Nursing Care Plan for Pulmonary Edema

Pulmonary edema is a condition of pathology in the extravascular fluid accumulation in the lungs. The disorder is caused by two circumstances, namely:

• Increased hydrostatic pressure.
• Increased pulmonary capillary permaebilitas.

Symptoms and Signs

• Jugular venous distention, Increased central venous pressure.
• Increased blood pressure, pulse full, strong.
• Slowing time emptying the veins hands.
• Peripheral and periorbital edema.
• Ascites, pleural effusion, acute pulmonary edema (dyspnea, tachypnea, crackles wet throughout the lung fields)
• Rapid weight gain: the addition of 2% = excess light, the addition of 5% = excess medium, addition of 8% = overweight.

Assessment for Pulmonary Edema

1. Pulmonary System

• Subjective: shortness of breath, chest distress, whiny.
• Objective: nostril breathing, hyperventilation, cough (productive / nonproductive), sputum lot, use a respirator muscles, diaphragm and abdominal breathing increases, increased respiratory rate, audible stridor, crackles in the lung fields.

2. Cardiovascular System

• Subjective: headache.
• Objective: increased pulse rate, blood vessel vasoconstriction, decreased blood quality, irregular heartbeat, extra heart sounds.

3. NeuroSensory System

• Subjective: restlessness, loss of consciousness, seizures.
• Objective: GCS decreased, reflexes decreased / abnormal, lethargy.

4. Musculoskeletal System

• Subjective: weak, tired.
• Objective: decreased muscle tone, muscle pain / normal, retraction of the lung and respiratory muscle use accessories.

5. Integumentary System

• Subjective: -
• Objective: pale skin, cyanosis, turgor decreases (due to dehydration secondary), a lot of sweat, skin temperature increases, redness.

6. Genitourinary system

• Objective: decreased urine production / normal.

7. Digestive System

• Subjective: nausea, sometimes vomiting.
• Objective: normal stool consistency / diarrhea.

Nursing Diagnosis for Pulmonary Edema

1. Ineffective airway clearance r / t intubation, ventilation, process of disease, weakness and fatigue.
2. Impaired gas exchange r / t secretion restrained, disease processes, or ventilator setting is not appropriate.
3. Impaired verbal communication r / t endotracheal tube installation.
4. Risk for infection r / t endotracheal tube installation.