Lecture Objectives
Upon completion of this lecture , the student will be able to:
 Be able to define Pulmonary Edema
 List 2 causes of Pulmonary Edema
 List 2 early and 2 late signs and symptoms of Pulmonary
Edema
 Describe 2 nursing interventions for caring for the patient
with a Pulmonary Embolism
 Identify 2 appropriate nursing diagnosis’ for patient’s with a
Pulmonary Embolism
Definition
Pulmonary edema refers to extravasation of fluid from the
pulmonary vasculature into the interstitium and alveoli of the lung.
Causes
 Increased capillary hydrostatic pressure
 Increased capillary permeability
 Decreased plasma oncotic pressure
 Lymphatic obstruction
Pathophysiology
The process of excess fluid accumulation in the lungs (Pulmonary
Edema) can be divided into three phases and occurs as follows:
 Stage 1 – Fluid transfer is increased into the lung interstitium
because lymphatic flow increases.
 Stage 2 – The capacity of the lymphatics to drain excess fluid
is overwhelmed and fluid begins to accumulate in the
interstitial space that surrounds the bronchioles and lung
vasculature.
 Stage 3 – As fluid continues to build up, increased pressure
causes it to track into the interstitial space around the alveoli
and disruption to the alveolar membrane occurs. Once this
occurs, gas exchange becomes impaired
Contributing Factors
 Infectious pulmonary edema (viral or bacterial)
 Inhaled toxins
 Circulating toxins
 Vasoactive substances (histamine, kinins)
 Disseminated intravascular coagulation
 Immunologic reactions
 Radiation pneumonia
 Uremia
 Near-drowning
 Aspiration pneumonia
Smoke inhalation
 Adult respiratory distress syndrome
Diagnosis
 Clinical findings on assessment
 ABG (PO2 low)
 Chest X-ray (may reveal fluid in/around lung space or
enlarged heart)
 Ultrasound (may reveal weak heart muscle or
leaking/narrow heart valves)
Symptoms (may develop slowly or acutely)
Early signs:
 Shortness of breath on exertion
 Sudden respiratory distress after sleep
 Difficulty breathing unless sitting upright
 Cough
Late signs:
 Labored and rapid breathing (causing respiratory alkalosis)
 Frothy or bloody sputum
 Tachycardia
 Cardiac Arrhythmias
 Cold, clammy, sweaty, bluish skin
 Decreased blood pressure
 Thready pulse
 Anxiety
 Pulse oximetry is commonly less than 85% and arterial Po2
of 30 to 50 mm Hg
Note: Non-specific symptoms may include weakness, lightheadedness, abdominal pain, malaise, wheezing and nausea.

Medical Treatment
 Medical treatment for Pulmonary Edema is considered an
emergency
 If possible, find and treat the underlying cause of Pulmonary
Edema
 O2 via nasal cannula or mask
 Intubation and mechanical ventilation may be necessary
 If intubated, pulmonary toilet, respiratory medication
treatments
 Furosemide (Lasix) – increases urine output and works
quickly to remove excess fluid from the body
 Morphine Sulfate – decreases anxiety and work load of
breathing.
Dobutamine – dilates the peripheral vessels to decrease work
load of left ventricle
 Aspirin – helps decrease blood viscosity for easy oxygen
delivery.
 If required, titrate inotropic and Vasoactive medications to
maintain contractility, preload and afterload parameters
Nursing Care and Management
Assessment:
 Identify type of artificial airway or supplemental oxygen
 If intubated, assess and document ET Tube size, position and
stability
 Check respirations for:
 Rate
 Depth
 Rhythm
 Symmetry
 Accessory muscle use
 If present note color, consistency and odor of sputum (pink
frothy is usually noted in Pulmonary Edema)
Auscultate lungs for equality and/or adventitious breath sounds
 Rales – also known as crackles are heard when fluid or
exudates is present in the terminal bronchioles. Most notable
on inspiration and are described as fine or coarse
 Rhonchi – is produced by passage of air through fluid filled
narrow air passages. Heard on both inspiration and
expiration and are described as musical, squeaky, rattling,
high pitched or low pitched
 Pleural Friction Rub – is produced by pleural inflammation
and is heard on both inspiration and expiration. Described as
rough or grating sound that varies depending on patient
position
Interventions:
 Monitor for symptoms of heart failure/decreased cardiac
output
 Monitor vital signs
 Observe for confusion, restlessness, agitation (may be sign of
decrease cardiac output)
 Monitor for chest pain, discomfort (note severity, radiation
and duration)
 If chest pain present (have patient lie down, give O2,
medicate for pain and notify physician)
 Cardiac monitor for dysrhythmias

If patient has a Pulmonary Artery Catheter, monitor for
increased PAWP, SVR and a decreased cardiac output
 O2 per physicians order
 If patient intubated, pulmonary toilet, suction, med-neb
treatments
 Monitor intake and output (kidney perfusion may be
compromised if cardiac output low)
 Note results of EKG, chest X-ray and other diagnostic tests
 Monitor labs work such as ABG, CBC, electrolytes (blood
work should be routine)
 Place patient in semi-fowlers or upright position
 Activity/Rest balance (gradually increase activity)
 If eating, diet should be sodium restricted, low cholesterol
(limit caffeine)
 Serve smaller more frequent meals
 Monitor bowel and bladder function (stool softeners prn)
 Minimize environmental stimuli (decrease anxiety for patient
and family)
 Daily weight
 Refer appropriately (heart failure programs, cardiac rehab,
support groups)
Patient/Family Education:
 Signs and symptoms of heart failure
 Importance of smoking cessation/avoidance of alcohol
 Stress reduction
 Diet restrictions (sodium, fluid intake guidelines)
 Assist patient to understand need for lifestyle changes
 Side effects of medications
 Early reporting of SOB or other respiratory difficulty
 Provide specific self-care and disease process information to
patient prior to discharge
Possible Nursing Diagnosis (NANDA)
 Alteration in Comfort: Pain
 Altered Breathing Pattern
 Ineffective Airway
 Impaired Gas Exchange
 Altered Tissue Perfusion: (peripheral, cardiac)
 Anxiety
 Ineffective Coping
 Knowledge Deficit
 Impaired Nutrition
 Potential for Skin Breakdown

PULMONARY EMBOLISM
Definition
A Pulmonary Embolism is a sudden lodgment of a blood clot in a
pulmonary artery that causes an obstruction of blood supply to
lung tissue.
Causes
A pulmonary embolism is most often caused by blood clots from
veins in the legs (Deep Vein Thrombosis DVT) or in the pelvis or
hip area. They can also be caused by air bubbles, fat droplets,
amniotic fluid or tumor cells that clump and obstruct pulmonary
vessels.
Pathophysiology
Once a thrombus separates from its site of origin, it travels through
the circulation to the inferior vena cava. From the inferior vena
cave, it then passes through the right ventricle which pumps the
thrombus into the pulmonary arteries where it finally lodges. Once
a Pulmonary embolism has lodged in an artery, a disruption of
both pulmonary hemodynamics and gas exchange occurs.
Diagnosis
 Physical Exam (Pulmonary Hemodynamics if Pulmonary
Artery Catheter in place)
 Chest X-ray
 Pulmonary ventilation/perfusion scan
 Pulmonary Angiogram
 Doppler Ultrasound (to rule out DVT)
 Venogram (to rule out DVT)
 Elevated Troponin Level (which indicates right ventricular
micro-infarction)
 Elevated pro-B-type peptide Level (which indicates right
ventricular overload)
Symptoms (may be vague or resemble other disease
processes)
 Cough (sudden onset)
 Bloody sputum
 Shortness of breath (sudden onset)
 Splinting of ribs with breathing
 Chest pain (under the breast bone described as sharp,
stabbing, burning)
 Tachycardia
 Tachyapnea
Wheezing
 Cool clammy skin (may be sweaty)
 Bluish skin discoloration
 Nasal flaring
 Pelvis/Leg pain (DVT)
 Swelling of leg (DVT)
 Hypotension
 Weak pulse
 Anxiety/Nervousness
 Lightheadedness/Dizziness
Medical Treatment
 Anticoagulation - When acute Pulmonary Embolism is
suspected, anticoagulation should be started immediately
(Heparin 80 unit/kg bolus followed by 18 units/kg/hr).
Target of activated partial thromboplastin should be between
60-8- seconds (Patient should eventually be weaned of IV
Heparin and oral Warfarin (Coumadin) should be started).
 Inferior Vena Caval Filters – Filters can be inserted
percutaneously to prevent further Pulmonary Embolism, but
they do not stop an already activated thrombolic process.
They are indicated for recurrent Pulmonary Embolism and
for cases when anticoagulation is contraindicated. Because
these filters are retrievable, they can be used on a temporary
basis.
 Thrombolysis – Recombinant Tissue Plasminogen (rt-PA) is
a treatment option for lysing Pulmonary Embolism. If
ordered it should be given as a 100mg IV infusion over 2
hours. (This treatment is somewhat controversial due to the
fact that most patients with Pulmonary Embolism also have
increased systemic arterial pressure and/or moderate to
severe right ventricular dysfunction). Other medications
include Streptokinase and Urokinase.
 Embolectomy – When thrombolysis is contraindicated, a
catheter (angio procedure that delivers high velocity jet
saline that blasts the clot) can be attempted or surgical
embolectomy can be considered
Note: More than 600,000 people in the United States have a
pulmonary embolism each year, and more than 60,000 die

Nursing Care and Management
Assessment:
 Identify patients at risk for the development of Pulmonary
Emboli and put preventative measures in place (ambulation,
range of motion, sequential/ted hose).
 Assess for Homan’s sign (may indicate impending
thrombosis of leg veins)
 Complete respiratory assessment to include complaints of
pleural pain, pain on inspiration, presence of crackles
 Assess for hemoptysis
Interventions:
 Avoid leaving IV catheters in place for long periods of time
 If SOB, HOB should be in semi-fowler’s position to assist
with air distribution
 O2 as prescribed (monitor for signs of hypoxia)
 Pulse Oximetry
 Administer Opioids for sever pain
 Administer anticoagulation as prescribed and monitor for
untoward bleeding (gums, bruising)
 Encourage verbalization of fear and anxiety
 Respiratory toilet to include:
 Nebulizer treatments
 Incentive spirometry
 Postural drainage (vibration and percussion)
Possible Nursing Diagnosis (NANDA)
 Alteration in Comfort: Pain
 Altered Breathing Pattern
 Ineffective Airway
 Impaired Gas Exchange
 Altered Tissue Perfusion: (peripheral, cardiac)
 Anxiety
 Ineffective Coping
 Knowledge Deficit
 Impaired Nutrition
 Potential for Skin Breakdown