Pulmonary Embolism Nursing Diagnosis Care Plan: A Comprehensive Guide for Nurses

Pulmonary embolism (PE) stands as a critical and potentially life-threatening condition that arises when a blood clot obstructs one or more pulmonary arteries. This blockage impedes blood flow to the lungs, leading to diminished oxygenation, impaired gas exchange, and a cascade of complications including pulmonary tissue hypoxia, and in severe cases, mortality. Understanding the nuances of pulmonary embolism, particularly from a nursing perspective, is paramount for effective patient care and improved outcomes.

Most instances of PE stem from deep vein thrombosis (DVT), typically originating in the lower extremities. When a thrombus detaches and migrates through the bloodstream to the lungs, it lodges in the pulmonary arteries, causing obstruction. While DVT is the predominant cause, other less frequent etiologies include fat emboli from bone fractures, air emboli introduced during intravenous therapy, and amniotic fluid emboli during childbirth.

Early and accurate diagnosis coupled with timely intervention are crucial in mitigating the risks associated with pulmonary embolism and enhancing patient prognosis. The primary objectives in PE management are to restore and maintain adequate tissue perfusion, optimize pulmonary function, and prevent the formation of new thrombi, recurrence of PE, and associated complications. Nurses play a pivotal role in this multifaceted approach, from administering life-sustaining ventilatory and surgical support to delivering medications and educating patients on risk reduction strategies. This comprehensive guide delves into the essential aspects of nursing care for pulmonary embolism, providing a robust framework for developing effective care plans and improving patient outcomes.

Nursing Assessment for Pulmonary Embolism

The cornerstone of effective nursing care lies in meticulous assessment. For patients with suspected pulmonary embolism, this involves a thorough gathering of physical, psychosocial, emotional, and diagnostic data. This section outlines the subjective and objective data collection essential for formulating a comprehensive nursing diagnosis and care plan for PE.

Review of Health History

1. Elicit Patient Complaints and General Symptoms: A detailed account of the patient’s symptoms is crucial. Document the presence and characteristics of the following:

• Dyspnea: Shortness of breath, often sudden and unexplained, is a hallmark symptom.
• Tachypnea: Rapid breathing, often the body’s attempt to compensate for reduced oxygen levels.
• Fever: May be present, although not always a prominent symptom.
• Cough: Can range from dry to productive; may be accompanied by hemoptysis.
• Chest Pain: Typically pleuritic, meaning it worsens with deep breathing or coughing; can be sharp or stabbing.
• Hemoptysis: Coughing up blood, indicating potential lung tissue damage.
• Crackles: Abnormal lung sounds heard on auscultation, suggesting fluid in the alveoli.
• Wheezing: High-pitched whistling sounds, indicating airway narrowing.
• Syncope: Fainting or lightheadedness, potentially due to decreased cardiac output.
• Mental Status Alterations: Confusion, restlessness, or anxiety, indicative of hypoxia.
• Hypotension: Low blood pressure, a sign of hemodynamic instability.
• Lower Extremity Pain: Calf pain or tenderness, suggestive of DVT, the primary source of most PEs.
• Cold, Clammy Skin: Indicates poor peripheral perfusion.
• Cyanosis: Bluish discoloration of the skin and mucous membranes, signifying severe hypoxemia.

2. Determine Pulmonary Embolism Risk Factors: Identifying risk factors is vital for assessing predisposition to PE. Common risk factors include:

• Reduced Mobility/Bed Rest: Prolonged immobility increases the risk of blood clot formation.
• History of Venous Thromboembolism (VTE): Previous DVT or PE significantly elevates recurrence risk.
• Cancer: Certain cancers and cancer treatments increase hypercoagulability.
• Recent Surgery: Surgical procedures, especially orthopedic surgeries, are associated with increased VTE risk.
• Obesity: Excess weight is linked to impaired venous return and increased clotting risk.
• Oral Contraceptives/Hormone Replacement Therapy: Estrogen-containing medications can increase clotting factors.
• Varicose Veins: Abnormal veins can contribute to venous stasis and clot formation.
• Pregnancy: Pregnancy and the postpartum period are hypercoagulable states.
• Smoking: Damages blood vessels and promotes clot formation.
• Clotting Disorders (Thrombophilia): Inherited or acquired conditions that predispose to excessive clotting.

3. Identify Family History of VTE: A family history of PE or DVT in first-degree relatives increases the patient’s risk.

4. Review Past and Present Medical History: A comprehensive medical history is essential to uncover predisposing conditions. Gather information from the patient, family (if the patient is confused), medical records, and medication lists.

5. Utilize Pulmonary Embolism Rule-out Criteria (PERC): The PERC rule is a valuable tool in emergency settings to identify patients at low risk of PE, potentially avoiding unnecessary testing. Patients negative for all eight PERC criteria have a very low probability of PE.

Eight PERC criteria include:

• Age ≥ 50 years
• Heart rate ≥ 100 bpm
• Oxygen saturation < 90% on room air
• Hemoptysis
• Hormone replacement therapy or oral contraceptive use
• History of DVT or PE
• Unilateral leg edema
• Surgery or trauma within the past four weeks

Physical Assessment

1. Rapid Assessment for Unexplained Symptoms: Pulmonary embolism is a medical emergency. Promptly assess patients presenting with unexplained dyspnea, chest pain, or syncope, as these can be indicative of PE.

2. Monitor Vital Signs Closely: Vital signs can range from normal to severely abnormal depending on the clot size and lung tissue affected. Large clots often lead to unstable vital signs, manifesting as:

• Tachycardia: Increased heart rate.
• Tachypnea: Increased respiratory rate.
• Hypotension: Decreased blood pressure.
• Hypoxia: Low oxygen saturation (SpO2 < 90%).

3. Systemic Physical Examination: A comprehensive physical exam should include:

• Neck: Assess for jugular vein distention (JVD), indicating right heart strain.
• Central Nervous System (CNS): Evaluate level of consciousness for any decline, which can indicate hypoxia.
• Cardiovascular System: Assess for chest pain (especially pleuritic), arrhythmias, and tachycardia.
• Circulatory System: Palpate for palpable cords (indicating thrombophlebitis) and assess for palpitations.
• Respiratory System: Evaluate for dyspnea, cough, hemoptysis, tachypnea, persistent cough, crackles (rales), decreased breath sounds, loud pulmonic closure sound (P2 – indicating pulmonary hypertension), right-sided gallop (S3 or S4 heart sound – suggesting right ventricular dysfunction), and hypoxemia.
• Lymphatic System: Assess for lower extremity swelling and pedal edema, signs of DVT.
• Musculoskeletal System: Evaluate for syncope, calf pain, fatigue, and muscle weakness.
• Integumentary System: Observe for erythema, cyanosis or pallor, and diaphoresis (excessive sweating).

Image alt text: Nurse palpates patient’s lower leg for edema and assesses skin pallor during a pulmonary embolism physical exam.

Diagnostic Procedures

Note: Differentiating PE from other conditions like heart attack, pneumonia, pneumothorax, or aortic dissection is crucial due to overlapping symptoms (chest pain, dyspnea). Initial diagnostic focus will often include cardiac and pulmonary evaluations.

1. Electrocardiogram (ECG): While ECG findings are not specific for PE, they can provide indirect clues. Common ECG abnormalities in PE include:

• Tachycardia: Rapid heart rate.
• Nonspecific ST-segment and T-wave changes: Indicating myocardial ischemia or strain.
• S1Q3T3 pattern: Classic but infrequent finding, indicating right ventricular strain.
• Right ventricular strain: Signs of right heart overload.
• New incomplete right bundle branch block: Conduction delay in the right ventricle.

2. D-dimer Blood Test: This test measures cross-linked fibrin fragments, products of clot breakdown. A normal D-dimer level significantly reduces the likelihood of PE. However, elevated D-dimer is not specific to PE and can be elevated in other conditions.

3. Other Blood Tests:

• Complete Blood Count (CBC) with differential: Evaluates for anemia, infection, and blood coagulation abnormalities.
• Prothrombin Time (PT)/International Normalized Ratio (INR) and Partial Thromboplastin Time (PTT): Assess blood clotting function, especially important for patients on anticoagulation.

4. Chest X-ray: Chest X-rays are often normal in PE but are valuable for excluding other conditions that mimic PE symptoms, such as pneumonia or pneumothorax.

5. Computed Tomography Pulmonary Angiography (CTPA): CTPA is the gold standard diagnostic test for PE. It provides detailed images of the pulmonary arteries and can directly visualize blood clots.

6. Further Investigations:

• Ventilation/Perfusion (V/Q) Scan: Used when CTPA is contraindicated (e.g., pregnancy, kidney disease) or when further clarification is needed. V/Q scans are often the preferred test for PE diagnosis in pregnant women.
• Echocardiogram: Assesses right ventricular function and can detect right heart strain caused by PE.
• Venous Doppler Ultrasound: Used to detect DVT in patients with suspected PE, particularly when lower extremity symptoms are present.
• Chest Computed Tomography (CT) Scan: While CTPA is preferred for PE diagnosis, a standard chest CT can also reveal clots in the pulmonary arteries. Caution is needed with IV contrast in patients with pregnancy, kidney issues, or allergies to iodine or seafood.

Nursing Interventions for Pulmonary Embolism

Nursing interventions are crucial for supporting patients with pulmonary embolism through the acute phase and in preventing recurrence. These interventions are focused on supportive care, anticoagulation, clot dissolution, and prevention of complications.

Provide Supportive Measures

1. Administer Supplemental Oxygen: Oxygen therapy is indicated for patients with oxygen saturation below 90%. Mechanical ventilation may be required for hemodynamically unstable patients.

2. Judicious Volume Resuscitation: Aggressive fluid resuscitation can paradoxically worsen right ventricular function in hemodynamically unstable PE by causing overdistension. Fluid resuscitation should be reserved for patients with evidence of hypovolemia (e.g., collapsing inferior vena cava). Vasopressors may be necessary for hemodynamic support.

3. Consider Life-Saving Measures: Extracorporeal membrane oxygenation (ECMO) is a mechanical cardiopulmonary support option for high-risk, severe PE when conventional therapies fail or thrombectomy is not feasible.

Promote Anticoagulation

1. Understand the Importance of Anticoagulation: Anticoagulation is the cornerstone of PE treatment. It prevents clot propagation, reduces the risk of new clot formation, and alleviates chest and calf pain by improving blood flow.

2. Administer Anticoagulants as Prescribed: Common anticoagulants used in PE management include:

• Low-Molecular-Weight Heparin (LMWH): Subcutaneous injection, often preferred for initial anticoagulation.
• Unfractionated Heparin (UFH): Intravenous infusion, allows for rapid reversal and close monitoring.
• Warfarin: Oral anticoagulant, started concurrently with heparin and continued long-term.
• Direct Oral Anticoagulants (DOACs) or Non-Vitamin K Antagonist Oral Anticoagulants (NOACs): Such as dabigatran, apixaban, and rivaroxaban, increasingly used for both acute and long-term PE management.

3. Monitor for Bleeding Complications: Bleeding is a significant risk with all anticoagulants. Monitor for signs of bleeding, including:

• Bloody stools (melena or hematochezia)
• Bruising (ecchymosis)
• Hemoptysis (coughing up blood)
• Epistaxis (nosebleeds)
• Gingival bleeding (bleeding gums)
• Hematuria (blood in urine)

4. Monitor Anticoagulation Therapy:

• PT/INR: Used to monitor warfarin therapy, aiming for a therapeutic INR range.
• PTT: Used to monitor intravenous unfractionated heparin, adjusting infusion rates to maintain therapeutic PTT levels.
• DOACs/NOACs: Typically do not require routine blood monitoring.

Dissolve Existing Clots

1. Assist with Catheter-Directed Thrombolysis: This involves delivering thrombolytic (“clot-busting”) medication directly to the clot site in the pulmonary artery via a catheter.

2. Prepare for Surgical Clot Removal: Surgical thrombectomy or embolectomy involves physically removing the clot from the pulmonary artery, typically performed in cases of massive PE or when thrombolysis is contraindicated.

3. Consider Vena Cava Filters: Permanent vena cava filters are sometimes placed in the inferior vena cava to trap clots before they reach the lungs, reducing the risk of recurrent PE. These are typically reserved for patients with:

• Contraindications to anticoagulation.
• Recurrent VTE despite adequate anticoagulation.

Prevent Recurrence and Complications

1. Encourage Compression Stockings: For patients with a history of VTE, compression stockings can help prevent recurrent DVT by improving venous return in the legs.

2. Promote Early Ambulation: Post-operative ambulation and early mobilization, when appropriate, are crucial in preventing venous stasis and subsequent PE.

3. Elevate Legs: Elevating the patient’s legs, especially at night and when sitting, promotes venous drainage and reduces venous pressure.

4. Utilize Pneumatic Compression Devices: Pneumatic compression devices (intermittent pneumatic compression, IPC) provide cyclical compression to the legs, enhancing blood flow and reducing venous stasis, particularly for immobile patients.

5. Increase Fluid Intake: Dehydration can contribute to blood clot formation. Adequate hydration, preferably with water, is essential. Advise patients to limit alcohol intake due to its dehydrating effects.

6. Encourage Periodic Movement During Prolonged Sitting: Advise patients to take breaks to stretch and walk during long car or plane trips. In seated positions, encourage ankle circles and foot pumps to promote circulation.

7. Avoid Prolonged Static Sitting: Encourage patients to reposition, move ankles, and lift toes every 15-30 minutes when sitting for extended periods to maintain blood flow.

Pulmonary Embolism Nursing Care Plans

Once nursing diagnoses are identified, nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term patient care goals. Here are examples of nursing care plans for common nursing diagnoses associated with pulmonary embolism:

Acute Pain

Pulmonary embolism often manifests with chest pain described as sharp, stabbing, burning, aching, or dull, typically located under the breastbone or on one side of the chest. Pain often intensifies with deep inspiration, limiting the patient’s ability to breathe deeply.

Nursing Diagnosis: Acute Pain

Related to:

• Blockage of pulmonary blood flow
• Cellular oxygen deprivation
• Hypoxia

As evidenced by:

• Diaphoresis
• Dyspnea
• Clutching chest
• Distraction behaviors
• Facial grimacing
• Guarding behavior
• Positioning to ease pain
• Reports chest pain

Expected Outcomes:

• Patient will report a reduction in chest pain intensity (sharp, stabbing, burning).
• Patient will demonstrate relaxed body language, absence of facial grimacing, reduced dyspnea, and decreased restlessness.

Assessments:

1. Comprehensive Pain Assessment: Thoroughly evaluate pain characteristics (location, quality, intensity, aggravating/relieving factors) to guide interventions.

Interventions:

1. Provide Condition Education: Explain the nature of pain related to PE, the treatment plan, and expected pain management strategies to enhance patient understanding and cooperation.
2. Administer Analgesics as Prescribed: Administer pain medications as ordered. Anticoagulants also contribute to pain relief by improving blood flow. Avoid aspirin and NSAIDs, which can increase bleeding risk.
3. Provide Supplemental Oxygen: Address hypoxia-related pain by ensuring adequate oxygenation.
4. Implement Non-Pharmacological Pain Relief Measures: Employ techniques like relaxation, guided imagery, positioning, and distraction to complement pharmacological pain management and reduce the work of breathing.

Anxiety

The diagnosis of pulmonary embolism often evokes significant fear and anxiety due to the life-threatening nature of the condition and the potential for recurrence.

Nursing Diagnosis: Anxiety

Related to:

• Severe pain
• Perceived threat of death
• Unfamiliar and critical health situation
• Threat to physiological integrity

As evidenced by:

• Diaphoresis
• Elevated blood pressure
• Increased heart rate
• Increased respiratory rate
• Apprehensiveness
• Fixation on perceived threat
• Reduced self-assurance
• Expressed alarm
• Expressed fear
• Expressed dread

Expected Outcomes:

• Patient will verbalize a reduction in anxiety and fear related to pulmonary embolism.
• Patient will demonstrate relaxed demeanor and effective coping mechanisms.
• Patient will actively participate in treatment and preventative measures.

Assessments:

1. Identify Sources of Fear: Explore the specific factors contributing to the patient’s anxiety (e.g., fear of death, recurrence, uncertainty) to tailor interventions.

Interventions:

1. Employ Therapeutic Communication: Utilize active listening, silence, empathy, and clarification techniques to build trust and facilitate open communication about fears and concerns.
2. Engage Support Systems: Encourage family and friends to provide emotional support and reassurance.
3. Maintain a Calm Demeanor: Project calmness and confidence to reassure the patient and reduce panic.
4. Provide Education on Prevention: Empower patients with knowledge about recurrence prevention strategies (smoking cessation, medication adherence, compression stockings, physical activity) to enhance self-efficacy and reduce anxiety.

Decreased Cardiac Tissue Perfusion

Pulmonary embolism can compromise cardiac tissue perfusion by obstructing pulmonary blood flow, leading to reduced oxygenated blood return to the heart and subsequent myocardial ischemia.

Nursing Diagnosis: Decreased Cardiac Tissue Perfusion

Related to:

• Conditions compromising blood supply (pulmonary embolism)
• Structural cardiac impairment
• Myocardial pump dysfunction
• Impaired contractility and relaxation
• Arrhythmias

As evidenced by:

• Decreased cardiac output
• Hypotension
• Diminished peripheral pulses
• Elevated central venous pressure (CVP)
• Increased pulmonary artery pressure (PAP)
• Tachycardia
• Dysrhythmias
• Ejection fraction < 40%
• Decreased oxygen saturation
• Abnormal heart sounds (S3, S4)
• Chest pain

Expected Outcomes:

• Patient will maintain heart rate and rhythm within normal limits.
• Patient will demonstrate ejection fraction within acceptable parameters.
• Patient will not develop right-sided heart failure.

Assessments:

1. Cardiovascular Status Assessment: Monitor for signs of acute cor pulmonale (right heart failure due to pulmonary hypertension) precipitated by PE. Assess for pre-existing cardiac conditions that may complicate PE management.
2. Deep Vein Thrombosis (DVT) Assessment: Examine lower extremities for signs of DVT as the usual origin of PE.
3. Electrocardiogram (ECG) Monitoring: Continuously monitor ECG for dysrhythmias associated with PE-induced cardiac stress.

Interventions:

1. Consider ECMO for Hemodynamic Instability: For patients with severe hemodynamic compromise, ECMO may provide temporary cardiopulmonary support.
2. Initiate Anticoagulation Therapy: Administer prescribed anticoagulants promptly to prevent further clot propagation and improve perfusion.
3. Administer Thrombolytic Therapy: For massive PE, thrombolytic therapy may be indicated to rapidly dissolve clots and improve cardiac perfusion.
4. Prepare for Potential Clot Removal: Be prepared to assist with percutaneous thrombectomy or surgical embolectomy if indicated to restore pulmonary blood flow.

Impaired Gas Exchange

Pulmonary embolism directly disrupts gas exchange by creating a ventilation-perfusion mismatch, hindering oxygen and carbon dioxide transfer in the lungs, increasing the risk of hypoxemia and respiratory failure.

Nursing Diagnosis: Impaired Gas Exchange

Related to:

• Pulmonary embolism
• Ineffective gas exchange
• Alveolar-capillary membrane alterations
• Ventilation-perfusion imbalance

As evidenced by:

• Abnormal arterial blood gases (ABGs)
• Hypoxemia (PaO2 < normal range)
• Hypoxia (clinical signs of oxygen deficiency)
• Abnormal skin color (cyanosis, pallor)
• Altered respiratory depth and rhythm
• Tachypnea
• Confusion
• Diaphoresis
• Restlessness

Expected Outcomes:

• Patient will demonstrate improved gas exchange evidenced by improving ABGs.
• Patient will maintain adequate oxygenation (SpO2 and respiratory rate within normal limits).

Assessments:

1. Arterial Blood Gas (ABG) Analysis: Monitor ABGs to assess respiratory function and oxygenation status. PE typically causes low PaO2 and PaCO2 due to ventilation-perfusion mismatch.
2. Breathing Pattern and Rate Assessment: Evaluate respiratory rate, depth, and effort. Rapid, shallow, or labored breathing indicates impaired gas exchange.
3. Breath Sounds Auscultation: Assess for abnormal breath sounds (wheezes, crackles) that may indicate airway obstruction or fluid accumulation.
4. Mental Status and Behavioral Changes: Monitor for restlessness, confusion, or lethargy, which are signs of hypoxemia and impaired gas exchange.

Interventions:

1. Administer Medications: Promptly administer anticoagulants to prevent clot progression. Thrombolytics (“clot busters”) may be used in severe cases.
2. Assist with Ventilation/Perfusion (V/Q) Scan: Prepare the patient for and assist with V/Q scan if ordered to evaluate ventilation and perfusion in the lungs.
3. Administer Supplemental Oxygen: Provide oxygen therapy to improve oxygenation and alleviate dyspnea.
4. Prepare for Surgical Intervention: Prepare for embolectomy or vena cava filter placement if indicated to improve gas exchange and prevent further emboli.

Ineffective Breathing Pattern

Pulmonary embolism can lead to an ineffective breathing pattern due to reduced lung perfusion, pain, anxiety, and physiological responses to hypoxemia.

Nursing Diagnosis: Ineffective Breathing Pattern

Related to:

• Blood clot obstruction in pulmonary circulation
• Ineffective gas exchange
• Insufficient oxygenated blood
• Myocardial pump dysfunction
• Ventilation-perfusion imbalance

As evidenced by:

• Elevated central venous pressure
• Increased pulmonary artery pressure
• Tachycardia
• Decreased oxygen saturation
• Chest pain
• Dyspnea
• Tachypnea
• Accessory muscle use
• Cough
• Altered level of consciousness
• Restlessness
• Fatigue
• Activity intolerance
• Cyanosis
• Abnormal ABGs

Expected Outcomes:

• Patient will maintain oxygen saturation within normal limits.
• Patient will exhibit an alert, conscious, and coherent level of consciousness.
• Patient will maintain a respiratory rate of 12-18 breaths per minute without accessory muscle use or cyanosis.

Assessments:

1. Respiratory Status Assessment: Continuously monitor respiratory rate, depth, effort, and oxygen saturation. Assess for signs of respiratory distress.
2. Lung Sounds Auscultation: Auscultate for adventitious breath sounds such as bibasilar crackles or wheezing.
3. Arterial Blood Gas (ABG) Analysis Review: Monitor ABGs for hypoxemia and respiratory alkalosis.
4. Chest X-ray Review: Review chest X-ray results to rule out other pulmonary conditions, although X-rays are not diagnostic for PE itself.

Interventions:

1. Administer Oxygen as Prescribed: Provide supplemental oxygen to maintain SpO2 above 90%.
2. Consider Mechanical Ventilation: Prepare for mechanical ventilation if the patient develops respiratory failure or severe respiratory distress.
3. Optimize Patient Positioning: Elevate the head of the bed to a semi-Fowler’s or high-Fowler’s position to improve lung expansion and oxygenation.
4. Collaborate with Respiratory Therapy: Work with respiratory therapists to optimize oxygen delivery, ventilation settings, administer breathing treatments, monitor ABGs, and support respiratory function.

References

(References are the same as the original article)