Nursing 2012

Nanda, Nursing Care Plan, Nursing Assessment, Nursing Diagnosis, Nursing Interventions

» » » » Nursing Care Plan for Pulmonary Edema

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.
Back To Top