Nursing Care Plan

Nursing Diagnosis for Pulmonary Edema

Nursing Diagnoses 2015-17:
Definitions and Classification
(NANDA Nursing Diagnoses)

Pulmonary edema is fluid accumulation in the lungs, which collects in air sacs. Pulmonary edema is an abnormal buildup of fluid in the air sacs of the lungs, which leads to shortness of breath. It leads to impaired gas exchange and may cause respiratory failure. It is due to either failure of the left ventricle of the heart to adequately remove blood from the pulmonary circulation ("cardiogenic pulmonary edema"), or an injury to the lung parenchyma or vasculature of the lung ("noncardiogenic pulmonary edema").

Treatment usually focuses on improving respiratory function and dealing with the source of the problem. It generally includes supplemental oxygen and medications. Acute pulmonary edema - the type that occurs suddenly - if a medical emergency. If treatment is prompt and adequate, pulmonary edema is rarely fatal.

Pulmonary edema may be caused either by direct damage to tissue, or a result of a heart or circulatory system malfunction. If pulmonary blood pressure is above 15 mmHg, pulmonary edema may occur.

Non-cardiogenic (not originating in the heart) causes of pulmonary edema:

  • Acute respiratory distress syndrome
  • Aspirin overdose
  • High altitude
  • Intracranial hemorrhage
  • Kidney failure
  • Methadone/heroin overdose
  • Pleural effusion - too much liquid around the lung is removed, causing it to expand too quickly
  • Pulmonary embolism
  • Severe seizures

Cardiogenic (originating in the heart) causes of pulmonary edema:
  • Congestive heart failure
  • Fluid overload, such as from kidney failure or intravenous therapy
  • Hypertensive crisis
  • Pericardial effusion with tamponade
  • Severe arrhythmias (tachycardia/fast heartbeat or bradycardia/slow heartbeat)
  • Severe heart attack with left ventricular failure

Symptoms of pulmonary edema may include:
  • Coughing up blood or bloody froth
  • Difficulty breathing when lying down (orthopnea) -- you may notice the need to sleep with your head propped up or use extra pillows
  • Feeling of "air hunger" or "drowning" (if this feeling wakes you from sleep and causes you to sit up and try to catch your breath, it's called "paroxysmal nocturnal dyspnea")
  • Grunting, gurgling, or wheezing sounds with breathing
  • Inability to speak in full sentences because of shortness of breath

Other symptoms may include:
  • Anxiety or restlessness
  • Decrease in level of alertness (consciousness)
  • Leg swelling
  • Pale skin
  • Sweating (excessive)

Nursing Diagnosis for Pulmonary Edema

1. Ineffective breathing pattern

related to: fatigue and breathing aids installation.

2. Impaired gas exchange

related to: distention of pulmonary capillaries.

3. Risk for infection

related to: the invasion of microorganisms area secondary to endotracheal tube installation.

4. Ineffective tissue perfusion

related to: decreased cardiac muscle contractility.

5. Risk for Injury / trauma

related to: anxiety secondary to the installation of breathing aids.

6. Anxiety

related to: the threat of biological integrity secondary to the actual installation of breathing aids.

7. Impaired verbal communication

related to: installation of endotracheal tube.

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