- Alveolar-capillary membrane changes, e.g., fluid collection/shifts into interstitial space/alveoli
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Respiratory Status: Gas Exchange (NOC)
- Demonstrate adequate ventilation and oxygenation of tissues by ABGs/oximetry within patient’s normal ranges and free of symptoms of respiratory distress.
- Participate in treatment regimen within level of ability/situation.
Nursing Interventions & Rationale
|Auscultate breath sounds, noting crackles, wheezes.||Reveals presence of pulmonary congestion/collection of secretions, indicating need for further intervention.|
|Instruct patient in effective coughing, deep breathing.||Clears airways and facilitates oxygen delivery.|
|Encourage frequent position changes.||Helps prevent atelectasis and pneumonia.|
|Maintain chair/bedrest, with head of bed elevated 20–30 degrees, semi-Fowler’s position. Support arms with pillows.||Reduces oxygen consumption/demands and promotes maximal lung inflation.|
|Monitor/graph serial ABGs, pulse oximetry.||Hypoxemia can be severe during pulmonary edema. Compensatory changes are usually present in chronic HF. Note: In patients with abnormal cardiac index, research suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7%.|
|Administer supplemental oxygen as indicated.||Increases alveolar oxygen concentration, which may correct/reduce tissue hypoxemia.|
|Administer medications as indicated:
Diuretics, e.g., furosemide (Lasix)Bronchodilators, e.g., aminophylline
|Reduces alveolar congestion, enhancing gas exchange.
Increases oxygen delivery by dilating small airways, and exerts mild diuretic effect to aid in reducing pulmonary congestion.