risk factors, interventions, and care plans.
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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
The Signs and Symptoms related to Pulmonary Edema
- Shortness of breath (dyspnea)
- Sweating and feeling clammy
- Rapid heartbeat (tachycardia) or slow heart rate (bradycardia)
- Cold, pale skin and blue lips due to low oxygen levels in the blood
- Fast breathing, with mouth open or pursed lips.
Nursing Diagnosis and Care Plan for Pulmonary Edema
This nursing care plan aims to provide an overview of the patient’s needs and the plan of action. This encompasses a list of tasks to be done by the nurse and provides information regarding how these tasks will benefit the patient in question.
This care plan focuses on pulmonary edema conditions but includes other factors that influence the person’s ability to receive care. The level of care that a patient needs will depend on the severity of illness or injury that they have. The following information will describe the different levels.
Level 3: Immediate Care. This level is identified by breathing problems caused by pulmonary edema with additional needs for cardiac support care. Patients admitted to this level require a comprehensive overview for managing their condition and immediate attention from the medical team.
LEVEL 4: Limited Care. This level is identified by mild respiratory condition with limitations on the number of visitors or activities to avoid aggravating their breathing condition. Since patients here are stable, they will stay in this room for a certain period of time. Here, patient’s needs are met so that they will be comfortable during their stay.
Level 5: Full Care. This level is identified by patients with normal breathing condition but requires support in physical needs such as food and fluids for a short period of time that they are admitted to this room. For the patient to receive proper care, they should be monitored frequently, especially when undergoing physical activity.
Nursing diagnosis for Pulmonary edema
After assessing the client, nurses use medical diagnoses to access study material for further studies or to better understand how they can care for their patients. With that in mind, every nurse needs to have extensive knowledge about nursing diagnosis, especially when dealing with pulmonary edema.
Following is a comprehensive list of nursing diagnoses that are related to Pulmonary Edema.
Breathing Pattern, Ineffective: Nurses working with clients who showed signs and symptoms associated with pulmonary edema should also assess if the client’s breathing pattern is ineffective. If you find out that it is inadequate, then notify your nurse manager or your doctor about it as soon as possible. However, if you find out that the breathing pattern is effective, then see to it that the client’s vital signs are checked regularly for any signs of abnormality.
Medicine Management, Incomplete: If you notice that your client is taking medications and treatment regimens but still experiences difficulty breathing or shortness of breath, check him frequently to ensure that his pulmonary edema is being treated effectively.
Chest x-ray, Abnormal: This is critical, especially if your client is experiencing elevated fluid levels in his lungs. With this diagnosis, you should contact the health care provider who caused the abnormal x-ray result and notify them about it so that they can plan alternative treatments for pulmonary edema.
Health Management, Ineffective: You must assess if your client can take care of himself effectively. If not, then notify the nurse manager about it so that intervention can be done immediately.
Wounds and Skin Integrity, Risk for Impaired: If your client is experiencing difficulty in breathing, you have to check him thoroughly for any skin lesions or wounds. If there is no wound present, then you might see to it that the skin becomes moistened with lotions or ointments to avoid dryness which can be an additional cause of difficulty in breathing.
Health Management, Ineffective: It is necessary for you to assess if your client has been able to take care of himself and predict or anticipate what possible problem might occur. In preventing pulmonary edema, it is important to know that the effectiveness of health management depends on planning, organization, diagnosis, and evaluation. Prepare a plan so that both you and your client can follow it effectively.
Nutrition, Imbalanced: If your client is experiencing difficulty breathing or shortness of breath, then monitor to see if he has enough fluid and food intake, especially if he has to provide energy for his weakened vital organs due to pulmonary edema.
Activity Intolerance: You should check with your client regarding his activity level to know if he is experiencing difficulty in breathing or shortness of breath. If you find out that he is experiencing these signs and symptoms, try to monitor him regularly. Provide adequate rest when necessary. Also, prepare a plan for your client’s daily activities so that he can perform them successfully.
Growth and Development, Delayed: If you find out that your client is exhibiting signs and symptoms associated with pulmonary edema, then as a nurse, be aware of the possibility that his growth may be affected. You should also assess if his physical development is delayed. Take into account any additional or special care needed for him to grow properly.
Mobility, Impaired: Be alert and check on your client if he has difficulty moving from one place to another. If he needs to move from one area to another, you should assist him, especially if he has shown signs of pulmonary edema.
Family Processes, Dysfunctional: When dealing with clients experiencing difficulty in breathing, you should assess if there is any dysfunction present within the family. If so, then make sure that you involve both the client and his family by informing them about the disease and its management to enable a smooth transition from home care to institutionalization.
Nursing Interventions for Pulmonary Edema
- Monitor ABCs – Airway, Breathing, Circulation.
- Placement of the patient in a high flower position can help improve oxygenation.
- The blood vessels and air passages should be flushed out to remove excess fluids and promote normal lung expansion.
- Monitor respiratory status every 15 minutes for signs of pulmonary edema.
- Make sure the patient gets sufficient amount of rest.
- Keep the patient hydrated to avoid dehydration and possible pulmonary edema.
- Provide nutritious food as ordered to prevent malnutrition which may increase the risk for pulmonary edema.
- Suction catheters need to be cleaned thoroughly and stored in a safe place when not in use.
Treatment for Pulmonary Edema
Treat the underlying cause.
Use diuretic and bronchodilator therapy to reduce fluid accumulation in the lungs.
In mild cases, supportive care alone is enough. Refeeding patients with low blood albumin, correcting electrolyte imbalance, and administering oxygen are important treatments for pulmonary edema caused by malnutrition.
If complications arise, it is important to consult with an inter-professional collaborative team to guide the management of the patient.
In Hospital :
- Assess breathing and vital signs every 15 minutes.
- Monitor for changes in oxygen saturation or dyspnea (difficulty breathing).
- Provide pain relief medications. Stop pain medication when fluid is reduced by half, then restart if needed.
- If the patient developed pulmonary edema during hospitalization, the following should be done:
- Continue to monitor breathing and oxygenation.
- Assess the patient for risk factors for ventilator use (i.e., cardiac, respiratory, and neurologic conditions).
- Reduce fluids by creating a dry environment.
- Monitor fluid volume status daily; replace lost fluids if necessary.
- Ensure that non-invasive positive pressure ventilation or bi-level positive airway pressure ventilation for hypoxemic patients.
- Continue to monitor breathing and oxygen levels.
- Maintain a dry environment – avoid baths; limit fluid intake; use stool softeners and laxatives; do not put long-term bed wetter/incontinent in diapers or soiled clothes.
- Consult with a physician to determine if the medication can be discontinued depending on the degree of recovery.
- Provide patient and family education about pulmonary edema, its risk factors, treatment options, and prognosis.
Discharge planning involves the following:
Ensure that proper medical follow-up is established before discharge home or into an assisted living facility.
Family support – involve/refer to social services if needed.
Inform patient and family about discharge planning, aftercare, medications, and follow-up appointments(phone call or home visit).