Pulmonary embolism (PE), a critical condition characterized by the blockage of pulmonary arteries by a blood clot, demands prompt diagnosis and intervention. These emboli, often originating from deep vein thrombosis (DVT), impede pulmonary blood flow, leading to compromised oxygenation, impaired gas exchange, and potentially life-threatening pulmonary tissue hypoxia. Less frequent causes include fat emboli from fractures, air emboli from intravenous procedures, and amniotic fluid emboli. In the realm of nursing, understanding the nuances of pulmonary embolism and formulating accurate nursing diagnoses are paramount for effective patient care and improved outcomes.
This article delves into the essential aspects of nursing care for patients with pulmonary embolism, focusing on the crucial role of nursing diagnosis. We will explore the nursing process, encompassing assessment, interventions, and care planning, all centered around the core concept of “Nursing Diagnosis For Pulmonary Embolism.” This guide aims to equip nurses and nursing students with the knowledge and skills necessary to provide optimal care for individuals experiencing this serious health challenge.
Nursing Process in Pulmonary Embolism
The nursing process serves as the cornerstone of effective care for patients with pulmonary embolism. Early and accurate diagnosis coupled with immediate treatment are critical in mitigating mortality risk. The primary goals of nursing care in PE management are multifaceted: to restore and maintain adequate tissue perfusion, optimize pulmonary function, and prevent the formation of new thrombi, subsequent complications, and the recurrence of PE. Nurses are integral to this process, providing life-sustaining ventilatory and surgical support, administering prescribed medications, and empowering patients through education to minimize their risk of future pulmonary embolic events.
Nursing Assessment: Gathering Crucial Data
The initial phase of the nursing process, nursing assessment, is where nurses systematically collect comprehensive data encompassing the patient’s physical, psychosocial, emotional, and diagnostic status. This data collection, involving both subjective and objective information, forms the bedrock upon which accurate nursing diagnoses and tailored care plans are built for pulmonary embolism.
Review of Health History: Uncovering Risk Factors and Symptoms
1. Comprehensive Symptom Assessment: A detailed evaluation of the patient’s complaints and presenting symptoms is the first step. Meticulous documentation should include:
- Dyspnea: Subjective experience of shortness of breath, a hallmark symptom of PE.
- Tachypnea: Rapid breathing, an objective sign of respiratory distress.
- Fever: Elevated body temperature, potentially indicating inflammation or infection, although less specific to PE.
- Cough: May be present, sometimes productive, but not always a prominent feature.
- Chest pain: Often pleuritic (sharp, worsened by breathing), but can vary.
- Hemoptysis: Coughing up blood, suggesting pulmonary tissue involvement.
- Crackles: Abnormal lung sounds heard on auscultation, indicating fluid in the lungs.
- Wheezing: High-pitched whistling sounds, suggesting airway narrowing, though less common in typical PE.
- Syncope: Fainting or loss of consciousness, potentially due to reduced cerebral perfusion from PE.
- Mental status alterations: Confusion, disorientation, or changes in alertness, indicating hypoxia or reduced brain perfusion.
- Hypotension: Low blood pressure, a sign of hemodynamic instability, especially in massive PE.
- Lower extremity pain: Calf pain or tenderness, suggestive of DVT, the primary source of most PEs.
- Cold, clammy skin: Signs of poor peripheral perfusion and shock.
- Cyanosis: Bluish discoloration of the skin and mucous membranes, indicating severe hypoxemia.
2. Risk Factor Identification: Determining the patient’s risk profile for PE is crucial. Key risk factors include:
- Reduced mobility/Bed rest: Prolonged immobility increases venous stasis and clot formation.
- History of venous thromboembolism (VTE): Prior DVT or PE significantly elevates future risk.
- Cancer: Certain cancers and cancer treatments increase hypercoagulability.
- Recent surgery: Surgical procedures, especially orthopedic and abdominal, increase VTE risk.
- Obesity: Associated with increased risk of DVT and PE.
- Oral contraceptives and Hormone Replacement Therapy (HRT): Estrogen-containing medications increase clotting risk.
- Varicose veins: Impaired venous flow in varicose veins can contribute to clot formation.
- Pregnancy: Pregnancy and the postpartum period are hypercoagulable states.
- Smoking: Damages blood vessels and increases hypercoagulability.
- Clotting disorders (thrombophilia): Inherited or acquired conditions that predispose to blood clots.
3. Family History Assessment: A family history of PE or venous blood clots in first-degree relatives (parents, siblings) increases the patient’s risk.
4. Past and Present Medical History Review: A comprehensive review of the patient’s medical history, including past illnesses, surgeries, medications, and allergies, is essential to identify predisposing factors for PE. Gathering information from the patient and family members is important, especially if the patient is confused. Examining medical records, including notes, family history, surgical history, and recent test results, provides valuable insights.
5. Pulmonary Embolism Rule-out Criteria (PERC) Utilization: The PERC rule is a valuable tool in emergency departments 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:
- Age ≥ 50 years
- Heart rate ≥ 100 bpm
- Oxygen saturation on room air < 90%
- Hemoptysis
- Hormone replacement therapy or oral contraceptive use
- Prior DVT or PE
- Unilateral leg edema
- Surgery or trauma within the past four weeks
Alt text: ECG readout displaying sinus tachycardia, a rapid heart rate, which can be indicative of pulmonary embolism.
Physical Assessment: Identifying Clinical Signs
1. Rapid Assessment of Unexplained Symptoms: Pulmonary embolism is a medical emergency. Promptly assess patients presenting with unexplained dyspnea, chest pain, or syncope, as these are cardinal symptoms of PE. These symptoms warrant immediate medical evaluation.
2. Vital Signs Monitoring: Vital signs provide critical physiological data. Depending on the clot size and the extent of lung tissue affected, vital signs may range from normal to significantly abnormal. Large emboli often lead to unstable vital signs, manifesting as:
- Tachycardia: Elevated heart rate, a compensatory mechanism to maintain cardiac output.
- Tachypnea: Increased respiratory rate, reflecting the body’s attempt to improve oxygenation.
- Hypotension: Low blood pressure, indicating hemodynamic compromise.
- Hypoxia: Low oxygen saturation, directly resulting from impaired gas exchange.
3. Systemic Assessment Approach: A systematic physical examination is essential to identify signs of PE across different body systems:
- Neck: Distended jugular veins (JVD) can indicate right ventricular strain and increased central venous pressure.
- Central Nervous System (CNS): Decreased level of consciousness can result from hypoxemia and reduced cerebral perfusion.
- Cardiovascular:
- Pleuritic chest pain: Pain worsened by inspiration, often localized.
- Arrhythmias: Irregular heart rhythms due to cardiac stress.
- Tachycardia: As mentioned earlier, a common cardiac response.
- Circulatory:
- Palpable cords: Indurated, tender veins in the extremities, suggestive of thrombophlebitis or DVT.
- Palpitations: Awareness of rapid or irregular heartbeat.
- Respiratory:
- Dyspnea: Shortness of breath, the most common respiratory symptom.
- Cough: May be present, non-productive or with hemoptysis.
- Hemoptysis: Coughing up blood.
- Tachypnea: Rapid breathing.
- Persistent cough: Unexplained or worsening cough.
- Rales (crackles): Abnormal lung sounds, indicating fluid in the alveoli.
- Decreased breath sounds: Reduced air entry in affected lung regions.
- Loud pulmonic closure sound (P2): Accentuated second heart sound component, suggesting pulmonary hypertension.
- Right-sided S3 or S4 gallop: Abnormal heart sounds, indicating right ventricular dysfunction.
- Hypoxemia: Low blood oxygen levels.
- Lymphatic: Swelling of lower extremities and pedal edema: Signs of venous insufficiency and potential DVT.
- Musculoskeletal:
- Syncope: Fainting.
- Calf pain: Suggestive of DVT.
- Fatigue: Generalized weakness and tiredness.
- Muscle weakness: May be present due to hypoxemia and general illness.
- Integumentary:
- Erythema: Redness of skin, potentially associated with DVT or inflammation.
- Cyanotic or pale skin: Reflecting hypoxemia or poor perfusion.
- Excessive sweating (diaphoresis): Autonomic response to stress and pain.
Alt text: Nurse auscultating a patient’s lungs with a stethoscope, a key diagnostic procedure for assessing pulmonary embolism.
Diagnostic Procedures: Confirming the Diagnosis
Note: It’s crucial to remember that chest pain and dyspnea are not specific to PE and can be indicative of other serious conditions like myocardial infarction, pneumonia, pneumothorax, or aortic dissection. Initial physical examination often focuses on ruling out these alternative diagnoses.
1. Electrocardiogram (ECG): While ECG findings in PE are often non-specific or even normal, certain abnormalities can suggest PE or rule out other cardiac conditions. Common ECG findings in PE include:
- Sinus Tachycardia: Rapid heart rate.
- Non-specific ST-segment and T-wave changes: Suggesting myocardial ischemia or strain.
- S1Q3T3 pattern: Classic but infrequent ECG pattern in PE, indicating right ventricular strain.
- Right ventricular strain: Signs of stress on the right ventricle.
- New incomplete right bundle branch block: Conduction delay in the right ventricle.
2. D-dimer Blood Test: This blood test measures D-dimer, a protein fragment resulting from clot breakdown. A normal D-dimer level makes PE less likely, but an elevated D-dimer is not specific for PE and can be elevated in other conditions. It’s useful for ruling out PE in low-risk patients but not for confirming it.
3. Other Blood Tests:
- Complete Blood Count (CBC) with differential: Assesses for anemia, infection, and platelet count, which can be relevant in PE management.
- Prothrombin Time (PT)/International Normalized Ratio (INR) and Partial Thromboplastin Time (PTT): Evaluate blood clotting function, important for anticoagulant therapy.
4. Chest X-ray: Chest X-rays in PE are often normal, but they are essential to rule out other pulmonary conditions such as pneumonia or pneumothorax that can mimic PE symptoms. Occasionally, subtle findings like Westermark’s sign or Hampton’s hump might be seen, but these are not sensitive or specific for PE.
5. Computed Tomography Pulmonary Angiography (CTPA): CTPA is the gold standard imaging modality for diagnosing PE. It provides detailed images of the pulmonary arteries, allowing for direct visualization of blood clots. It is highly sensitive and specific for PE diagnosis.
6. Further Investigations:
- Ventilation/Perfusion (V/Q) Scan: A nuclear medicine scan that compares airflow (ventilation) and blood flow (perfusion) in the lungs. Useful when CTPA is contraindicated (e.g., pregnancy, severe kidney disease, contrast allergy) or when additional testing is needed. V/Q scan remains the preferred imaging test for PE in pregnancy.
- Echocardiogram: Ultrasound of the heart, can detect signs of right ventricular strain and pulmonary hypertension, supportive of PE diagnosis.
- Venous Doppler Ultrasound: Used to detect DVT in the legs, a common source of PE. Particularly helpful in patients with leg pain or swelling.
- Chest CT Scan (without angiography): While CTPA is preferred for PE, a standard chest CT can sometimes identify large, proximal emboli and rule out other lung diseases. Caution is needed with IV contrast in pregnant patients and those with kidney problems or contrast allergies.
Nursing Interventions: Providing Supportive and Therapeutic Care
Nursing interventions are crucial for the recovery and well-being of patients with pulmonary embolism. These interventions encompass supportive care, anticoagulation management, clot dissolution strategies, and measures to prevent recurrence and complications.
Provide Supportive Measures: Stabilizing the Patient
1. Supplemental Oxygen Administration: Oxygen therapy is indicated for patients with oxygen saturation below 90%. The goal is to maintain adequate oxygenation and alleviate hypoxemia. Unstable patients may require advanced respiratory support, including mechanical ventilation.
2. Volume Resuscitation (Cautious): While fluid resuscitation might seem intuitive for hypotension, it must be approached cautiously in PE. Aggressive volume resuscitation in hemodynamically unstable PE, particularly massive PE, can exacerbate right ventricular (RV) failure by causing RV overdistension and reduced cardiac output. Fluid resuscitation should be reserved for patients with clear signs of hypovolemia (e.g., flat jugular veins). Vasopressors may be necessary for hemodynamic support.
3. Life-Saving Measures: ECMO: Extracorporeal membrane oxygenation (ECMO) is a mechanical cardiopulmonary support system that can be life-saving in high-risk, severe PE when conventional therapies fail or if the patient is not a candidate for thrombectomy. ECMO provides temporary circulatory and respiratory support, allowing time for definitive treatment.
Promote Anticoagulation: Preventing Clot Propagation
1. Anticoagulation Rationale: Anticoagulation is the cornerstone of PE treatment. It prevents further clot propagation, reduces the risk of recurrent embolism, and allows the body’s natural fibrinolytic system to break down the existing clot. Anticoagulation also helps alleviate chest and calf pain by improving blood flow.
2. Anticoagulant Administration: Various anticoagulants are used to treat PE:
- Low-molecular-weight heparin (LMWH): Subcutaneous injection, provides predictable anticoagulation, often preferred for initial treatment.
- Unfractionated heparin (UFH): Intravenous infusion, requires close monitoring but can be rapidly reversed if needed.
- Vitamin K antagonists (e.g., Warfarin): Oral medication, requires INR monitoring, used for long-term anticoagulation.
- Non-vitamin K antagonist oral anticoagulants (NOACs) or Direct Oral Anticoagulants (DOACs) (e.g., Apixaban, Rivaroxaban, Dabigatran): Oral medications, offer predictable anticoagulation without routine monitoring, increasingly used for both acute and long-term treatment of DVT and PE.
3. Bleeding Monitoring: A significant risk with all anticoagulants is bleeding. Nurses must diligently monitor for signs of bleeding, including:
- Bloody stools (melena, hematochezia)
- Bruising (ecchymosis)
- Hemoptysis
- Epistaxis (nosebleeds)
- Gingival bleeding
- Unexplained drop in hemoglobin or hematocrit
- Changes in vital signs (hypotension, tachycardia)
4. NOACs/DOACs in PE Management: NOACs/DOACs have become first-line agents for many patients with PE due to their ease of administration and reduced monitoring requirements compared to warfarin. However, specific patient factors and contraindications must be considered.
5. PTT/INR Monitoring: Intravenous unfractionated heparin therapy requires regular monitoring of partial thromboplastin time (PTT) to ensure therapeutic anticoagulation levels. Warfarin therapy requires monitoring of the International Normalized Ratio (INR) to guide dosage adjustments. DOACs generally do not require routine coagulation monitoring.
Dissolve the Clots: Advanced Therapies
1. Catheter-Directed Thrombolytic Therapy: This minimally invasive procedure involves delivering thrombolytic (clot-busting) medication directly to the pulmonary artery at the site of the clot via a catheter. It is considered for patients with massive or submassive PE and high bleeding risk with systemic thrombolysis.
2. Surgical Clot Removal (Thrombectomy/Embolectomy): Surgical removal of the clot may be necessary in patients with massive PE who are hemodynamically unstable and in whom thrombolysis is contraindicated or has failed. This can be performed via catheter-based techniques or open surgical embolectomy.
3. Vena Cava Filters: Inferior vena cava (IVC) filters are small devices placed in the vena cava to trap large clots before they reach the lungs. IVC filters are generally reserved for patients:
- With contraindications to anticoagulation.
- With recurrent VTE despite adequate anticoagulation.
- With massive PE and high risk of recurrent embolism.
It’s important to note that IVC filters are not a substitute for anticoagulation and are associated with long-term complications. Their use should be carefully considered and guideline-driven.
Prevent Recurrence and Complications: Long-Term Strategies
1. Compression Stockings: Graduated compression stockings can aid in preventing post-thrombotic syndrome and recurrent DVT, particularly in patients with a history of VTE. They improve venous blood flow in the legs.
2. Early Ambulation: Encouraging early mobilization after surgery or prolonged immobility is crucial to prevent venous stasis and VTE, including PE.
3. Leg Elevation: Elevating the legs, especially at night and during prolonged sitting, promotes venous drainage and reduces venous pressure in the lower extremities.
4. Pneumatic Compression Devices: Intermittent pneumatic compression (IPC) devices, using thigh-high or calf-high cuffs that inflate and deflate sequentially, enhance venous blood flow and prevent venous stasis, especially in immobile patients.
5. Increased Fluid Intake: Dehydration can increase blood viscosity and promote clot formation. Adequate hydration, especially with water, is important. Alcohol should be avoided due to its diuretic effect.
6. Periodic Movement During Prolonged Sitting: Encourage patients to take breaks to stretch and walk during long car or plane trips. During prolonged sitting, advise ankle circles and foot pumps to promote circulation.
7. Avoid Prolonged Sitting: Advise patients to reposition frequently, even while sitting, and avoid prolonged static positions to maintain blood flow.
Nursing Care Plans: Addressing Specific Patient Needs
Once nursing diagnoses are identified for pulmonary embolism, nursing care plans provide a structured framework for prioritizing assessments and interventions to achieve both short-term and long-term patient goals. The following are examples of nursing care plans for common nursing diagnoses associated with PE.
Acute Pain
Chest pain is a frequent complaint in patients with PE, often described as sharp, stabbing, burning, aching, or dull, located under the breastbone or on one side of the chest. The pain is often pleuritic, exacerbated by deep breathing, which can limit the patient’s ability to take deep breaths.
Nursing Diagnosis: Acute Pain
Related to:
- Blockage of blood flow in pulmonary arteries
- Tissue hypoxia
- Inflammatory mediators
As evidenced by:
- Diaphoresis
- Dyspnea
- Clutching chest
- Distraction behavior
- Facial grimacing
- Guarding behavior
- Positioning to ease pain
- Self-report of chest pain
Expected Outcomes:
- Patient will report a reduction in chest pain intensity and improved comfort level within a specified timeframe.
- Patient will demonstrate relaxed body posture and reduced pain behaviors (e.g., grimacing, guarding).
Assessment:
1. Comprehensive Pain Assessment: Thoroughly assess pain characteristics: location, intensity (using a pain scale), quality, onset, duration, aggravating and relieving factors. Understanding pain characteristics guides intervention strategies.
Interventions:
1. Patient Education about Condition and Pain: Provide clear and accurate information about PE, the cause of chest pain, and the treatment plan. Education reduces anxiety and enhances coping.
2. Administer Analgesics as Prescribed: Administer pain medications as ordered, considering pain intensity and patient needs. Opioids and non-opioid analgesics may be used. Avoid NSAIDs and aspirin due to their antiplatelet effects, which could increase bleeding risk in anticoagulated patients.
3. Supplemental Oxygen Therapy: Administer supplemental oxygen to improve oxygenation and reduce hypoxia-related pain.
4. Non-Pharmacological Pain Relief Measures: Implement non-pharmacological techniques to complement pharmacological pain management:
- Relaxation techniques (deep breathing, guided imagery)
- Positioning for comfort (semi-Fowler’s position)
- Distraction (music, conversation)
- Comfort measures (cool compresses, back rub)
Anxiety
Patients diagnosed with PE often experience significant anxiety and fear due to the seriousness of the condition, the sudden onset of symptoms, and the perceived threat to life. Fear of recurrence is also common even after treatment.
Nursing Diagnosis: Anxiety
Related to:
- Severe pain and dyspnea
- Perceived threat to life/possibility of death
- Unfamiliar hospital environment and procedures
- Uncertainty about prognosis and recovery
As evidenced by:
- Diaphoresis
- Increased blood pressure, heart rate, and respiratory rate
- Apprehensiveness, restlessness
- Focus on perceived threat
- Expressed fear, worry, or dread
- Decreased self-assurance
Expected Outcomes:
- Patient will report a reduction in anxiety levels and demonstrate improved coping mechanisms.
- Patient will exhibit relaxed demeanor, stable vital signs, and engage in calm communication.
Assessment:
1. Anxiety Assessment: Assess the level of anxiety using a validated anxiety scale if appropriate. Explore the specific sources and triggers of the patient’s anxiety.
Interventions:
1. Therapeutic Communication: Employ therapeutic communication techniques to establish trust and rapport:
- Active listening: Pay attention to verbal and nonverbal cues.
- Silence: Allow time for patient to express feelings.
- Offering self: Show willingness to be present and supportive.
- Seeking clarification: Ensure understanding of patient’s concerns.
- Empathy: Communicate understanding and compassion.
2. Involve Support Systems: Encourage family and friends to provide emotional support and presence. Facilitate communication between patient and support network.
3. Maintain Calm Environment: Project a calm and reassuring demeanor. Minimize environmental stressors and noise.
4. Education about PE and Prevention: Provide comprehensive education about PE, treatment, prognosis, and strategies to prevent recurrence. Knowledge empowers patients and reduces fear of the unknown. Address concerns about long-term anticoagulation and lifestyle modifications.
Decreased Cardiac Tissue Perfusion
Pulmonary embolism can significantly impair cardiac tissue perfusion due to the mechanical obstruction of pulmonary blood flow, leading to increased pulmonary vascular resistance, right ventricular strain, and ultimately reduced cardiac output and systemic oxygen delivery.
Nursing Diagnosis: Decreased Cardiac Tissue Perfusion
Related to:
- Pulmonary embolism obstructing pulmonary blood flow
- Increased pulmonary vascular resistance
- Right ventricular dysfunction
As evidenced by:
- Decreased cardiac output
- Hypotension
- Decreased peripheral pulses
- Elevated central venous pressure (CVP) and pulmonary artery pressure (PAP)
- Tachycardia, dysrhythmias
- Reduced ejection fraction (< 40%)
- Hypoxemia
- Abnormal heart sounds (S3, S4)
- Chest pain
Expected Outcomes:
- Patient will maintain adequate cardiac output and tissue perfusion, evidenced by stable vital signs, palpable peripheral pulses, and improved oxygen saturation.
- Patient will not develop right-sided heart failure or other cardiovascular complications.
Assessment:
1. Cardiovascular Status Assessment: Continuously monitor cardiovascular parameters: heart rate, blood pressure, ECG, heart sounds, peripheral pulses, capillary refill, and signs of right ventricular failure (JVD, edema). Assess for any pre-existing cardiac conditions.
2. Deep Vein Thrombosis (DVT) Assessment: Examine legs for signs of DVT (swelling, redness, warmth, tenderness), as DVT is the most common source of PE.
3. ECG Monitoring: Continuously monitor ECG for dysrhythmias and ST-T wave changes indicative of myocardial ischemia or strain.
Interventions:
1. ECMO Consideration for Hemodynamic Instability: In hemodynamically unstable patients with massive PE, ECMO may be necessary to provide temporary circulatory support.
2. Anticoagulation Therapy Initiation: Promptly initiate anticoagulation therapy as ordered to prevent further clot propagation.
3. Thrombolytic Therapy Administration: Administer thrombolytic therapy as indicated for massive PE to dissolve the clot and improve pulmonary blood flow.
4. Prepare for Clot Removal Procedures: Prepare patient for potential percutaneous thrombectomy or surgical embolectomy if indicated.
Impaired Gas Exchange
Pulmonary embolism directly disrupts gas exchange by creating a ventilation-perfusion mismatch. Blocked pulmonary arteries impede blood flow to ventilated alveoli, reducing oxygen uptake and carbon dioxide removal. This can lead to hypoxemia and hypercapnia, increasing the risk of respiratory failure and death.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Ventilation-perfusion mismatch due to pulmonary embolism
- Altered blood flow to alveoli
- Physiological dead space
As evidenced by:
- Abnormal arterial blood gases (ABGs) (hypoxemia, hypercapnia, respiratory acidosis)
- Hypoxemia (SpO2 < 90% on room air)
- Dyspnea, tachypnea
- Altered respiratory depth and rhythm
- Cyanosis, abnormal skin color
- Confusion, restlessness, altered mental status
- Diaphoresis
Expected Outcomes:
- Patient will demonstrate improved gas exchange, evidenced by improved ABGs, oxygen saturation ≥ 90% on supplemental oxygen as needed, and reduced dyspnea.
- Patient will maintain adequate ventilation and oxygenation.
Assessment:
1. Arterial Blood Gas (ABG) Analysis: Monitor ABGs to assess oxygenation (PaO2), carbon dioxide levels (PaCO2), and pH. ABGs provide objective data on gas exchange status.
2. Respiratory Rate and Pattern Assessment: Assess respiratory rate, depth, and effort. Note for tachypnea, labored breathing, use of accessory muscles.
3. Breath Sounds Auscultation: Auscultate breath sounds for adventitious sounds (wheezes, crackles), indicating airway obstruction or fluid accumulation. Note areas of decreased or absent breath sounds.
4. Mental Status and Behavior Assessment: Monitor mental status for restlessness, confusion, lethargy, or agitation, which can indicate hypoxemia.
Interventions:
1. Medication Administration: Administer prescribed medications, including anticoagulants and thrombolytics, to address the underlying PE and improve gas exchange.
2. Assist with V/Q Scan: Prepare patient for and assist with ventilation-perfusion (V/Q) scan if ordered to evaluate ventilation and perfusion patterns in the lungs.
3. Supplemental Oxygen Administration: Administer supplemental oxygen to maintain SpO2 ≥ 90%. Titrate oxygen delivery based on patient needs and ABG results.
4. Prepare for Surgical Interventions: Prepare patient for potential surgical embolectomy or vena cava filter placement if indicated.
Ineffective Breathing Pattern
Pulmonary embolism can lead to an ineffective breathing pattern due to pain, anxiety, hypoxemia, and the physiological effects of the embolus on lung mechanics and gas exchange. Patients may exhibit rapid, shallow breathing, use of accessory muscles, and signs of respiratory distress.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Pulmonary embolism and associated physiological changes
- Pain, anxiety
- Hypoxemia
As evidenced by:
- Tachypnea, dyspnea
- Accessory muscle use
- Cough
- Altered respiratory depth and rhythm
- Decreased oxygen saturation
- Cyanosis
- Altered level of consciousness, restlessness, fatigue
- Abnormal ABGs
Expected Outcomes:
- Patient will demonstrate an effective breathing pattern, evidenced by respiratory rate within normal limits (12-20 breaths/min), regular and unlabored respirations, and SpO2 ≥ 90%.
- Patient will maintain an alert and oriented level of consciousness.
Assessment:
1. Respiratory Status Assessment: Assess respiratory rate, rhythm, depth, and effort. Observe for signs of respiratory distress (nasal flaring, retractions, accessory muscle use).
2. Lung Sounds Auscultation: Auscultate lung sounds to identify adventitious sounds or areas of diminished breath sounds.
3. ABG Analysis Review: Review ABG results for hypoxemia, hypercapnia, and respiratory acidosis, which can contribute to ineffective breathing patterns.
4. Chest X-ray Review: Review chest X-ray findings to rule out other pulmonary conditions and assess for any PE-related findings (although often normal).
Interventions:
1. Oxygen Administration: Administer supplemental oxygen to maintain SpO2 ≥ 90%.
2. Mechanical Ventilation Consideration: Prepare for and assist with mechanical ventilation if the patient develops respiratory failure or severe respiratory distress.
3. Patient Positioning: Position patient in an upright position (semi-Fowler’s or high-Fowler’s) to optimize lung expansion and ventilation.
4. Respiratory Therapy Collaboration: Collaborate with respiratory therapists for oxygen management, ventilation strategies, breathing treatments, and ABG monitoring and interpretation.
