Pulmonary Embolism (PE) is a life-threatening condition that occurs when a blood clot blocks the pulmonary arteries in the lungs, impairing oxygen exchange and leading to potential complications like respiratory failure and death. Quick recognition and treatment are vital.
Nursing Assessment
Subjective Data:
- Shortness of breath
- Chest pain, worsening with deep breaths
- Anxiety and fear
Objective Data:
- Tachypnea (rapid breathing)
- Tachycardia (increased heart rate)
- Low oxygen saturation
- Hypotension
Diagnostic tests include a D-dimer test, chest CT scan, and ECG to confirm diagnosis.
Nursing Diagnoses
- Impaired Gas Exchange
Related to: Pulmonary obstruction reducing oxygen and carbon dioxide exchange.
Evidenced by: Dyspnea, low oxygen saturation, cyanosis.
Goals and Outcomes: The patient will maintain adequate oxygenation as evidenced by normal ABG levels and improved SpO2 readings.
Interventions:- Administer supplemental oxygen as needed.
- Monitor arterial blood gases (ABGs).
- Position the patient in a semi-Fowler’s position to improve lung expansion.
- Ineffective Breathing Pattern
Related to: Increased workload from obstruction in pulmonary arteries.
Evidenced by: Rapid, shallow breathing, use of accessory muscles.
Goals and Outcomes: The patient will establish an effective breathing pattern.
Interventions:- Encourage deep breathing exercises.
- Administer anticoagulants to prevent further clot formation.
- Monitor respiratory rate and effort regularly.
- Acute Pain
Related to: Inflammatory response in lung tissue.
Evidenced by: Pleural chest pain.
Goals and Outcomes: The patient will report pain relief.
Interventions:- Administer pain medications (e.g., NSAIDs, opioids).
- Provide comfort measures such as positioning and relaxation techniques.
- Decreased Cardiac Output
Related to: Obstruction of blood flow through the lungs.
Evidenced by: Hypotension, tachycardia, decreased peripheral pulses.
Goals and Outcomes: The patient will maintain adequate tissue perfusion.
Interventions:- Monitor vital signs closely (heart rate, blood pressure).
- Administer thrombolytic agents as prescribed.
- Provide continuous cardiac monitoring.
Nursing Interventions
- Administer Anticoagulants
Heparin and warfarin are typically prescribed to prevent further clot formation. Monitor for signs of bleeding. - Oxygen Therapy
Administer oxygen to ensure adequate tissue perfusion and reduce hypoxemia. - Positioning
Encourage a semi-Fowler’s position to aid breathing and improve lung expansion. - Monitor for Complications
Watch for signs of complications such as recurrent emboli, right ventricular failure, and shock. - Patient Education
Educate the patient on the importance of anticoagulant therapy, movement, and wearing compression stockings to prevent further clots.
Prevention and Complications
- Prevention:
- Encourage early ambulation for post-surgical or bedridden patients.
- Use compression stockings and anticoagulants in at-risk patients.
- Educate the patient on lifestyle changes, such as smoking cessation and weight management.
- Complications to Watch For:
- Respiratory failure
- Recurrent emboli
- Right-sided heart failure
Managing a patient with a pulmonary embolism requires prompt identification and interventions that address impaired gas exchange, circulation issues, and pain management. Early anticoagulant therapy and continuous monitoring are key to reducing complications and improving outcomes.
References
- American Heart Association (2023). “Pulmonary Embolism.”
- National Library of Medicine (2022). “Pulmonary Embolism Management and Care.”
- MedlinePlus (2023). “Pulmonary Embolism: Symptoms, Diagnosis, and Treatment.”
- NurseStudy.net. (2022). Pulmonary Embolism Nursing Diagnosis and Care Plan. Retrieved from https://nursestudy.net/pulmonary-embolism-nursing-diagnosis/