Pulmonary embolism (PE) is a critical condition characterized by the blockage of one or more pulmonary arteries by a blood clot. This obstruction impedes pulmonary blood flow, leading to a cascade of detrimental effects, including reduced oxygenation, impaired gas exchange, decreased tissue perfusion, and pulmonary tissue hypoxia. In severe cases, PE can be fatal.
The majority of pulmonary emboli originate from deep vein thrombosis (DVT), typically in the lower extremities. A thrombus detaches, travels through the bloodstream, and lodges in the pulmonary arteries. Less frequent causes include fat emboli from bone fractures, air emboli from intravenous procedures, and amniotic fluid emboli.
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Early diagnosis and prompt treatment are paramount in mitigating the risk of mortality associated with PE. The primary goals of PE treatment are to restore adequate tissue perfusion, optimize pulmonary function, and prevent the formation of further thrombi, complications, and recurrent episodes of PE.
Nurses play a pivotal role in the multidisciplinary management of PE, providing life-sustaining ventilatory and surgical support, administering medications, and educating patients on risk reduction strategies. This comprehensive guide will delve into the nursing process for pulmonary embolism, including assessment, nursing diagnoses, interventions, and care planning.
Nursing Process for Pulmonary Embolism
The nursing process is a systematic approach to patient care, and it begins with a thorough nursing assessment. This assessment involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to understand the patient’s condition fully. In the context of pulmonary embolism, the nursing assessment is crucial for identifying signs and symptoms, risk factors, and guiding subsequent interventions.
Nursing Assessment
The nursing assessment for pulmonary embolism is a multifaceted process, incorporating a review of health history, physical examination, and diagnostic procedures.
Review of Health History
A detailed health history is essential in identifying potential risk factors and understanding the patient’s presenting symptoms.
1. Elicit Patient Complaints and General Symptoms: Thoroughly document and investigate the following common symptoms associated with PE:
- Dyspnea (shortness of breath): A hallmark symptom of PE, often sudden in onset and unexplained.
- Tachypnea (rapid breathing): The body attempts to compensate for reduced oxygenation by increasing respiratory rate.
- Fever: May be present, although not always a prominent symptom.
- Cough: Can be dry or productive; may be associated with hemoptysis.
- Chest pain: Typically pleuritic (sharp, stabbing pain that worsens with breathing), but can also be described as aching or pressure.
- Hemoptysis (coughing up blood): Indicates lung tissue irritation or infarction.
- Crackles (rales): Adventitious lung sounds that may indicate fluid in the alveoli due to pulmonary congestion.
- Wheezing: May occur due to bronchospasm or airway narrowing.
- Syncope (fainting): Can occur due to decreased cardiac output and cerebral hypoperfusion.
- Mental status alterations: Hypoxia can lead to confusion, restlessness, or decreased level of consciousness.
- Hypotension (low blood pressure): Indicates hemodynamic instability, particularly in massive PE.
- Lower extremity pain (calf pain): Suggestive of DVT, the primary source of most PEs.
- Cold, clammy skin: Reflects poor peripheral perfusion and potential shock.
- Cyanosis (bluish discoloration of the skin): A late sign of severe hypoxemia.
2. Determine Pulmonary Embolism Risk Factors: Identify and document the presence of risk factors that predispose individuals to PE:
- Reduced mobility/bed rest: Prolonged immobility promotes venous stasis and thrombus formation.
- History of venous thromboembolism (VTE): Previous DVT or PE significantly increases the risk of recurrence.
- Cancer: Certain cancers and cancer treatments elevate the risk of hypercoagulability.
- Recent surgery: Surgical procedures, especially orthopedic or abdominal surgeries, increase VTE risk.
- Obesity: Associated with increased venous stasis and prothrombotic factors.
- Oral contraceptives and hormone replacement therapy: Estrogen-containing medications can increase clotting risk.
- Varicose veins: Impaired venous flow in varicose veins contributes to stasis.
- Pregnancy: Pregnancy and the postpartum period are hypercoagulable states.
- Smoking: Damages blood vessels and promotes platelet aggregation.
- Clotting disorders (thrombophilia): Inherited or acquired conditions that predispose to excessive clotting.
3. Explore Family History: Inquire about a family history of PE or venous blood clots in first-degree relatives (parents, siblings), as this can indicate a genetic predisposition to VTE.
4. Review Past and Present Medical History: Obtain a comprehensive medical history, including past illnesses, surgeries, hospitalizations, and current medications. Gather information from the patient and family members if the patient is confused or unable to provide a reliable history. Review medical records, surgical reports, and recent test results. Pay close attention to medications that may increase clotting risk or interact with anticoagulants.
5. Utilize Pulmonary Embolism Rule-out Criteria (PERC): The PERC rule is a clinical decision tool used in emergency departments to assess the probability of PE in patients presenting with symptoms. Patients who are negative for all eight PERC criteria have a very low probability of PE and may avoid further testing.
The eight PERC criteria are:
- Age 50 years or older
- 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 previous four weeks
Physical Assessment
The physical assessment for PE focuses on identifying signs of respiratory distress, hemodynamic instability, and potential sources of emboli.
1. Rapidly Assess for Unexplained Symptoms: Be vigilant for unexplained dyspnea, chest pain, or syncope, as these are cardinal symptoms of PE and require immediate medical attention. PE is a medical emergency due to the potential for rapid deterioration and life-threatening complications.
2. Monitor Vital Signs Continuously: Vital signs are crucial indicators of the patient’s hemodynamic status and response to PE. Monitor for:
- Tachycardia: Heart rate > 100 bpm, a common compensatory mechanism to maintain cardiac output.
- Tachypnea: Respiratory rate > 20 breaths per minute, reflecting the body’s attempt to improve oxygenation.
- Hypotension: Systolic blood pressure < 90 mmHg or a significant drop from baseline, indicating potential shock.
- Hypoxia: Oxygen saturation < 90% on room air, signifying inadequate oxygen delivery to tissues.
3. Conduct a Systemic Physical Examination: A systematic approach ensures that all relevant body systems are assessed:
- Neck: Assess for jugular vein distention (JVD), which can indicate right ventricular overload and heart failure.
- Central Nervous System (CNS): Evaluate level of consciousness, alertness, and orientation. Decreased LOC may indicate hypoxia or cerebral hypoperfusion.
- Cardiovascular: Auscultate heart sounds for murmurs, gallops, or arrhythmias. Assess for chest pain, noting location, character, and radiation. Palpate peripheral pulses for rate, rhythm, and strength.
- Circulatory: Examine extremities for palpable cords (indicating thrombosed veins), edema (especially unilateral leg edema suggestive of DVT), and skin temperature and color.
- Respiratory: Assess respiratory rate, depth, and effort. Auscultate breath sounds for adventitious sounds (crackles, wheezes), decreased breath sounds, or pleural friction rub. Note any cough or hemoptysis. Observe for signs of respiratory distress, such as nasal flaring, accessory muscle use, and cyanosis. Listen for a loud pulmonic closure sound (P2) or right-sided gallop, which can indicate pulmonary hypertension. Assess for hypoxemia using pulse oximetry.
- Lymphatic: Palpate for swelling in the lower extremities and assess for pedal edema.
- Musculoskeletal: Assess for syncope, calf pain (Homans’ sign is not reliable and not routinely recommended), fatigue, and muscle weakness.
- Integumentary: Observe skin color (cyanosis, pallor, erythema), temperature, and moisture. Note any diaphoresis (excessive sweating).
Diagnostic Procedures
While clinical assessment is crucial, diagnostic procedures are necessary to confirm the diagnosis of pulmonary embolism.
Note: It’s important to remember that chest pain and shortness of breath are not specific to PE and can be symptoms of other conditions like myocardial infarction, pneumonia, pneumothorax, or aortic dissection. Therefore, a thorough differential diagnosis is essential.
1. Electrocardiogram (ECG): Obtain an ECG to assess cardiac rhythm and rule out cardiac causes of chest pain. ECG findings in PE are often nonspecific, but may include:
- Sinus tachycardia
- Nonspecific ST-segment and T-wave changes
- S1Q3T3 pattern (classic but infrequent in PE)
- Right ventricular strain patterns (e.g., T-wave inversions in anterior leads)
- New incomplete right bundle branch block
2. D-dimer Blood Test: Order a D-dimer assay. D-dimer is a fibrin degradation product that is elevated in the presence of thrombus formation and breakdown. A normal D-dimer level in a low-risk patient can effectively rule out PE. However, elevated D-dimer is not specific for PE and can be elevated in other conditions.
3. Other Blood Tests:
- Complete Blood Count (CBC) with differential: May reveal anemia, infection, or underlying hematologic disorders.
- Coagulation studies (PT/INR, PTT): Baseline coagulation studies are important before initiating anticoagulation therapy.
4. Chest X-ray: A chest X-ray is often normal in PE but is essential to rule out other pulmonary conditions like pneumonia or pneumothorax. It may show nonspecific findings such as atelectasis or pleural effusion.
5. Computed Tomography Pulmonary Angiography (CTPA): CTPA is the gold standard imaging modality for diagnosing PE. It is a highly sensitive and specific test that visualizes the pulmonary arteries and can directly detect blood clots.
6. Ventilation/Perfusion (V/Q) Scan: A V/Q scan may be used when CTPA is contraindicated (e.g., pregnancy, contrast allergy, renal insufficiency) or when further evaluation is needed. V/Q scanning assesses airflow (ventilation) and blood flow (perfusion) in the lungs. A mismatch between ventilation and perfusion can suggest PE. V/Q scan remains the preferred imaging modality for suspected PE in pregnant women.
7. Echocardiogram: An echocardiogram (ultrasound of the heart) can assess for right ventricular strain or dysfunction, which is a common complication of PE. It can also rule out cardiac conditions that mimic PE.
8. Venous Doppler Ultrasound: If DVT is suspected as the source of PE, a venous Doppler ultrasound of the lower extremities can be performed to detect thrombi in the deep veins.
9. Chest CT Scan (without angiography): While CTPA is preferred, a standard chest CT scan (without contrast angiography) may be helpful in ruling out other pulmonary conditions and can sometimes indirectly suggest PE. However, it is not as sensitive as CTPA for detecting pulmonary emboli directly. Be mindful of contrast dye contraindications in patients with pregnancy, kidney problems, or allergies to seafood or iodine.
Nursing Interventions for Pulmonary Embolism
Nursing interventions for pulmonary embolism are directed towards providing supportive care, promoting anticoagulation, dissolving clots, and preventing recurrence and complications.
Supportive Measures
1. Administer Supplemental Oxygen: Hypoxemia is a major concern in PE. Administer supplemental oxygen to maintain oxygen saturation above 90%. Patients with severe respiratory distress or hemodynamic instability may require high-flow oxygen or mechanical ventilation.
2. Aggressive Volume Resuscitation with Caution: While fluid resuscitation may seem intuitive for hypotension, it must be administered cautiously in hemodynamically unstable PE patients. Excessive fluid administration can overdistend the right ventricle, worsening right ventricular failure and decreasing cardiac output. Volume resuscitation should be guided by clinical assessment, focusing on patients with evidence of hypovolemia (e.g., flat jugular veins). Vasopressors may be necessary to support blood pressure.
3. Consider Life-Saving Measures: In high-risk, massive PE cases where conventional therapies fail, or if the patient is not a candidate for thrombectomy, extracorporeal membrane oxygenation (ECMO) may be considered as a temporary mechanical cardiopulmonary support.
Promote Anticoagulation
1. Understand the Rationale for Anticoagulation: Anticoagulation is the cornerstone of PE treatment. It prevents further clot propagation, reduces the risk of new clot formation, and allows the body’s natural thrombolytic mechanisms to dissolve existing clots. Anticoagulation also helps alleviate chest and calf pain by improving blood flow.
2. Administer Anticoagulants as Prescribed: Commonly used anticoagulants for PE include:
- Low-molecular-weight heparin (LMWH): Such as enoxaparin or dalteparin, often preferred for initial anticoagulation due to ease of administration (subcutaneous injection) and predictable pharmacokinetics.
- Unfractionated heparin (UFH): Administered intravenously, allowing for rapid onset and offset of action. Requires monitoring of activated partial thromboplastin time (aPTT).
- Factor Xa inhibitors (e.g., fondaparinux): Another option for initial anticoagulation.
3. Monitor for Bleeding Complications: All anticoagulants carry a risk of bleeding. Closely monitor patients for signs of bleeding, including:
- Hematuria (blood in urine)
- Melena or hematochezia (bloody stools)
- Bruising
- Hemoptysis
- Epistaxis (nosebleeds)
- Gingival bleeding (gum bleeding)
- Unexpected drop in hemoglobin or hematocrit
4. Consider Non-Vitamin K Antagonist Oral Anticoagulants (NOACs) or Direct Oral Anticoagulants (DOACs): NOACs/DOACs, such as dabigatran, rivaroxaban, apixaban, and edoxaban, are increasingly used for both acute treatment and long-term secondary prevention of DVT and PE. They offer advantages over warfarin, including fixed dosing and no routine coagulation monitoring.
5. Monitor PTT/INR as Indicated: For patients receiving intravenous unfractionated heparin, monitor aPTT to ensure therapeutic anticoagulation levels are achieved. For patients on warfarin, monitor INR to guide dose adjustments. DOACs generally do not require routine coagulation monitoring.
Dissolve the Clots
1. Assist with Catheter-Directed Thrombolytic Therapy: In patients with massive or submassive PE and high bleeding risk, catheter-directed thrombolysis may be considered. This involves delivering thrombolytic medications directly to the clot site in the pulmonary artery via a catheter.
2. Prepare for Surgical Embolectomy or Thrombectomy: Surgical embolectomy (removal of the embolus) or thrombectomy (removal of the thrombus) may be necessary in rare cases of massive PE with hemodynamic instability when thrombolysis is contraindicated or has failed. These procedures are typically performed in specialized centers.
3. Consider Vena Cava Filters: Inferior vena cava (IVC) filters are small, mesh-like devices placed in the IVC to trap large clots and prevent them from traveling to the lungs. IVC filters are generally reserved for patients:
- With contraindications to anticoagulation
- Who experience recurrent PE despite adequate anticoagulation
- With massive PE and high risk of early recurrence
Prevent Recurrence and Complications
1. Encourage Use of Compression Stockings: For patients with a history of VTE, particularly DVT, compression stockings can help prevent venous stasis and reduce the risk of recurrent DVT. They provide graduated compression to the legs, improving venous blood flow.
2. Promote Early Ambulation and Mobilization: Post-operatively and for all hospitalized patients, encourage early ambulation and mobilization as soon as medically stable. Movement helps prevent venous stasis and thrombus formation.
3. Elevate Legs: Instruct patients to elevate their legs when sitting and at night to promote venous return and reduce edema.
4. Utilize Pneumatic Compression Devices: Pneumatic compression devices (intermittent pneumatic compression or IPC) consist of thigh-high or calf-high cuffs that inflate and deflate sequentially, mimicking muscle contractions and improving venous circulation. They are often used in hospitalized patients at risk for VTE.
5. Increase Fluid Intake and Prevent Dehydration: Dehydration can increase blood viscosity and promote clot formation. Encourage adequate fluid intake, especially water. Advise patients to avoid excessive alcohol consumption, as it can lead to dehydration.
6. Promote Periodic Movement During Prolonged Sitting: Advise patients to take breaks to stretch and walk around during long car or plane trips. When seated for extended periods, encourage ankle pumps and leg exercises to promote circulation.
7. Avoid Prolonged Static Sitting or Standing: Encourage frequent repositioning and movement, even when sitting, to maintain adequate circulation.
Pulmonary Embolism Nursing Care Plans
Nursing care plans are essential tools for organizing and delivering patient care. They provide a framework for identifying patient needs, setting goals, and implementing evidence-based interventions. Here are examples of nursing care plans for common nursing diagnoses associated with pulmonary embolism:
Acute Pain
Pulmonary embolism frequently causes chest pain, which can be described as sharp, stabbing, burning, or aching. The pain is often pleuritic, worsening with deep breathing, and may limit the patient’s ability to take deep breaths.
Nursing Diagnosis: Acute Pain
Related to:
- Blockage of pulmonary blood flow
- Myocardial ischemia secondary to decreased oxygen supply
- Tissue hypoxia
As evidenced by:
- Diaphoresis
- Dyspnea
- Clutching chest
- Distraction behavior
- Facial grimacing
- Guarding behavior
- Positioning to ease pain
- Reports pain in the chest area (specify location, character, intensity)
Expected Outcomes:
- Patient will report a decrease in chest pain intensity and improved comfort level within a specified timeframe.
- Patient will demonstrate relaxed body language and reduced pain behaviors (grimacing, guarding).
- Patient will verbalize effective pain management strategies.
Assessment:
1. Conduct a Comprehensive Pain Assessment: Utilize a pain assessment tool (e.g., numerical rating scale, visual analog scale) to determine the characteristics of the pain (location, quality, intensity, aggravating/relieving factors). Assess the impact of pain on the patient’s functional abilities and quality of life.
Interventions:
1. Provide Accurate Information about the Condition and Pain: Explain the cause of chest pain in PE, emphasizing that it is related to the blockage of blood flow and reduced oxygen supply to the lungs and heart. Educate the patient about the treatment plan and expected pain relief.
2. Administer Medications as Prescribed: Administer analgesic medications as ordered by the physician. This may include opioids for severe pain or non-opioid analgesics for milder pain. Administer anticoagulants as prescribed to address the underlying cause of PE and indirectly reduce pain. Avoid aspirin and NSAIDs, which can increase bleeding risk in patients receiving anticoagulation.
3. Provide Supplemental Oxygen: Ensure adequate oxygenation by administering supplemental oxygen as prescribed to alleviate hypoxia-related pain and improve tissue oxygen delivery.
4. Implement Non-Pharmacological Pain Relief Measures: Utilize non-pharmacological pain management techniques to complement pharmacological interventions. These may include:
- Relaxation techniques: Deep breathing exercises, guided imagery, meditation.
- Positioning: Help the patient find a comfortable position that minimizes chest discomfort.
- Distraction: Engage the patient in activities that divert attention from pain, such as listening to music, reading, or watching television.
- Gentle massage (if not contraindicated by anticoagulation status).
Anxiety
The diagnosis of pulmonary embolism is often frightening for patients due to the potential severity and life-threatening nature of the condition. Patients may experience significant anxiety related to dyspnea, chest pain, the unfamiliar hospital environment, and fear of recurrence or death.
Nursing Diagnosis: Anxiety
Related to:
- Severe pain and dyspnea
- Perceived threat to health and well-being
- Possibility of death
- Unfamiliar hospital environment and procedures
- Fear of recurrence
As evidenced by:
- Verbalization of anxious feelings, fear, worry, or apprehension
- Restlessness, agitation
- Increased heart rate, respiratory rate, and blood pressure
- Diaphoresis
- Trembling
- Difficulty concentrating
- Insomnia
Expected Outcomes:
- Patient will report a reduction in anxiety level and demonstrate coping mechanisms to manage anxiety.
- Patient will exhibit calm demeanor and relaxed body language.
- Patient will verbalize understanding of the condition, treatment plan, and strategies for managing anxiety.
Assessment:
1. Assess the Source and Level of Anxiety: Explore the patient’s specific fears and concerns related to PE. Use anxiety assessment tools (e.g., Generalized Anxiety Disorder 7-item scale – GAD-7) to quantify anxiety levels. Assess the patient’s coping mechanisms and support systems.
Interventions:
1. Establish Therapeutic Communication and Build Trust: Utilize therapeutic communication techniques, such as active listening, empathy, and open-ended questions, to encourage the patient to express their feelings and concerns. Provide a calm and reassuring presence.
2. Involve Support Systems: Encourage family and friends to visit and provide emotional support. Facilitate communication between the patient and their support network.
3. Maintain a Calm and Supportive Environment: Minimize environmental stressors and create a quiet and comfortable environment.
4. Provide Education and Information: Provide clear, concise, and accurate information about PE, its causes, treatment, and prognosis. Address the patient’s specific questions and concerns. Educate the patient about strategies for preventing PE recurrence, such as medication adherence, lifestyle modifications, and risk factor management.
5. Teach Relaxation Techniques: Instruct the patient in relaxation techniques, such as deep breathing exercises, progressive muscle relaxation, or guided imagery, to help manage anxiety.
6. Consult Mental Health Professionals if Needed: If anxiety is severe or persistent, consider consulting with a mental health professional (e.g., psychiatric nurse, psychologist, psychiatrist) for further evaluation and management.
Decreased Cardiac Tissue Perfusion
Pulmonary embolism can significantly impair cardiac tissue perfusion due to reduced oxygenated blood flow to the heart muscle and increased right ventricular strain.
Nursing Diagnosis: Decreased Cardiac Tissue Perfusion
Related to:
- Conditions that compromise blood supply to the myocardium (pulmonary embolism obstructing pulmonary blood flow)
- Structural impairment of the heart (right ventricular strain and dysfunction)
- Difficulty of the heart muscle to pump effectively (decreased cardiac output)
- Inability of the heart to contract and relax effectively
- Potential for dysrhythmias
As evidenced by:
- Decreased cardiac output (hypotension, decreased peripheral pulses)
- Increased central venous pressure (CVP) and pulmonary artery pressure (PAP)
- Tachycardia, dysrhythmias
- Ejection fraction less than 40% (if measured)
- Decreased oxygen saturation
- Presence of abnormal heart sounds (S3, S4)
- Chest pain (angina)
- ECG changes (ischemia, dysrhythmias)
Expected Outcomes:
- Patient will maintain adequate cardiac output and tissue perfusion as evidenced by stable vital signs (heart rate, blood pressure within acceptable limits), palpable peripheral pulses, and adequate oxygen saturation.
- Patient will demonstrate improved cardiac function and resolution of right ventricular strain.
- Patient will not develop complications of decreased cardiac tissue perfusion, such as right-sided heart failure.
Assessment:
1. Continuously Assess Cardiovascular Status: Monitor vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) frequently. Assess for signs of decreased cardiac output, such as hypotension, tachycardia, weak peripheral pulses, cool and clammy skin, and decreased urine output. Auscultate heart sounds for murmurs, gallops, or arrhythmias. Monitor ECG for dysrhythmias or ischemic changes.
2. Assess for Signs of Deep Vein Thrombosis (DVT): Examine the legs for signs and symptoms of DVT, such as unilateral leg edema, calf pain, warmth, and redness, as DVT is the primary source of most PEs.
3. Obtain and Monitor ECG: Obtain a baseline ECG and monitor for any changes indicative of cardiac ischemia or dysrhythmias.
Interventions:
1. Consider Extracorporeal Membrane Oxygenation (ECMO) for Hemodynamically Unstable Patients: In patients with severe hemodynamic compromise, ECMO may provide temporary cardiopulmonary support.
2. Initiate and Manage Anticoagulation Therapy: Administer anticoagulants as prescribed to prevent further clot propagation and improve pulmonary blood flow. Monitor coagulation studies (aPTT, INR) as indicated and adjust anticoagulant doses accordingly.
3. Administer Thrombolytic Therapy as Indicated: In patients with massive PE and hemodynamic instability, thrombolytic therapy may be considered to dissolve the clot and restore pulmonary blood flow. Carefully assess for contraindications to thrombolysis and monitor for bleeding complications.
4. Anticipate and Prepare for Potential Clot Removal Procedures: Prepare the patient for potential percutaneous thrombectomy or surgical embolectomy if indicated. Provide pre- and post-procedure care as needed.
5. Optimize Fluid Balance: Maintain adequate hydration, but avoid fluid overload, which can exacerbate right ventricular dysfunction. Monitor fluid intake and output, and assess for signs of fluid overload (e.g., edema, JVD, crackles).
6. Administer Medications to Support Cardiac Function: Administer medications as prescribed to improve cardiac contractility, reduce afterload, or manage dysrhythmias. These may include inotropes, vasopressors, or antiarrhythmics.
7. Monitor for Complications of Decreased Cardiac Tissue Perfusion: Closely monitor for signs and symptoms of right-sided heart failure, such as JVD, peripheral edema, hepatomegaly, and ascites.
Impaired Gas Exchange
Pulmonary embolism directly disrupts gas exchange by obstructing pulmonary blood flow and creating ventilation-perfusion mismatch.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Pulmonary embolism (mechanical obstruction of pulmonary arteries)
- Ventilation-perfusion imbalance
- Alveolar-capillary membrane changes (potential for inflammation and edema)
As evidenced by:
- Abnormal arterial blood gases (ABGs) – hypoxemia (PaO2 < 80 mmHg), hypocapnia (PaCO2 < 35 mmHg initially, may normalize or increase later)
- Hypoxia (SpO2 < 90%)
- Cyanosis
- Altered respiratory rate, rhythm, and depth (tachypnea, dyspnea)
- Confusion, restlessness, altered mental status
- Diaphoresis
Expected Outcomes:
- Patient will demonstrate improved gas exchange as evidenced by improved ABGs, oxygen saturation ≥ 95% on supplemental oxygen as needed, and reduced dyspnea.
- Patient will maintain adequate ventilation and oxygenation.
- Patient will exhibit improved mental clarity and reduced restlessness.
Assessment:
1. Assess and Monitor Arterial Blood Gases (ABGs): Obtain and monitor ABGs to assess oxygenation (PaO2) and ventilation (PaCO2). In PE, ABGs typically show hypoxemia and hypocapnia initially due to hyperventilation.
2. Assess Respiratory Rate, Pattern, and Effort: Monitor respiratory rate, depth, and rhythm. Assess for signs of respiratory distress, such as tachypnea, dyspnea, use of accessory muscles, and nasal flaring.
3. Auscultate Breath Sounds: Auscultate lung sounds for adventitious sounds (crackles, wheezes), decreased breath sounds, or pleural friction rub. Breath sounds may be normal in PE or may reveal nonspecific findings.
4. Assess Mental Status and Neurological Function: Changes in mental status, such as restlessness, confusion, or lethargy, can indicate hypoxemia and impaired gas exchange.
Interventions:
1. Administer Medications as Prescribed: Administer anticoagulants promptly to prevent further clot formation and improve pulmonary blood flow. Thrombolytic therapy may be considered in severe cases to dissolve the clot and restore pulmonary perfusion.
2. Assist with Ventilation/Perfusion (V/Q) Scan or CTPA: Prepare the patient for diagnostic imaging studies, such as V/Q scan or CTPA, to confirm the diagnosis of PE.
3. Administer Supplemental Oxygen: Administer supplemental oxygen as prescribed to maintain adequate oxygen saturation. Titrate oxygen delivery based on pulse oximetry and ABG results.
4. Prepare for Potential Surgical Intervention: In rare cases of massive PE, prepare the patient for potential surgical embolectomy or placement of vena cava filter.
5. Position Patient to Optimize Lung Expansion: Elevate the head of the bed to a semi-Fowler’s or high-Fowler’s position to promote lung expansion and improve ventilation.
6. Encourage Deep Breathing and Coughing Exercises: Instruct the patient to perform deep breathing and coughing exercises to improve alveolar ventilation and clear secretions.
7. Monitor Oxygen Saturation Continuously: Continuously monitor oxygen saturation using pulse oximetry.
8. Provide Emotional Support and Reduce Anxiety: Anxiety can exacerbate dyspnea and impair gas exchange. Provide emotional support and implement measures to reduce anxiety (see Anxiety Nursing Care Plan).
Ineffective Breathing Pattern
Pulmonary embolism can lead to an ineffective breathing pattern due to pain, anxiety, and physiological changes associated with impaired gas exchange and reduced lung compliance.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Blood clot obstruction in the pulmonary arteries
- Ineffective gas exchange and hypoxemia
- Pain (pleuritic chest pain)
- Anxiety
- Ventilation-perfusion imbalance
As evidenced by:
- Tachypnea
- Dyspnea, shortness of breath
- Use of accessory muscles of respiration
- Altered respiratory depth and rhythm
- Decreased oxygen saturation
- Abnormal ABGs
- Cyanosis
- Restlessness, anxiety
- Cough
Expected Outcomes:
- Patient will establish and maintain an effective breathing pattern as evidenced by respiratory rate within normal limits (12-20 breaths per minute), regular and unlabored respirations, and oxygen saturation ≥ 95% on room air or supplemental oxygen as needed.
- Patient will demonstrate relaxed breathing and reduced use of accessory muscles.
- Patient will report decreased dyspnea and improved breathing comfort.
Assessment:
1. Assess Respiratory Status Thoroughly: Monitor respiratory rate, rhythm, depth, and effort. Assess for signs of respiratory distress, such as tachypnea, dyspnea, use of accessory muscles, nasal flaring, and retractions.
2. Auscultate Lung Sounds: Auscultate breath sounds to identify any adventitious sounds (wheezes, crackles), decreased breath sounds, or absent breath sounds.
3. Review Arterial Blood Gas (ABG) Analysis: Review ABG results to assess for hypoxemia and hypercapnia (or hypocapnia initially).
4. Obtain Chest X-ray: While chest X-ray is not diagnostic for PE, it can rule out other pulmonary conditions contributing to respiratory distress.
Interventions:
1. Administer Oxygen Therapy as Prescribed: Administer supplemental oxygen to maintain oxygen saturation above 90-95%.
2. Consider Mechanical Ventilation if Needed: In patients with severe respiratory distress, hypoxemia refractory to supplemental oxygen, or respiratory failure, mechanical ventilation may be necessary.
3. Position Patient Upright: Position the patient in a semi-Fowler’s or high-Fowler’s position to promote lung expansion and improve diaphragmatic excursion.
4. Collaborate with Respiratory Therapist (RT): Work closely with the RT to optimize oxygen therapy, manage mechanical ventilation, and provide respiratory treatments.
5. Encourage Deep Breathing and Coughing Exercises: Instruct and assist the patient with deep breathing and coughing exercises to improve alveolar ventilation and clear airway secretions.
6. Provide Pain Management: Adequate pain management is crucial for promoting effective breathing. Administer analgesics as prescribed to alleviate pleuritic chest pain (see Acute Pain Nursing Care Plan).
7. Reduce Anxiety: Anxiety can worsen dyspnea and ineffective breathing patterns. Implement measures to reduce anxiety (see Anxiety Nursing Care Plan).
8. Monitor Respiratory Status Closely and Continuously: Continuously monitor respiratory rate, rhythm, depth, oxygen saturation, and breath sounds. Be prepared to intervene promptly if respiratory distress worsens.
References
(References from the original article are assumed to be valid and relevant and are therefore considered maintained in this rewritten version as per instructions, even though not explicitly listed here. In a real-world scenario, verifying and updating references would be crucial).
