Nursing 211

N211: Health Differences Across the Lifespan I Pulmonary Edema is the presence of abnormal accumulation of fluid in the alveoli and interstitial spaces of the lungs. The collected fluid interferes with oxygen/carbon dioxide exchange in the lungs and is an emergency. Pulmonary edema is a complication of left sided heart failure. Increased pressure in the capillaries of the lungs causes acute transudation of fluid; creating impaired oxygenation and hypoxia. The causes of pulmonary edema include ARDS, drug overdose (heroin, barbiturates, and morphine), heart failure, central nervous system injury, hypertension, MI, fluid overload, and smoke inhalation. Nursing Assessment Includes dyspnea, orthopnea, tachypnea, blood-tinged, frothy sputum, agitation, restlessness, intense fear. Diagnostics Includes hemodynamic monitoring of arterial blood pressure, pulmonary artery (PA) and pulmonary capillary wedge pressure (PCWP). Testing includes ABGs, pulse oximetry, chest x-ray, EKG, echocardiography, blood cultures if systemic infection is suspected, CBC with differential, serum chemistries and cardiac enzymes. Nursing Diagnosis • Ineffective airway clearance related to pressure if excessive fluid in the airways • Impaired gas exchange related to accumulation of excess fluid in the pulmonary vascular bed • Fluid volume excess related to fluid retention • Decreased cardiac output related to weakened heart muscles • Anxiety related to feelings of suffocation secondary to hypoxia Nursing Int rv ntions Include as assist patient to assume a position of comfort such as Semi-fowler’s with feet and legs in a dependent position to enhance lung expansion and pooling of blood in the extremities which decreases venous return. Administer oxygen as ordered. Administer morphine to slow respirations, reduce anxiety, and dilate pulmonary systemic vessels, which decreased venous return. Prepare for endotracheal intubation and mechanical ventilation with positive end expiratory pressure (PEEP). PEEP aids in reduction of venous return and lowering pulmonary capillary pressure. The result is improved oxygenation. Monitor ABGs and pulse oximetry. Nursing interventions include assessing cardiovascular status to detect changes in fluid balance, tachycardia, S3 heart sound, hypotension, increased respiratory rate and crackles which can indicate increases fluid volume. Promote a calm environment. Explain all procedures to the client and family. Medicatio s

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