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 broad categories of this condition.
Cardiogenic: Blood that enters through veins from the lung cannot be pumped out by the left ventricle of the heart. 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 ECG changes.
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 are in this category.
Signs of both cardiogenic and noncardiogenic pulmonary edema include:
- Tachypnea
- Abnormal lung sounds such as rales or crackles on 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
- Jugular venous pressure
- Peripheral edema
Signs of non-cardiogenic pulmonary edema include:
- Infection symptoms, such as fever
- Productive cough
- Acute respiratory distress syndrome
Auscultation of lung sounds will help determine cardiogenic from noncardiogenic pulmonary edema. Electrocardiograms (ECGs) can quickly assess heart-associated pulmonary edema, along with the evaluation of troponin and BNP levels.
The Nursing Process
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.
For earlier detection of pulmonary edema with impending respiratory distress, comprehensive assessment and monitoring by nurses is essential. Effective history-taking will identify complex comorbidities, medication nonadherence, and lifestyle risk factors that place the client at risk for pulmonary edema.
Nursing Care Plans Related to Pulmonary Edema
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
Impaired Gas Exchange 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.
Impaired Gas Exchange 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
Impaired Spontaneous Ventilation 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.
Impaired Spontaneous Ventilation 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.
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
Anxiety 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.
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.
References and Sources
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- National Center for Biotechnology Information. (2022). Pulmonary edema – StatPearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK557611/
- Purvey, M., & Allen, G. (2017). Managing acute pulmonary oedema. Australian Prescriber, 40(2), 59-63. https://doi.org/10.18773/austprescr.2017.013
- Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
