4/28/23, 9:09 AM Pulmonary Edema Nursing Diagnosis & Care Plan | NurseTogether

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Pulmonary Edema Nursing

Diagnosis & Care Plan
Written by
Kathleen Salvador, MSN, RN

Reviewed by
Maegan Wagner, BSN, RN, CCM

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:

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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.

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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:

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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.

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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
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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

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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
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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.

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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

1. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide:
Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
2. National Center for Biotechnology Information. (2022). Pulmonary edema –
StatPearls – NCBI bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK557611/
3. Purvey, M., & Allen, G. (2017). Managing acute pulmonary oedema. Australian
Prescriber, 40(2), 59-63. https://doi.org/10.18773/austprescr.2017.013
4. Silvestri, L. A., Silvestri, A. E., & Grimm, J. (2022). Saunders comprehensive
review for the NCLEX-RN examination (9th ed.). Elsevier Inc.

Published on November 12, 2022

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Kathleen Salvador, MSN, RN

Kathleen Salvador is a registered nurse and a nurse educator holding a Master’s
degree. She has more than 10 years of clinical and teaching experience and worked
as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East. Her
nursing career has brought her through a variety of specializations, including
medical-surgical, emergency, outpatient, oncology, and long-term care.

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