LARA, KIT B.

DISEASES

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BSNIII-A

SAINT LOUIS UNIVERSITY

School of Nursing
NCM 103 7:30-10:00 MW / 7:30-11:30 T

DEFINITION
defined as
abnormal
accumulation of
fluid in the lung
tissue and/or
alveolar space. It is
a severe, life
threatening
condition.

Is an excess of

PATHOPHYSIOLOGY
Pulmonary edema most commonly
occurs as a result of increased
microvascular pressure from
abnormal cardiac function. The
backup of blood into the pulmonary
vasculature resulting from
inadequate left ventricular function
causes an increased microvascular
pressure, and fluid begins to leak
into the interstitial
space and the alveoli. Other causes
of pulmonary edema are
hypervolemia or a sudden increase
in the intravascular pressure
in the lung. One example of this is
in the patient who has undergone
pneumonectomy. When one lung
has been removed, all
the cardiac output then goes to the
remaining lung. If the patients
fluid status is not monitored closely,
pulmonary edema
can quickly develop in the
postoperative period as the
patients
pulmonary vasculature attempts to
adapt. This type of pulmonary
edema is sometimes termed flash
pulmonary edema.
A second example is called reexpansion pulmonary edema. This
may be due to a rapid reinflation of
the lung after removal of air
from a pneumothorax or evacuation
of fluid from a large pleural effusion.

MANIFESTATIONS
The patient has
increasing respiratory
distress,
characterized by
dyspnea, air hunger,
and central cyanosis.
The patient is usually
very anxious and
often agitated. As the
fluid leaks into the
alveoli
and mixes with air, a
foam or froth is
formed. The patient
coughs up or the
nurse suctions out
these foamy, frothy,
and
often blood-tinged
secretions. The
patient has acute
respiratory
distress and may
become confused or
stuporous.

In certain disorders, fluid may

Usually the clinical

NURSING
DIAGNOSIS
Impaired Gas
Exchange
related to
excess fluid in
the lungs
Anxiety related to
sensation of
suffocation and
fear
Ineffective
breathing
pattern related
to increased
rate and
decreased
depth of
respirations
associated with
fear and anxiety
Decreased
cardiac output
related to
alterations in
rate, rhythm,
electrical
conduction

August 31, 2016

NURSING
INTERVENTION
REFERENCES
Assessed signs of
Smeltzer, S. C. O.,
Hinkle, J. L. ., Cheever,
hypoxia,
K. H. ., & Bare, B. G..
restlessness,
(2010). Brunner &
confusion,
Suddarth's textbook of
headache
medical-surgical
Supplementary
nursing (12th, North
oxygen with face
American Edition,
mask
Help patient relax to Combined Volume
edition.).Gas Exchange
promote
and Respiratory
oxygenation
Function (pp. 542-543)
Place the patient in
Philadelphia: Wolters
high fowlers
position to enhance Kluwer
Health/Lippincott
lung expansion
Carefully record the Williams & Wilkins.
time morphine is
given and
administered
Elevated the head
side or keep sitting
Monitor vital signs
IV line
Catheterization
Cardiac monitoring
ECG
Pulse oximetry

Swearingen, P. L.
(1994). Manual of
medical-surgical
nursing care: Nursing
interventions and
collaborative
management.(5th
Edition). Pulmonary
Edema (pp. 191195).St. Louis, Mo:
Mosby.
Smadi, Nader
(2009).Pulmonary
Edema. Retrieved from
https://www.scribd.com/
doc/11824252/Pulmona
ry-Edema

Ineffective

Assess breath sounds,

Smeltzer, S. C. O.,

fluids in the pleural

space. Normally
this space contains
a small amount of
extracellular fluid
that lubricates the
pleural surfaces.
Increased
production or
inadequate
removal of this fluid
results in
transudate or
exudate pleural
effusion. Empyema
is the accumulation
of pus and necrotic
tissue in the pleural
space.

3.

P
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H
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X

In pneumothorax,
air or gas
accumulates

SAINT LOUIS UNIVERSITY

School of Nursing
accumulate in the pleural space to
manifestations are
a point where it becomes clinically
those caused by the
evident. This almost always
underlying
has pathologic significance. The
disease. Pneumonia
effusion can be composed of a
causes fever, chills,
relatively clear fluid, or it can be
and pleuritic chest
bloody or purulent. An effusion of
pain,
clear fluid may be a transudate or
whereas a malignant
an exudate. A transudate
effusion may result in
(filtrates of plasma that move
dyspnea and
across intact capillary walls) occurs coughing.
when factors influencing the
The size of the

formation and reabsorption of

effusion and the
pleural fluid are altered, usually by
patients underlying
imbalances in hydrostatic or
lung disease
oncotic pressures. The finding of a
determine the severity
transudative effusion generally
of symptoms. A large
implies that the pleural membranes pleural effusion
are not diseased. The most
causes
common cause of a transudative
shortness of breath.
effusion is heart failure. An exudate When a small to
(extravasation of fluid into tissues
moderate pleural

or a cavity) usually results

effusion is
from inflammation by bacterial
present, dyspnea may
products or tumors involving the
be absent or only

pleural surfaces.
minimal. The severity
of
the symptoms
assessed depends on
the time course of the
development
of the pleural effusion
and the patients
underlying disease..

The pathophysiology of
pneumothorax varies according to
classification.

The signs and

symptoms associated
with pneumothorax

Breathing
respiratory rate, depth
Pattern RT
and rhythm
Decreased
Elevate head of the pt.
Lung Volume
Provide relaxing
Capacity as
environmentevidenced by
Administer
tachypnea,
supplemental oxygen
presence of
as ordered
crackles on
Assisst client in the use
both lung fields
of relaxation
and dyspnea
technique
Impaired Gas
Elevate the head of the
Exchange R/T
bed
Alveolar
Assist the client in
Capillary
learning and
Membrane
demonstrating
Changes and
appropriate safety
respiratory
measures
fatigue
Notice presence of
Secondary to
cyanosis
Pleural Effusion Encourage frequent
Activity
position changes and
intolerance
deep-breathing
Acute pain
exercises
Impaired skin
Administer prescribed
integrity related
medications as
to surgical
ordered
procedure
Maximize respiratory
Disturbed body
effort with good
image related to
posture and effective
insertion of
use if accessory
chest
muscles.
thoracotomy
Encourage adequate
rest periods between
activities

Hinkle, J. L. ., Cheever,
K. H. ., & Bare, B. G..
(2010). Brunner &
Suddarth's textbook of
medical-surgical
nursing (12th, North
American Edition,
Combined Volume
edition.).Gas Exchange
and Respiratory
Function (pp. 559-560)
Philadelphia: Wolters
Kluwer
Health/Lippincott
Williams & Wilkins.

Identify
Impaired gas
etiology/precipitating
exchange relat
factors, e.g.,
ed to
spontaneous

Smeltzer, S. C. O.,
Hinkle, J. L. ., Cheever,
K. H. ., & Bare, B. G..

Lippincott Williams &

Wilkins. (2012).
Medical-surgical
nursing made
incredibly easy!.
Philadelphia: (3rd
edtion). Common
Respiratory Disorder
(pp. 404-405).Wolters
Kluwer
Health/Lippincott
Williams & Wilkins.
Vera, Matt (2013). 6
Pleural Effusion
Nursing Care Plans.
Retrieved from
http://nurseslabs.com/6
-pleural-effusionnursing-care-plans/

between the
parietal and
visceral pleurae,
causing the lungs
to collapse. The
amount of air or
gas trapped
determines the
degree of lung
collapsed. In some
cases, venous
return to the heart
is impeded,
causing a lifethreatening
condition called
tension
pneumothorax

SAINT LOUIS UNIVERSITY

School of Nursing
1. A change in atmosphere
depend
Open pneumothorax results
on its size and cause.
when atmosphere air (positive
Pain is usually
pressure) flows directly into the
sudden and may be
pleural cavity (negative
pleuritic.
pressure). As the air pressure in The patient may have
the pleural cavity becomes
only minimal
positive, the lung collapse on
respiratory distress
the affected side. Lung collapse
with
leads to decreased total lung
slight chest discomfort
capacity. The patient then
develop V/Q imbalance, leading and tachypnea with a
small simple or
to hypoxia.
uncomplicated
2. Leaking lung
Closed pneumothorax occurs
pneumothorax. If the
when air enters the pleural
pneumothorax is large
space from within the lung,
and the
causing increased pleural
lung collapses totally,
pressure and preventing lung
acute respiratory
expansion during inspiration. It
distress occurs. The
may e called traumatic
patient
pneumothorax when blunt chest
is anxious, has
trauma causes lung tissue to
rupture, resulting in air leakage. dyspnea and air
hunger, has increased
use of
the accessory
muscles, and may
develop central
cyanosis from severe
hypoxemia. Severe
chest pain may occur,
accompanied by
tachypnea, decreased
movement of the
affected side of the
thorax,
a tympanic sound on
percussion of the

decreased
oxygen
diffusion
capacity
Anxiety related
to
breathlessnes
s and fear of
suffocation
Activity
Intolerance rel
ated to
insufficient
oxygen for
activity and
fatigue
Impaired
Verbal
Communicatio
n related to
dyspnea
Risk for
trauma

collapse, trauma,
malignancy,
infection,
complication of
mechanical
ventilation.
Evaluate respiratory
function, noting
rapid/shallow
respirations,
dyspnea, reports of
air hunger,
development of
cyanosis, changes
in vital signs.

Monitor for
synchronous
respiratory pattern
when using
mechanical
ventilator. Note
changes in airway
pressures.
Auscultate breath
sounds.
Note chest
excursion and
position of trachea.
Offered adequate
amount of fluids
Place on
semifowlers position
Adminiter oxygen
ASSESS
FREMITUS.
Check fluid level in
water-seal chamber;
maintain at
prescribed level.

(2010). Brunner &

Suddarth's textbook of
medical-surgical
nursing (12th, North
American Edition,
Combined Volume
edition.). Management
of Patients With Chest
and Lower Respiratory
Tract Disorders (pp.
561-562) Philadelphia:
Wolters Kluwer
Health/Lippincott
Williams & Wilkins.
Lippincott Williams &
Wilkins. (2012).
Medical-surgical
nursing made
incredibly easy!.
Philadelphia: (3rd
edtion). Respiratory
Disorder (pp. 406407).Wolters Kluwer
Health/Lippincott
Williams & Wilkins.
Vera, Matt (2014).3
Hemothorax and
Pneumothorax Nursing
Care Plans. Retrieved
from
http://nurseslabs.com/3
hemothoraxpneumotho
rax-nursing-care-plans/

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A form of
pulmonary edema
that leads to ARF,
acute respiratory
distress syndrome
(ARDS) results
from increased
permeability of the
alveolocapillary
membrane.
Although severs
ARDS may be
fatal, recovering
the patients may
have little or no
permanent lung
damge.

SAINT LOUIS UNIVERSITY

School of Nursing
chest wall, and
decreased
or absent breath
sounds and tactile
fremitus on the
affected side.
ARDS occurs as a result of an
Clinically, the acute
Ineffective
inflammatory trigger that initiates
phase of ARDS is
breathing
pattern
the release of cellular and chemical marked by a rapid
Impaired Gas
mediators, causing injury to the
onset
Exchange
alveolar capillary membrane. This
of severe dyspnea
Ineffective
results in leakage of fluid into
that usually occurs 12
airway
the alveolar interstitial spaces and
to 48 hours after the
clearance
alterations in the capillary bed.
initiating

Decreased
Severe ventilationperfusion
event. A characteristic
Cardiac Output
mismatching occurs in ARDS.
feature is arterial

Risk
for Injury
Alveoli collapse because of the
hypoxemia that
Excess Fluid
inflammatory infiltrate, blood,
does not respond to
Volume
fluid, and surfactant dysfunction.
supplemental oxygen.
Impaired Verbal
Small airways are narrowed
On chest x-ray, the
Communication
because
findings are similar to

Impaired
Physical
of interstitial fluid and bronchial
those seen with
Mobility
obstruction. The lung compliance
cardiogenic

Impaired
Skin
becomes markedly decreased (stiff pulmonary
Integrity
lungs), and the result is
edema and present
a characteristic decrease in
as bilateral infiltrates Sleep Pattern
Disturbance
functional residual capacity and
that quickly worsen.
Ineffective Coping
severe
The
hypoxemia. The blood returning to
the lung for gas exchange is
pumped through the nonventilated,
nonfunctioning areas of the
lung, causing a shunt to develop.
This means that blood is interfacing
with nonfunctioning alveoli and gas
exchange is markedly
impaired, resulting in severe,

acute lung injury then

progresses to
fibrosing alveolitis
with persistent,
severe hypoxemia.
The patient also has
increased alveolar
dead space
(ventilation to alveoli,

Temporary support of
the circulation
through the use of
mechanical devices
or pumps
Facilitation of regular
physical exercise to
maintain or advance
to a higher level of
fitness and health
Assisting with or
providing a balanced
dietary intake of
foods and fluids
: Collection and
analysis of patient
data to ensure
airway patency and
adequate gas
exchange
Administration of
oxygen and
monitoring of its
effectiveness
Assisst client in the
use of relaxation
technique
Elevate the head of
the bed
Assist the client in
learning and

Smeltzer, S. C. O.,
Hinkle, J. L. ., Cheever,
K. H. ., & Bare, B. G..
(2010). Brunner &
Suddarth's textbook of
medical-surgical
nursing (12th, North
American Edition,
Combined Volume
edition). Gas Exchange
and Respiratory
Function (pp. 5445545) Philadelphia:
Wolters Kluwer
Health/Lippincott
Williams & Wilkins.
Lippincott Williams &
Wilkins. (2012).
Medical-surgical
nursing made
incredibly easy!.
Philadelphia: (3rd
edtion). Respiratory
Disorders (pp.387388).Wolters Kluwer
Health/Lippincott
Williams & Wilkins.
Vera, Matt
(2012).Acute
Respiratory Distress
Syndrome. Retrieved
from
http://nurseslabs.com/a

refractory hypoxemia.

SAINT LOUIS UNIVERSITY

School of Nursing
but poor perfusion)
and decreased
pulmonary
compliance (stiff
lungs, which are
difficult
to ventilate). Clinically,
a patient is thought to
be in the recovery
phase if the
hypoxemia gradually
resolves, the chest xray improves,
and the lungs become
more compliant (Ware
& Matthay,
2000).

demonstrating
appropriate safety
measures
Notice presence of
cyanosis
Encourage frequent
position changes and
deep-breathing
exercises

cute-respiratorydistress-syndromeards-nursingmanagement/