Pulmonary Edema, Acute

Pulmonary Edema, Acute

(Pulmonary Congestion)

Is a pathologic state in which there is an abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs. This Fluid causes impaired gas exchange by interfering with diffusion between the pulmonary capillaries and the alveoli. It is commonly caused by left ventricular failure, altered capillary permeability of the lungs, ARDS, neoplasm, overhydration, and hypoalbumenemia. Acute pulmonary edema is considered a medical emergency.

Nursing Diagnosis

Impaired Gas Exchange

Related to:

Pulmonary-venous congestion

Alveolar-capillary membrane changes

Defining Characteristics

• Restlessness’
• Irritablity
• Pink, frothy sputum
• Hypercapia
• Hypoxia
• Cough
• Crackers
• Dyspnea
• Cyanosis

Expected Outcome

Patient exhibits signs and symptoms of improve ventilation and oxygenation, as evidence by:

• Normal ABGs
• O2 saturation >90%
• Decrease crakers, rales; clear breath sounds
• Relaxed, comfortable appearance

Assessment

1. Assess respiratory rate, dept; presence of shortness of breath; use of accessory muscles, in the early

stages there is mild increase in respiratory rate

2. Assess breath sounds in all lung fields, presence of rales, wheezes. Bubbling rales. Wheezes, and

rhonchi are easily heard over the entire chest reflecting fluid-filled airways.

3. Asses secretions, Frothy, blood tinged sputum

4. Obtain and monitor ABGs

5. Monitor O2 saturation with pulse Oximeter

6. Monitor mental status. Hypoxia is reflected in restlessness and irritability

7. Chest Xray

Nursing Intervention

1. Position the Patient; high Fowler’s position for optimal beathing pattern. Upright position to reduce

venous filling.

2. Assist with coughing or suctioning prn

3. Provide O2 as ordered by the physician to maintain Po2 at acceptable level

4. Administered medication as ordered.

Nitrates: reduced preload

Morphine Sulfate: Reduced preload by vasodilation, decrease pulmonary rate

Naloxone (Narcan): Keep available at bedside in case of morphine overdose

Diuretics: Reduced intravascular fluid volume

Aminophylline: Dilate bronchioles, Dilate venous vessels. Cardiac stumlant, Patient may be

observed for cardiac dysrhytmias.