Pulmonary edema, characterized by the abnormal accumulation of fluid in the lung alveoli, significantly impairs gas exchange and presents a critical respiratory challenge. This condition is broadly classified into cardiogenic pulmonary edema, stemming from cardiac dysfunction, and noncardiogenic pulmonary edema, arising from lung injury or systemic illnesses. Understanding the nuances of each type is paramount for effective nursing management and accurate Acute Pulmonary Edema Nursing Diagnosis.
Cardiogenic pulmonary edema occurs when the left ventricle fails to efficiently pump blood received from the pulmonary circulation. This hemodynamic compromise leads to elevated pulmonary capillary hydrostatic pressure, forcing fluid into the alveoli. Conditions such as acute myocarditis, congestive heart failure, myocardial infarction, and cardiac arrhythmias are frequently implicated.
Noncardiogenic pulmonary edema, conversely, is triggered by increased pulmonary vascular permeability due to lung injury or systemic inflammatory responses. This disrupts the alveolar-capillary barrier, allowing protein-rich fluid to leak into the interstitial and alveolar spaces. Acute respiratory distress syndrome (ARDS), pneumonia, inhalation injuries, sepsis, shock, acute pancreatitis, and rapid ascent to high altitudes are common noncardiogenic etiologies.
Effective nursing care is indispensable for the early detection, accurate diagnosis, and timely management of pulmonary edema. This article delves into the essential aspects of acute pulmonary edema nursing diagnosis, encompassing comprehensive assessment strategies, relevant nursing diagnoses, targeted interventions, and meticulous care planning, ensuring optimal patient outcomes.
Nursing Assessment for Acute Pulmonary Edema
A thorough nursing assessment is the cornerstone of identifying and managing acute pulmonary edema. This process involves gathering subjective and objective data, reviewing the patient’s health history, conducting a meticulous physical examination, and interpreting relevant diagnostic findings.
Review of Health History
A detailed health history is crucial in discerning the underlying cause and risk factors associated with pulmonary edema.
1. Evaluate General Symptom Presentation: Distinguishing between cardiogenic and noncardiogenic pulmonary edema often begins with symptom analysis:
-
Shared Indicators (Cardiogenic and Noncardiogenic):
- Tachypnea: Increased respiratory rate as the body attempts to compensate for impaired oxygenation.
- Rales or Crackles: Adventitious lung sounds heard during auscultation, indicating fluid in the alveoli.
- Progressive Dyspnea: Worsening shortness of breath, a hallmark symptom of pulmonary edema.
-
Cardiogenic Pulmonary Edema-Specific Signs:
- Hypoxemia due to Fluid Overload: Reduced blood oxygen levels directly related to fluid accumulation.
- Cough with Frothy Pink Sputum: A characteristic sign of alveolar fluid mixed with air and potentially some blood.
- S3 Gallop or Murmurs: Abnormal heart sounds indicative of underlying cardiac dysfunction.
- Elevated Jugular Vein Pressure (JVP): Distention of neck veins reflecting increased central venous pressure due to heart failure.
- Peripheral Edema: Swelling in extremities due to fluid retention and circulatory compromise.
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Noncardiogenic Pulmonary Edema-Specific Signs:
- Infection Symptoms (e.g., Fever): Suggesting infectious etiologies like pneumonia or sepsis.
- Productive Cough: May be present, but sputum is typically not frothy pink unless there’s concurrent alveolar hemorrhage.
- Dyspnea: Prominent, but other cardiogenic signs may be absent.
2. Cardiovascular History Review: Identify pre-existing heart conditions that predispose to cardiogenic pulmonary edema. Congestive heart failure remains the most common culprit. Other cardiac risk factors include:
- Arrhythmias (e.g., atrial fibrillation)
- Cardiomyopathy
- Myocardial infarction
- Hypertension
- Myocarditis
- Pericardial effusion
- Heart valve defects
- Coronary artery disease
3. Medical History Exploration: Uncover noncardiac conditions that can trigger noncardiogenic pulmonary edema:
- Acute respiratory distress syndrome (ARDS)
- Lung infections (pneumonia)
- Pulmonary embolism
- Sepsis
- Trauma
- Pancreatitis
- Multiple blood transfusions (Transfusion-Associated Circulatory Overload – TACO)
- Inhalation injuries
Furthermore, consider systemic conditions that can disrupt fluid balance and contribute to edema formation:
- Kidney disease
- Thyroid disease
- Liver conditions
- Hemochromatosis (excessive iron buildup)
- Amyloidosis (protein buildup)
4. Medication Reconciliation: Certain medications can induce pulmonary edema. Inquire about:
- Aspirin
- Illicit drugs (heroin, cocaine)
- Other potential drug-induced causes
5. Smoking History Assessment: Smoking, including tobacco and fire-related smoke inhalation, damages the alveolar-capillary membrane, increasing permeability and fluid leakage.
6. Lifestyle and Occupational History: High-altitude pulmonary edema (HAPE) risk is elevated in individuals who ascend rapidly to high altitudes without acclimatization, such as:
- Mountain climbers
- Hikers
- Skiers
7. Drowning Incident Inquiry: Near-drowning experiences can disrupt the alveolar-capillary membrane, increasing permeability and fluid shifts, predisposing to pulmonary edema.
Physical Assessment
A focused physical assessment complements the health history, providing objective data to support the acute pulmonary edema nursing diagnosis.
1. Assess the ABCs (Airway, Breathing, Circulation): Prioritize assessment of airway patency, breathing effectiveness, and circulatory status. Pulmonary edema can rapidly escalate to a life-threatening emergency.
2. Vital Sign Monitoring: Frequent vital sign assessment is critical:
- Blood Pressure: May be elevated, normal, or decreased depending on the underlying cause and stage of pulmonary edema.
- Heart Rate: Tachycardia (rapid heart rate) is common as the heart attempts to compensate for reduced oxygen delivery.
- Respiratory Rate: Tachypnea (increased respiratory rate) is a key indicator of respiratory distress.
- Oxygen Saturation (SpO2): Decreased SpO2 reflects hypoxemia.
3. Respiratory Status Evaluation: Focus on respiratory parameters:
- Progressive Dyspnea: Note the severity and progression of shortness of breath.
- Tachypnea: Observe for rapid, shallow breathing.
- Auscultation for Rales/Crackles: Listen for these characteristic lung sounds, which may be fine or coarse and localized or diffuse.
4. Cardiovascular Status Examination: Assess for signs of cardiac involvement:
- Peripheral Edema: Evaluate for edema in the extremities, noting location and severity.
- Jugular Vein Pressure (JVP): Assess for jugular venous distention, indicative of increased central venous pressure.
- Heart Sounds Auscultation: Listen for S3 or S4 gallops, murmurs, or other abnormal heart sounds.
- Cough and Sputum: Note the presence, nature, and characteristics of cough and sputum production.
5. General Appearance Observation: Patients with pulmonary edema often exhibit:
- Restlessness and Anxiety: Driven by dyspnea and the sensation of suffocation.
6. Blood Transfusion History Review: Inquire about recent blood transfusions and any prior transfusion reactions, as rapid or large-volume transfusions can trigger Transfusion-Associated Circulatory Overload (TACO) and noncardiogenic pulmonary edema.
Diagnostic Procedures
Diagnostic procedures are essential to confirm the diagnosis of pulmonary edema, identify the underlying etiology, and guide treatment strategies.
1. Electrocardiogram (ECG): Obtain an ECG promptly to:
- Detect myocardial infarction as a potential cause.
- Identify cardiac arrhythmias that may contribute to or result from pulmonary edema.
2. Laboratory Testing: Various lab tests aid in determining the underlying cause:
-
Systemic Etiologies:
- Complete Blood Count (CBC): To assess for infection (elevated WBCs), anemia, or other hematologic abnormalities.
- Metabolic Panel: To evaluate electrolyte balance, renal function, and liver function.
- Kidney Function Tests (e.g., BUN, creatinine): To assess for kidney disease as a contributing factor.
- Thyroid Function Tests (e.g., TSH, T4): To rule out thyroid disorders.
-
Cardiac Etiologies:
- Brain Natriuretic Peptide (BNP): Elevated levels strongly suggest heart failure as the cause of pulmonary edema.
- Troponin: To assess for myocardial injury, particularly in cases of suspected myocardial infarction.
- Serum Albumin: Low albumin levels can contribute to fluid shifts and edema formation.
-
Toxic Ingestion Suspicion:
- Serum Electrolyte Levels: To identify electrolyte imbalances caused by toxins.
- Renal Function Tests: To assess for toxin-induced kidney damage.
- Serum Osmolarity: To evaluate fluid balance and possible toxic effects.
- Toxicology Screening: To detect specific ingested toxins.
-
Acute Pancreatitis Suspicion:
- Lipase and Amylase Levels: Elevated levels indicate pancreatic inflammation.
3. Chest X-ray: A crucial imaging modality for confirming pulmonary edema and differentiating between cardiogenic and noncardiogenic types:
-
Cardiogenic Pulmonary Edema Features:
- Pleural Effusions: Fluid accumulation in the pleural space.
- Kerley B Septal Lines: Short, horizontal lines in the periphery of the lungs, indicating interstitial edema.
- Peribronchial Cuffing: Thickening of bronchial walls due to fluid accumulation.
- Central Edema: Fluid distribution predominantly in the central lung regions.
- Increased Heart Size (Cardiomegaly): Suggestive of underlying heart failure.
-
Noncardiogenic Pulmonary Edema Features:
- Patchy and Peripheral Edema: Fluid distribution more scattered and in the outer lung zones.
- Air Bronchograms: Air-filled bronchioles visible against the background of alveolar fluid.
- Ground-Glass Opacities/Consolidation: Hazy or dense areas indicating alveolar filling.
4. Arterial Blood Gases (ABGs): Essential for assessing:
- Hypoxemia: Low blood oxygen levels.
- Hypercapnia: Elevated blood carbon dioxide levels, indicating ventilatory failure in severe cases.
5. Echocardiography: To evaluate cardiac structure and function:
- Identify valvular defects.
- Assess left ventricular systolic dysfunction, a hallmark of heart failure.
6. Advanced Diagnostic Techniques: Modern techniques can provide more detailed and earlier diagnoses:
- Lung Ultrasound: A noninvasive, radiation-free method to detect extravascular lung water accumulation, often preceding clinical symptoms.
- Pulmonary Artery Catheterization (Swan-Ganz Catheter): An invasive “gold standard” for hemodynamically complex cases, directly measuring:
- Systemic Vascular Resistance (SVR)
- Cardiac Output (CO)
- Pulmonary Artery Wedge Pressure (PAWP) – to differentiate between cardiogenic and noncardiogenic causes.
- Transpulmonary Thermodilution: An invasive technique used in patients undergoing major thoracic, cardiac, or vascular surgeries, providing continuous hemodynamic monitoring.
Chest X-ray demonstrating bilateral pulmonary edema, showcasing the characteristic “batwing” appearance centrally and Kerley B lines peripherally, indicative of fluid overload and interstitial edema, crucial for acute pulmonary edema nursing diagnosis.
Nursing Interventions for Acute Pulmonary Edema
Nursing interventions are critical for managing acute pulmonary edema, alleviating symptoms, addressing the underlying cause, and preventing recurrence.
Managing Acute Pulmonary Edema
The primary goals of nursing interventions are to stabilize the patient, improve oxygenation and ventilation, and treat the underlying cause of pulmonary edema.
1. Address the Underlying Etiology: Treatment must target the root cause of pulmonary edema. This may involve:
- Managing heart failure with medications and lifestyle modifications.
- Treating infections (e.g., pneumonia, sepsis) with antibiotics.
- Managing ARDS with supportive care and mechanical ventilation.
- Addressing other underlying medical conditions.
2. Administer Supplemental Oxygen: Oxygen therapy is the initial and crucial intervention.
- Nasal Cannula or Mask: Start with supplemental oxygen via nasal cannula or face mask to alleviate dyspnea and improve oxygen saturation.
- Continuous Oxygen Saturation Monitoring: Closely monitor SpO2 and adjust oxygen delivery as needed.
3. Enhance Ventilation: If oxygenation remains inadequate despite supplemental oxygen, ventilatory support becomes necessary.
- Non-Invasive Ventilation (NIV): Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP) can improve oxygenation and reduce the work of breathing, often preventing the need for intubation.
- Invasive Mechanical Ventilation: May be required in severe cases of respiratory failure to provide adequate oxygenation and ventilation.
4. Pharmacological Management: Medications play a vital role in managing pulmonary edema. Common drug classes include:
- Diuretics (e.g., Furosemide): Reduce fluid volume overload by promoting diuresis, alleviating pulmonary congestion.
- Vasodilators (e.g., Nitroglycerin):
- Reduce preload and afterload, decreasing cardiac workload and pulmonary congestion.
- Calcium Channel Blockers (e.g., Clevidipine, Nifedipine): May be used, especially nifedipine for prophylaxis and treatment of HAPE.
- Inotropes (e.g., Dobutamine, Dopamine): Enhance cardiac contractility and improve cardiac output in cardiogenic pulmonary edema with reduced ejection fraction.
- Morphine: Can reduce anxiety and dyspnea, and may have some vasodilatory effects; use cautiously due to potential respiratory depression.
5. High-Altitude Pulmonary Edema (HAPE) Specific Treatment: In addition to general measures:
- Oxygen Administration: First-line treatment for HAPE.
- Portable Hyperbaric Chamber: If available, simulates descent to a lower altitude, reducing pulmonary artery pressure.
- Descent to Lower Altitude: The definitive treatment for HAPE; immediate descent is crucial.
Preventing Fluid Accumulation in the Lungs
Preventive strategies are essential to minimize the risk of pulmonary edema development or recurrence.
1. Comorbidity Management: Effective management of underlying conditions is paramount:
- Diabetes Mellitus: Strict blood glucose control.
- Hypertension: Maintain blood pressure within target ranges.
- Heart Failure: Adherence to medication regimens, dietary restrictions (sodium and fluid), and lifestyle modifications.
- Encourage regular exercise for cardiovascular health and weight management.
2. Risk Factor Avoidance: Lifestyle modifications can significantly reduce risk:
- Avoidance of Illicit Drugs and Excessive Alcohol.
- Gradual Ascent to High Altitudes: For individuals traveling to high altitudes, allowing for acclimatization.
- Consider prophylactic medications (acetazolamide or nifedipine) for high-risk individuals planning rapid ascent.
3. Smoking Cessation Promotion: Educate patients about the detrimental effects of smoking on lung health and pulmonary edema risk. Offer smoking cessation resources and support.
4. Heart-Healthy Meal Plan Guidance: Promote a balanced diet rich in:
- Whole grains
- Fruits
- Vegetables
- Lean proteins
- Limit added sugars, salt, saturated and trans fats.
5. Blood Transfusion Precautions: Minimize transfusion-related risks:
- Transfuse blood products judiciously, avoiding unnecessary transfusions.
- Monitor closely for transfusion reactions, particularly Transfusion-Related Acute Lung Injury (TRALI) and Transfusion-Associated Circulatory Overload (TACO).
Nursing Care Plans for Acute Pulmonary Edema
Nursing care plans provide a structured framework for delivering holistic and individualized care to patients with acute pulmonary edema. Common nursing diagnoses and associated care plans include:
Anxiety
Anxiety is a frequent psychological response to pulmonary edema, triggered by dyspnea, fear of respiratory distress, and the perceived threat to life.
Nursing Diagnosis: Anxiety
Related to:
- Change in health status
- Fear of respiratory instability
- Physiological effects of hypoxemia and hypercapnia
As evidenced by:
- Verbalization of apprehension, fear, and health concerns
- Expressed distress
- Increased tension and restlessness
- Gasping for air, hyperventilation
- Dizziness, lightheadedness
- Diaphoresis (excessive sweating)
Expected Outcomes:
- Patient will verbalize reduced feelings of anxiety related to their respiratory status.
- Patient will demonstrate a calmer demeanor and relaxed facial expression.
- Patient will report feeling more in control of their breathing.
Nursing Assessments:
- Assess Anxiety Level: Utilize anxiety scales or questionnaires to quantify anxiety severity, especially in patients with underlying cardiac conditions where anxiety can exacerbate pulmonary edema.
- Monitor for Hyperventilation Signs: Observe for rapid, shallow breathing, dizziness, and paresthesias (tingling sensations) indicative of hyperventilation secondary to anxiety.
- Observe Nonverbal Anxiety Cues: Monitor for restlessness, irritability, decreased cooperation, and preoccupation, which can be subtle indicators of escalating anxiety.
Nursing Interventions:
- Provide Patient Education: Explain the treatment plan, prognosis, and mechanisms of ventilation to reduce uncertainty and fear.
- Involve Family and Support Systems: Encourage family presence and support to provide reassurance and distraction.
- Teach Breathing Techniques: Instruct and coach the patient in slow, deep breathing, diaphragmatic breathing, or pursed-lip breathing to promote relaxation and improve breathing control.
- Administer Anxiolytics as Prescribed: Administer medications like morphine (cautiously for dyspnea and anxiety) or other anxiolytics as ordered, while carefully monitoring respiratory status.
Impaired Gas Exchange
Impaired gas exchange is a primary physiological consequence of pulmonary edema, resulting from alveolar fluid accumulation hindering oxygen and carbon dioxide diffusion.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Alveolar-capillary membrane fluid accumulation
- Fluid shifts within lung compartments
- Cardiac conditions (heart failure)
- Noncardiogenic conditions (pneumonia, ARDS)
- High altitude exposure
As evidenced by:
- Irregular breathing pattern, changes in rate and depth of respirations
- Dyspnea, restlessness, irritability, confusion
- Productive cough, use of accessory muscles
- Abnormal ABGs (hypoxemia, hypercapnia)
- Abnormal chest X-ray findings
- Adventitious breath sounds (rales, crackles)
Expected Outcomes:
- Patient will achieve and maintain oxygen saturation within the normal range (95-100%).
- Patient will exhibit clear breath sounds bilaterally.
- Patient will demonstrate improved arterial blood gas values.
Nursing Assessments:
- Identify Causative Factors: Differentiate between cardiogenic and noncardiogenic causes of impaired gas exchange to guide appropriate treatment.
- Monitor Respiratory Status: Frequently assess respiratory rate, depth, pattern, and oxygen saturation, recognizing that pulmonary edema can progress rapidly.
- Auscultate Breath Sounds: Identify and document adventitious breath sounds, noting the location and characteristics of crackles, wheezing, or bubbling. Differentiating fine crackles (cardiogenic) from coarser crackles can be diagnostically helpful.
- Review Diagnostic Imaging: Analyze chest X-ray findings for hallmarks of cardiogenic (central edema, pleural effusions, cardiomegaly) and noncardiogenic (patchy, peripheral edema, ground-glass opacities) pulmonary edema.
Nursing Interventions:
- Optimize Patient Positioning: Elevate the head of the bed (high Fowler’s position) or position the patient on their side to promote lung expansion and drainage of secretions.
- Administer Supplemental Oxygen: Apply oxygen therapy to maintain adequate oxygen saturation, titrating delivery based on patient response and ABG results.
- Monitor Arterial Blood Gases (ABGs): Regularly assess ABGs to evaluate the effectiveness of oxygen therapy and ventilation and detect worsening respiratory status.
- Administer Diuretics as Prescribed: Administer diuretics (e.g., furosemide) cautiously, monitoring fluid balance, electrolytes, and renal function.
- Administer Vasodilators as Prescribed: Use vasodilators (e.g., IV nitroglycerin) as adjuvant therapy to diuretics to reduce preload and pulmonary congestion.
- Administer Prophylactic Medications for HAPE: For individuals at risk for HAPE, administer prophylactic nifedipine as ordered, especially with rapid ascent or recent respiratory infection.
- Administer Inotropes as Prescribed: In cases of cardiogenic pulmonary edema with tissue hypoperfusion, administer inotropes (e.g., dobutamine, dopamine) to enhance cardiac output.
Impaired Spontaneous Ventilation
Impaired spontaneous ventilation occurs when the patient’s respiratory effort is insufficient to maintain adequate oxygenation and carbon dioxide removal, often due to respiratory muscle fatigue and uncontrolled secretions.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Respiratory muscle fatigue
- Anxiety
- Impaired inspiration and expiration mechanisms in pulmonary edema
- Uncontrolled secretions
As evidenced by:
- Dyspnea, restlessness
- Tachycardia
- Accessory muscle use
- Shallow breathing, apneic periods
- Mental confusion
Expected Outcomes:
- Patient will demonstrate a regular respiratory rate and rhythm.
- Patient will maintain oxygen saturation within the normal range (95-100%).
- Patient will exhibit clear breath sounds.
- If mechanically ventilated, patient will progress towards ventilator weaning.
Nursing Assessments:
- Monitor for Impending Respiratory Failure: Closely observe for signs of worsening ventilation, such as shallow, apneic breathing (respiratory muscle fatigue), and altered mental status (confusion).
- Observe Respiratory Symptoms: Assess for irregular breathing, gasping for air, and increased use of accessory muscles, indicating escalating respiratory distress.
- Assess Arterial Blood Gases (ABGs): Evaluate ABGs to determine the degree of hypoxemia and hypercapnia, guiding the need for ventilatory support.
Nursing Interventions:
- Ensure Endotracheal Intubation and Placement: Assist with endotracheal intubation if indicated and confirm proper tube placement through auscultation, chest X-ray, and monitoring for symmetric chest expansion.
- Suction Airway as Needed: Maintain airway patency by suctioning secretions as needed, using sterile technique and appropriate suction pressure and duration.
- Monitor Mechanical Ventilator Settings: Frequently monitor ventilator settings (FiO2, tidal volume, PEEP, respiratory rate) and collaborate with respiratory therapists to optimize settings.
- Consult with Respiratory Therapists: Collaborate with respiratory therapists for medication administration, respiratory treatments, ventilator management, and weaning strategies.
Ineffective Airway Clearance
Ineffective airway clearance arises from the accumulation of fluid, secretions, and potential bronchospasm in pulmonary edema, obstructing airflow and impairing oxygenation.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Fluid in alveoli
- Increased mucus production
- Weak cough reflex
- Bronchospasm
As evidenced by:
- Dyspnea, hypoxemia
- Anxiety, restlessness
- Rales/crackles on auscultation
- Productive cough (potentially with frothy pink sputum in cardiogenic edema)
- Adventitious breath sounds (wheezing)
Expected Outcomes:
- Patient will maintain a patent airway, free of excessive secretions.
- Patient will exhibit clear lung sounds or improved breath sounds.
- Patient will effectively expectorate secretions.
Nursing Assessments:
- Assess Respiratory Rate, Pattern, Depth, and Quality: Changes in respiratory characteristics (tachypnea, labored breathing) indicate respiratory compromise.
- Monitor Breath Sounds: Auscultate for and document breath sounds, noting the presence, location, and characteristics of crackles, wheezing, or diminished breath sounds.
- Assess Cough Effectiveness and Sputum Production: Evaluate the patient’s ability to cough effectively and note the characteristics of sputum (color, consistency, amount).
Nursing Interventions:
- Initiate Oxygen Therapy: Begin with supplemental oxygen to address hypoxemia, escalating to noninvasive or invasive ventilation if needed.
- Elevate Head of Bed: Position the patient in a high Fowler’s position to promote lung expansion and facilitate secretion drainage.
- Administer Diuretics: Administer diuretics to reduce fluid overload and pulmonary congestion, improving airway clearance.
- Utilize Vasodilators: Administer vasodilators to reduce pulmonary congestion and improve cardiac function, indirectly aiding airway clearance.
- Encourage Coughing and Deep Breathing Exercises: Instruct and assist the patient with effective coughing and deep breathing techniques to mobilize and expectorate secretions.
- Consider Chest Physiotherapy: If appropriate and not contraindicated, chest physiotherapy (e.g., postural drainage, percussion, vibration) may be used to facilitate secretion removal.
- Suction Airway as Needed: Suction the airway to remove secretions if the patient is unable to clear their airway effectively through coughing.
Ineffective Breathing Pattern
Ineffective breathing pattern in pulmonary edema results from fluid accumulation and underlying physiological disturbances, leading to inadequate ventilation and oxygenation.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Cardiac conditions (CHF, MI, CAD)
- High altitudes (HAPE)
- Lung infections (pneumonia)
- Anxiety
- Fluid buildup in the lungs
As evidenced by:
- Dyspnea, tachypnea
- Hypoxemia
- Use of accessory muscles
- Altered chest excursion
- Restlessness, anxiety
Expected Outcomes:
- Patient will report a subjective improvement in breathing comfort.
- Patient will demonstrate a respiratory rate within the normal range for their age and condition.
- Patient will achieve and maintain ABGs within acceptable limits.
Nursing Assessments:
- Monitor Respiratory Rate and Pattern: Assess for tachypnea, labored breathing, shallow respirations, and irregular breathing patterns.
- Observe for Restlessness and Anxiety: Recognize that anxiety can exacerbate ineffective breathing patterns and respiratory distress.
- Evaluate Diagnostic Tests: Review chest X-rays, CT scans, and echocardiography for evidence of pulmonary edema and underlying cardiac conditions.
Nursing Interventions:
- Administer Oxygen as Prescribed: Provide supplemental oxygen immediately to alleviate dyspnea and prevent hypoxemia.
- Continuously Monitor SpO2: Utilize continuous pulse oximetry to monitor oxygen saturation and detect desaturation promptly.
- Provide Emotional Support: Offer reassurance and a calm environment to reduce anxiety and oxygen demand, especially during episodes of dyspnea.
- Monitor Hemodynamic Stability: Closely monitor for signs of acute respiratory distress syndrome or cardiac collapse (ventilatory failure, acidosis, hypotension), requiring immediate medical intervention.
- Optimize Patient Positioning: Elevate the head of the bed to promote lung expansion and improve breathing mechanics.
- Teach Relaxation Techniques: Instruct the patient in relaxation techniques to reduce anxiety and promote more effective breathing patterns.
References
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