Nursing Diagnosis for Pulmonary Embolism: A Comprehensive Care Plan

Pulmonary embolism (PE) is a critical condition characterized by the obstruction of one or more pulmonary arteries by a thrombus, most commonly originating from deep vein thrombosis (DVT) in the lower extremities. This blockage disrupts pulmonary blood flow, leading to decreased oxygenation, impaired gas exchange, and potentially life-threatening complications. Prompt diagnosis and effective nursing care are paramount in improving patient outcomes and reducing mortality associated with pulmonary embolism.

Nurses play a vital role in the multidisciplinary management of pulmonary embolism, from initial assessment and stabilization to implementing life-saving interventions and patient education. This comprehensive guide focuses on nursing diagnoses relevant to pulmonary embolism and outlines a detailed care plan to guide nursing interventions, optimize patient care, and improve recovery.

In-Depth Nursing Assessment for Pulmonary Embolism

A thorough nursing assessment is the cornerstone of effective care for patients with suspected or confirmed pulmonary embolism. It involves gathering both subjective and objective data to identify risk factors, clinical manifestations, and guide the selection of appropriate nursing diagnoses and interventions.

Detailed Review of Health History

1. Comprehensive Symptom Evaluation: Elicit a detailed account of the patient’s presenting symptoms, as these can vary widely depending on the size and location of the embolus. Key symptoms to document include:

• Dyspnea: Sudden onset of shortness of breath, often unexplained and disproportionate to exertion.
• Tachypnea: Rapid breathing, often exceeding 20 breaths per minute, as the body attempts to compensate for reduced oxygenation.
• Chest Pain: Typically pleuritic in nature, worsening with deep inspiration or coughing; may be described as sharp, stabbing, or aching.
• Cough: May be present, sometimes productive of blood-tinged sputum (hemoptysis).
• Hemoptysis: Coughing up blood, indicating pulmonary tissue injury or infarction.
• Syncope: Fainting or lightheadedness, potentially due to decreased cardiac output and cerebral hypoperfusion.
• Anxiety and Restlessness: Common responses to dyspnea and hypoxia.
• Lower Extremity Pain or Swelling: Suggestive of DVT, the primary source of most pulmonary emboli.

2. Thorough Risk Factor Identification: Assess for predisposing factors that increase the patient’s susceptibility to venous thromboembolism (VTE), including DVT and PE:

• Immobility: Prolonged bed rest, paralysis, or prolonged travel significantly increase risk.
• Previous VTE: A history of DVT or PE is a strong predictor of recurrence.
• Active Cancer: Malignancy and its treatment (chemotherapy, radiation) are major risk factors.
• Recent Surgery: Especially orthopedic or major abdominal surgery, increases hypercoagulability and immobility.
• Obesity: Excess weight contributes to venous stasis and hypercoagulability.
• Oral Contraceptives & Hormone Replacement Therapy: Estrogen-containing medications increase clotting risk.
• Pregnancy & Postpartum Period: Pregnancy-related hormonal changes and venous compression increase risk.
• Smoking: Damages blood vessels and promotes hypercoagulability.
• Inherited Clotting Disorders (Thrombophilia): Genetic predispositions to excessive clotting.
• Varicose Veins: Impaired venous return and stasis contribute to clot formation.
• Trauma: Especially fractures of the pelvis, hip, or femur, release fat emboli and promote hypercoagulability.

3. Family History of VTE: Inquire about any family history of pulmonary embolism or deep vein thrombosis, as genetic factors can increase individual risk.

4. Past and Present Medical History Review: Obtain a comprehensive medical history, including:

• Cardiovascular Disease: Pre-existing heart conditions can exacerbate the hemodynamic effects of PE.
• Chronic Lung Disease: Conditions like COPD or asthma may complicate the respiratory symptoms of PE.
• Surgical History: Recent surgeries, especially those involving prolonged immobilization or major trauma.
• Medication History: Document all current medications, including anticoagulants, hormones, and over-the-counter drugs.

5. Pulmonary Embolism Rule-out Criteria (PERC) Application: In emergency settings, the PERC rule can help identify low-risk patients who may not require immediate extensive testing for PE. The eight PERC criteria are:

• Age < 50 years
• Heart rate < 100 bpm
• Oxygen saturation ≥ 95% on room air
• No hemoptysis
• No hormone replacement therapy or oral contraceptives
• No prior VTE
• No unilateral leg edema
• No surgery or trauma requiring hospitalization within the past 4 weeks

Patients negative for all eight PERC criteria have a very low probability of PE and may avoid further diagnostic testing.

Detailed Physical Assessment

1. Rapid Assessment of Critical Symptoms: Prioritize assessment based on symptom severity. Unexplained dyspnea, chest pain, and syncope are red flags requiring immediate attention and evaluation for pulmonary embolism.

2. Vital Signs Monitoring: Closely monitor vital signs for indicators of hemodynamic instability. Abnormal findings may include:

• Tachycardia: Heart rate > 100 bpm, a compensatory mechanism for decreased cardiac output and oxygenation.
• Tachypnea: Respiratory rate > 20 breaths per minute, reflecting the body’s attempt to improve oxygen intake.
• Hypotension: Systolic blood pressure < 90 mmHg, indicating significant hemodynamic compromise, especially in massive PE.
• Hypoxia: Oxygen saturation < 90% on room air, reflecting impaired gas exchange.
• Fever: May be present, especially in cases of pulmonary infarction.

3. Systematic Physical Examination: Perform a head-to-toe assessment, focusing on systems most affected by PE:

• Neck: Assess for jugular vein distention (JVD), indicating right ventricular dysfunction and increased central venous pressure.
• Central Nervous System (CNS): Evaluate level of consciousness, orientation, and presence of confusion or restlessness, which may signify hypoxia.
• Cardiovascular System:
  • Auscultate heart sounds for murmurs, gallops (S3 or S4), and accentuated pulmonic component of the second heart sound (P2), which can indicate pulmonary hypertension.
  • Assess for chest pain, noting location, character, and radiation.
  • Palpate peripheral pulses for rate, rhythm, and quality, noting any signs of decreased perfusion.
• Respiratory System:
  • Observe respiratory rate, depth, and effort, noting any use of accessory muscles.
  • Auscultate breath sounds for adventitious sounds such as wheezes, crackles, or pleural friction rub. Note any areas of decreased or absent breath sounds.
  • Assess for cough and sputum production.
  • Evaluate for signs of cyanosis (bluish discoloration of skin and mucous membranes), indicating hypoxemia.
• Circulatory System:
  • Inspect skin color and temperature, noting pallor, cyanosis, or coolness, especially in extremities.
  • Palpate for peripheral edema, particularly in the lower extremities, which may suggest DVT.
  • Assess for calf tenderness, warmth, or palpable cords, suggestive of DVT.
• Musculoskeletal System: Evaluate for muscle weakness, fatigue, or syncope.
• Integumentary System: Assess skin for color, temperature, moisture, and presence of diaphoresis (excessive sweating).

Diagnostic Procedures and Interpretation

It’s crucial to remember that chest pain and dyspnea are non-specific symptoms that can mimic other conditions such as myocardial infarction, pneumonia, or pneumothorax. Diagnostic testing is essential to confirm or exclude pulmonary embolism.

1. Electrocardiogram (ECG): While ECG findings are often non-specific in PE, certain abnormalities may raise suspicion or help rule out cardiac etiologies. Common ECG changes include:

• Sinus Tachycardia: The most frequent finding.
• Non-specific ST-segment and T-wave changes: Suggestive of myocardial ischemia or strain.
• S1Q3T3 Pattern: Classic but infrequent finding, indicating right ventricular strain (deep S wave in lead I, Q wave in lead III, and inverted T wave in lead III).
• Right Ventricular Strain: Evidenced by T-wave inversions in anterior precordial leads (V1-V4).
• New Incomplete Right Bundle Branch Block: Suggestive of right ventricular overload.

2. D-dimer Blood Test: This highly sensitive test measures fibrin degradation products, which are elevated when clots are being broken down.

• Elevated D-dimer: Suggests the presence of clot formation and breakdown, but is not specific for PE (can be elevated in other conditions like infection, malignancy, pregnancy). A negative D-dimer in a low-risk patient effectively rules out PE.
• Normal D-dimer: Strongly suggests absence of acute PE in low-risk patients.

3. Other Blood Tests:

• Complete Blood Count (CBC) with Differential: May reveal underlying infection or anemia, but is not diagnostic for PE.
• Coagulation Studies (PT/INR, PTT): Baseline coagulation tests are important before initiating anticoagulation therapy. PTT is used to monitor unfractionated heparin therapy.

4. Chest X-ray: Often normal in PE, but essential to rule out other pulmonary conditions such as pneumonia or pneumothorax. May show subtle findings like Westermark’s sign (focal oligemia) or Hampton’s hump (wedge-shaped pleural infiltrate), but these are infrequent and non-specific.

5. Computed Tomographic Pulmonary Angiography (CTPA): The gold standard imaging modality for diagnosing PE.

• High Sensitivity and Specificity: Effectively visualizes pulmonary arteries and detects clots with high accuracy.
• Rapid and Widely Available: CTPA is readily accessible in most hospitals and can be performed quickly.
• Contrast Dye: Requires intravenous contrast dye, which is contraindicated in patients with severe renal insufficiency or allergy to iodinated contrast. Pre-hydration and alternative imaging modalities may be necessary in these patients.

6. Ventilation/Perfusion (V/Q) Scan: An alternative imaging technique, particularly useful when CTPA is contraindicated (e.g., pregnancy, contrast allergy, renal insufficiency).

• Assesses Airflow and Blood Flow: Compares ventilation (air reaching alveoli) to perfusion (blood flow to lungs).
• Mismatch Pattern: A “mismatch” (normal ventilation with reduced perfusion) suggests PE.
• Less Sensitive than CTPA: V/Q scans are less sensitive and specific than CTPA for detecting small peripheral emboli.
• Indeterminate Results: V/Q scans can be indeterminate, requiring further investigation.

7. Echocardiography: Particularly useful in patients with hemodynamically unstable PE or suspected right ventricular dysfunction.

• Evaluates Right Ventricular Function: May show right ventricular dilation, hypokinesis, and increased pulmonary artery pressure, indicative of right heart strain due to PE.
• Identifies Proximal Emboli: In rare cases, may directly visualize large emboli in the right atrium or pulmonary arteries.

8. Venous Doppler Ultrasound: Used to detect DVT in the lower extremities, the most common source of PE.

• Non-invasive and Readily Available: Useful in patients with suspected DVT as the source of PE.
• Positive DVT: Confirms a source for PE and may guide treatment decisions.
• Negative DVT: Does not rule out PE, as the embolus may have already traveled to the lungs.

Prioritized Nursing Diagnoses for Pulmonary Embolism

Based on the assessment findings, several nursing diagnoses are commonly relevant in patients with pulmonary embolism. Prioritization of these diagnoses depends on the individual patient’s clinical presentation and severity of illness. Key nursing diagnoses include:

1. Impaired Gas Exchange related to ventilation-perfusion mismatch secondary to pulmonary embolism, as evidenced by hypoxemia, dyspnea, and abnormal arterial blood gases (ABGs).
2. Acute Pain related to pulmonary tissue hypoxia and inflammatory processes secondary to pulmonary embolism, as evidenced by chest pain, dyspnea, and guarding behavior.
3. Anxiety related to fear of death, severity of illness, and unfamiliar hospital environment secondary to pulmonary embolism, as evidenced by restlessness, tachycardia, and expressed concerns.
4. Decreased Cardiac Output related to increased pulmonary vascular resistance and right ventricular dysfunction secondary to pulmonary embolism, as evidenced by hypotension, tachycardia, and decreased peripheral perfusion.
5. Ineffective Breathing Pattern related to pain and hypoxemia secondary to pulmonary embolism, as evidenced by tachypnea, dyspnea, and use of accessory muscles.

Comprehensive Nursing Care Plans and Interventions

For each prioritized nursing diagnosis, a comprehensive care plan is developed, incorporating specific goals, nursing interventions, and expected outcomes.

1. Nursing Care Plan for Impaired Gas Exchange

Nursing Diagnosis: Impaired Gas Exchange related to ventilation-perfusion mismatch secondary to pulmonary embolism.

Desired Outcomes:

• Patient will demonstrate improved gas exchange as evidenced by oxygen saturation ≥ 95% on room air or baseline, respiratory rate 12-20 breaths per minute, and improved ABGs within patient-specific parameters.
• Patient will report decreased dyspnea and increased comfort with breathing.
• Patient will exhibit improved activity tolerance without significant desaturation.

Nursing Interventions:

1. Optimize Oxygen Therapy:

   • Administer supplemental oxygen as prescribed to maintain oxygen saturation at the target level.
   • Monitor oxygen saturation continuously using pulse oximetry.
   • Assess for signs of hypoxemia (cyanosis, restlessness, confusion) and adjust oxygen delivery as needed.
   • Consider advanced oxygen delivery methods (e.g., high-flow nasal cannula, non-invasive ventilation) if conventional oxygen therapy is inadequate.

2. Promote Optimal Positioning:

   • Elevate the head of the bed to a semi-Fowler’s or high-Fowler’s position to facilitate lung expansion and improve ventilation.
   • Encourage frequent position changes to optimize ventilation and perfusion matching.
   • Assist patient to turn, cough, and deep breathe every 2 hours to mobilize secretions and improve alveolar ventilation.

3. Administer Medications as Prescribed:

   • Anticoagulants: Administer prescribed anticoagulants (heparin, low-molecular-weight heparin, direct oral anticoagulants, warfarin) promptly to prevent further thrombus formation and allow for natural clot lysis. Monitor for bleeding complications.
   • Thrombolytics: In cases of massive PE with hemodynamic instability, prepare for and assist with thrombolytic therapy administration to dissolve the existing clot. Monitor for bleeding and reperfusion injury.

4. Monitor Respiratory Status Closely:

   • Assess respiratory rate, rhythm, depth, and effort regularly.
   • Auscultate breath sounds frequently for adventitious sounds (wheezes, crackles) or diminished breath sounds.
   • Monitor ABGs as ordered to evaluate oxygenation and ventilation status.
   • Assess for signs of respiratory distress (increased work of breathing, nasal flaring, accessory muscle use).

5. Provide Emotional Support and Reduce Anxiety:

   • Address patient’s anxiety and fear related to dyspnea and the severity of the condition.
   • Provide calm reassurance and explain all procedures and treatments.
   • Encourage relaxation techniques and provide a calm environment.

2. Nursing Care Plan for Acute Pain

Nursing Diagnosis: Acute Pain related to pulmonary tissue hypoxia and inflammatory processes secondary to pulmonary embolism.

Desired Outcomes:

• Patient will report pain is managed to a tolerable level (e.g., pain score ≤ 3 on a 0-10 scale).
• Patient will demonstrate relaxed facial expressions and body posture.
• Patient will be able to participate in deep breathing and coughing exercises without significant pain exacerbation.

Nursing Interventions:

1. Comprehensive Pain Assessment:

   • Assess pain characteristics: location, intensity, quality, onset, duration, aggravating and relieving factors.
   • Use a pain scale (numeric rating scale, visual analog scale) to quantify pain intensity.
   • Assess the impact of pain on patient’s functional status and quality of life.

2. Pharmacological Pain Management:

   • Administer prescribed analgesics as ordered, considering pain severity and patient’s overall condition.
   • Opioid analgesics (morphine, fentanyl) may be necessary for severe pain.
   • Non-opioid analgesics (acetaminophen) may be used for mild to moderate pain or in conjunction with opioids.
   • Avoid NSAIDs and aspirin due to increased bleeding risk with anticoagulation.
   • Administer pain medications proactively, before pain becomes severe, and provide breakthrough pain medication as needed.

3. Non-Pharmacological Pain Relief Measures:

   • Positioning: Assist patient to find a comfortable position that minimizes chest discomfort.
   • Relaxation Techniques: Teach and encourage relaxation techniques (deep breathing, guided imagery, meditation).
   • Distraction: Provide diversional activities (reading, music, conversation) to distract from pain.
   • Heat or Cold Application: Apply heat or cold packs to the chest as tolerated and if prescribed, to alleviate muscle tension and pain.

4. Monitor Pain Response and Medication Effectiveness:

   • Reassess pain intensity and characteristics after pain interventions.
   • Monitor for side effects of pain medications, especially respiratory depression with opioids.
   • Adjust pain management plan as needed based on patient’s response and ongoing assessment.

3. Nursing Care Plan for Anxiety

Nursing Diagnosis: Anxiety related to fear of death, severity of illness, and unfamiliar hospital environment secondary to pulmonary embolism.

Desired Outcomes:

• Patient will report a reduction in anxiety and fear.
• Patient will demonstrate coping mechanisms to manage anxiety.
• Patient will verbalize understanding of the treatment plan and prognosis.
• Patient will exhibit stable vital signs and reduced physical manifestations of anxiety.

Nursing Interventions:

1. Therapeutic Communication and Active Listening:

   • Establish a trusting and supportive nurse-patient relationship.
   • Encourage patient to verbalize feelings, fears, and concerns about their condition and prognosis.
   • Listen attentively and empathetically to patient’s expressions of anxiety.
   • Use open-ended questions to facilitate communication and exploration of anxieties.

2. Provide Accurate Information and Education:

   • Explain the nature of pulmonary embolism, treatment plan, and expected outcomes in a clear and understandable manner.
   • Address patient’s misconceptions and provide realistic reassurance.
   • Provide information about preventive measures to reduce the risk of recurrent VTE.

3. Involve Support Systems:

   • Encourage family and friends to visit and provide emotional support.
   • Facilitate communication between patient and family.
   • Consider involving pastoral care or social work services if needed.

4. Create a Calm and Restful Environment:

   • Minimize environmental stressors (noise, interruptions).
   • Promote rest and sleep to reduce anxiety and improve coping.
   • Ensure patient comfort and address basic needs.

5. Teach Coping Strategies:

   • Teach and encourage relaxation techniques (deep breathing, progressive muscle relaxation).
   • Promote positive self-talk and cognitive reframing techniques.
   • Encourage mindfulness and present moment focus.
   • Consider referral to mental health professionals for ongoing anxiety management if needed.

4. Nursing Care Plan for Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to increased pulmonary vascular resistance and right ventricular dysfunction secondary to pulmonary embolism.

Desired Outcomes:

• Patient will maintain adequate cardiac output as evidenced by stable vital signs (blood pressure, heart rate), adequate peripheral perfusion, and urine output.
• Patient will exhibit improved hemodynamic parameters (CVP, PAP) if monitored.
• Patient will not develop signs of right-sided heart failure (e.g., peripheral edema, JVD).

Nursing Interventions:

1. Hemodynamic Monitoring:

   • Continuously monitor vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation).
   • Monitor for signs of hypotension, tachycardia, and decreased peripheral perfusion.
   • Consider invasive hemodynamic monitoring (arterial line, central venous catheter, pulmonary artery catheter) in hemodynamically unstable patients as ordered, to assess CVP, PAP, and cardiac output.

2. Fluid Management:

   • Administer intravenous fluids cautiously to maintain adequate preload and support cardiac output, but avoid fluid overload, which can exacerbate right ventricular dysfunction.
   • Monitor fluid balance closely, including intake and output, daily weights, and signs of fluid overload (edema, crackles).
   • In hemodynamically unstable patients, vasopressors (norepinephrine, dopamine) may be required to maintain blood pressure and organ perfusion as prescribed.

3. Optimize Cardiac Function:

   • Administer medications as prescribed to improve cardiac function and reduce pulmonary vascular resistance:
     • Inotropes (dobutamine): May be used to enhance right ventricular contractility in severe cases.
     • Pulmonary Vasodilators (nitric oxide, prostacyclin): May be used in specialized settings to reduce pulmonary artery pressure and improve right ventricular function.

4. Monitor for Complications:

   • Assess for signs of right-sided heart failure (JVD, peripheral edema, hepatomegaly).
   • Monitor for arrhythmias and ECG changes indicative of myocardial ischemia or strain.
   • Be prepared to initiate advanced cardiac life support (ACLS) measures if cardiac arrest occurs.

5. Promote Rest and Reduce Cardiac Workload:

   • Encourage rest and limit activities that increase cardiac demand.
   • Maintain a calm and quiet environment to reduce stress and anxiety.
   • Space nursing activities to allow for rest periods.

5. Nursing Care Plan for Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective Breathing Pattern related to pain and hypoxemia secondary to pulmonary embolism.

Desired Outcomes:

• Patient will establish and maintain an effective breathing pattern as evidenced by respiratory rate 12-20 breaths per minute, regular rhythm, and adequate depth.
• Patient will demonstrate effective coughing and deep breathing techniques.
• Patient will maintain oxygen saturation ≥ 95% with minimal or no supplemental oxygen.
• Patient will report decreased dyspnea and improved breathing comfort.

Nursing Interventions:

1. Respiratory Assessment and Monitoring:

   • Continuously monitor respiratory rate, rhythm, depth, and effort.
   • Auscultate breath sounds regularly for adventitious sounds or diminished breath sounds.
   • Monitor oxygen saturation continuously using pulse oximetry.
   • Assess for signs of respiratory distress (nasal flaring, accessory muscle use, cyanosis).

2. Promote Effective Breathing Techniques:

   • Instruct and assist patient with deep breathing and coughing exercises every 1-2 hours to improve alveolar ventilation and clear secretions.
   • Teach pursed-lip breathing to slow respiratory rate and improve oxygenation.
   • Encourage diaphragmatic breathing to maximize lung expansion.
   • Assist patient to use incentive spirometry to promote lung expansion and prevent atelectasis.

3. Optimize Positioning:

   • Elevate the head of the bed to a semi-Fowler’s or high-Fowler’s position to facilitate lung expansion.
   • Encourage frequent position changes to prevent atelectasis and promote optimal ventilation.

4. Manage Pain and Anxiety:

   • Provide effective pain management to reduce pain-related splinting and promote deeper breathing.
   • Address anxiety and fear, as anxiety can contribute to rapid and shallow breathing.

5. Assist with Respiratory Treatments:

   • Administer bronchodilators or mucolytics if prescribed to improve airway clearance and reduce bronchospasm (though these are not primary treatments for PE, they may be used for co-existing conditions or symptom management).
   • Prepare for and assist with mechanical ventilation if the patient develops respiratory failure.

Preventing Pulmonary Embolism Recurrence and Long-Term Management

Preventing recurrence and managing long-term complications are crucial aspects of pulmonary embolism care. Nursing interventions play a key role in patient education and promoting adherence to preventive strategies.

1. Anticoagulation Education:

• Provide thorough education about prescribed anticoagulation therapy, including medication name, dosage, route, frequency, duration, and purpose.
• Emphasize the importance of adherence to the anticoagulation regimen to prevent recurrent VTE.
• Instruct patient on potential side effects of anticoagulants, particularly bleeding risks, and signs and symptoms to report to healthcare providers.
• Provide guidance on medication interactions and dietary considerations related to warfarin (if applicable).

2. Lifestyle Modifications:

• Encourage smoking cessation and provide resources for smoking cessation programs.
• Advise on maintaining a healthy weight and engaging in regular physical activity to improve circulation and reduce VTE risk.
• Educate on the importance of hydration to prevent dehydration and promote optimal blood viscosity.
• Recommend avoiding prolonged periods of sitting or standing still, and encourage frequent movement and leg exercises, especially during travel.

3. Compression Stockings:

• Explain the purpose and proper use of compression stockings to prevent venous stasis and reduce the risk of DVT and recurrent PE, particularly for patients with chronic venous insufficiency or post-thrombotic syndrome.
• Provide instructions on how to apply and remove compression stockings correctly and ensure proper fit.

4. Follow-up and Monitoring:

• Emphasize the importance of regular follow-up appointments with healthcare providers to monitor anticoagulation therapy, assess for recurrent symptoms, and address any concerns.
• Educate patient on recognizing signs and symptoms of recurrent PE (sudden onset of dyspnea, chest pain, hemoptysis) and the need to seek immediate medical attention if these occur.

Conclusion

Effective nursing care is indispensable in the management of pulmonary embolism. By utilizing comprehensive nursing assessments, prioritizing relevant nursing diagnoses, and implementing evidence-based care plans, nurses can significantly improve patient outcomes, reduce morbidity and mortality associated with PE, and enhance the quality of life for individuals affected by this critical condition. The focus on “Nursing Diagnosis For Pulmonary Embolism Care Plan” underscores the crucial role of nurses in providing holistic, patient-centered care throughout the continuum of pulmonary embolism management.

References

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