Pulmonary Embolism Nursing Care Plans Diagnosis and Interventions
Pulmonary Embolism NCLEX Review and Nursing Care Plans
Pulmonary embolism is a serious and life-threatening medical condition resulting from a blockage in one of the pulmonary arteries in the lungs.
The most common cause for developing pulmonary embolism is deep vein thrombosis (DVT), which develops due to a blood clot formed in the lower extremities.
When a portion of the blood clot detaches, it travels to the bloodstream going to different areas of the body.
The clot can lodge into the lungs, impeding the circulation of blood flow to the lungs causing pulmonary embolism.
This can cause serious respiratory difficulties that can be fatal if not treated promptly.
Preventive measures against deep vein thrombosis lower the risk of developing the disease.
Signs and Symptoms of Pulmonary Embolism
The nature of symptoms and severity depend on the size and location of the blood clot, how much of the lung is affected and presence of any underlying condition.
Some symptoms may be vague and can take a while to occur while some are severe and sudden. These include:
- Sudden and severe shortness of breath that gets worse with activity
- Chest pain that is sharp and felt upon inhalation causing breathing difficulties
- Cough. It may be bloody or may produce a blood-tinged sputum
- Rapid, irregular heartbeat
- Light headedness or dizziness
- Diaphoresis – Excessive sweating
- Leg pain or swelling commonly seen in the calf area
- Cyanosis – Clammy or bluish discoloration of the skin
Causes and Risk Factors of Pulmonary Embolism
Pulmonary embolism develops when an embolus, a particle that moves through the blood vessels, reaches and blocks the arteries in the lungs.
It can be from a blood clot (most common root cause), a tumor, a broken bone, o air bubbles.
When a blood clot develops in deep veins of lower extremities (DVT) and a fragment of it breaks off, it is then called an embolus.
This travels through the bloodstream and may get lodged into the pulmonary artery.
If multiple clots are involved, this can result in the obstruction of blood supply in the arteries and may even cause lung tissues to die, a condition known as pulmonary infarction, which then leads to inadequate oxygenation within the body.
There are certain conditions and treatments that increase the risk for pulmonary embolism such as:
- Surgery. One of the leading causes for formation of blood clots especially in the case of big operations
- Family history of venous blood clots or pulmonary embolism
- Cardiovascular diseases particularly heart failure
- Cancer. Particularly cancers in the brain, ovary, pancreas, colon, stomach, lung and kidney and those in advanced stage. Chemotherapy and intake of Tamoxifen or Raloxifene also increases risks for blood clots.
- Blood or clotting disorders
- Prolonged immobility
- Supplemental estrogen
Complications of Pulmonary Embolism
Pulmonary embolism is a life-threatening condition that requires immediate intervention.
Around thirty three percent of undiagnosed and untreated cases do not survive.
Early diagnosis and treatment reduce the mortality rate for this condition.
Obstruction of the arteries in the lungs brought about by pulmonary embolism, forces the heart to compensate by pumping harder which increases blood pressure, a condition known as pulmonary hypertension.
In the long run, pulmonary hypertension causes the heart to gradually weaken.
There are also rare occasions wherein it progresses to chronic pulmonary hypertension or chronic thromboembolic pulmonary hypertension, where the small emboli periodically occur and develop at a later time.
Diagnosis of Pulmonary Embolism
- Medical history and Physical Assessment
- D dimer and other blood tests
- Chest X-ray
- CT Pulmonary angiography. Detects abnormalities thru 3D images
- Ventilation-perfusion scan (V/Q scan)- used when there is contraindication for contrast and radiation exposure
- Pulmonary angiogram- provides better visualization of the blood flow in the lung arteries
Treatment of Pulmonary Embolism
The treatment goal for pulmonary embolism is the prevention of clot formation and removal of an existing clot.
This involves surgery and medication therapy. Immediate intervention is vital to prevent further complications and mortality.
Since there is a risk of developing another venous thrombosis or pulmonary embolism, it is important to remain on certain medications and have regular doctor visits for monitoring and evaluation.
1. Medications. The following medications may be given orally or intravenously and are usually prescribed to prevent clot formation.
- Anticoagulant or blood thinners. These drugs inhibit formation of new clots and prevents enlargement of existing clots. Its side effects include bleeding which is why it is important to observe bleeding precaution at all times.
- Thrombolytics or clot dissolvers. Although the clots usually dissolve on their own, thrombolytics helps speed up the process. Thrombolytics can be given in emergency situations.
2. Surgery. In case of pulmonary embolism that is unresponsive to medications, surgical intervention is recommended, which may include:
- Embolectomy. This is the surgical removal of a blood clot through an open surgery or the use of a catheter, a thin flexible tube threaded into the blood vessels. It is indicated if the clot is too extensive and lethal.
- Vein filter. Inferior vena cava filter placement is recommended for people unable to tolerate anticoagulants and those who have recurrent clots despite the medications. A catheter is used to position the filter in place and is gently inserted in the vein either through the groin or neck going to the right side of the heart.
Nursing Diagnosis for Pulmonary Embolism
Pulmonary Embolism Nursing Care Plan 1
Nursing Diagnosis: Impaired Gas Exchange related to altered oxygen supply secondary to pulmonary embolism, as evidenced by shortness of breath, oxygen saturation of 82%, restlessness, and reduced activity tolerance
Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by an oxygen saturation of at least 96% (88-92% in COPD patients).
|Pulmonary Embolism Nursing Interventions||Rationales|
|Assess the patient’s vital signs, especially the respiratory rate and depth. Auscultate the lungs and monitor for wheezing or other abnormal breath sounds.||To create a baseline set of observations for the pulmonary embolism patient, and to monitor any changes in the vital signs as the patient receives medical treatment.|
|Monitor the color of skin and mucous membrane.||Peripheral cyanosis (bluish discoloration of the skin, ear lobes, or nail beds) may be evident with hypoxemia. Central cyanosis involving the mucosa may indicate further reduction of oxygen levels.|
|Administer thrombolytics and/or anticoagulants as prescribed.||The airways experience impaired gas exchange primarily due to an embolus.|
|Provide humidified oxygen as prescribed.||To reduce the risk of drying out the lungs.|
|Reposition the patient by elevating the head of the bed and encouraging him/her to sit on an upright position. Encourage pursed lip breathing and deep breathing exercises.||To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse.|
|Refer the patient to a chest physiotherapist.||To enable to patient to receive more information and specialized care in the removal of thick lung secretions and enabling of improved gas exchange.|
Pulmonary Embolism Nursing Care Plan 2
Nursing Diagnosis: Deficient Knowledge related to new diagnosis of pulmonary embolism as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”
Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of pulmonary embolism and its management.
|Pulmonary Embolism Nursing Interventions||Rationales|
|Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of diagnosis or poor lifestyle habits).||To address the patient’s cognition and mental status towards the new diagnosis of pulmonary embolism and to help the patient overcome blocks to learning.|
|Explain what pulmonary embolism is, its cause and treatment plan. Avoid using medical jargons and explain in layman’s terms.||To provide information on pulmonary embolism and its pathophysiology and management in the simplest way possible.|
|Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) to treat pulmonary embolism. Ask the patient to repeat or demonstrate the self-administration details to you.||To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.|
|Educate the patient about pursed lip breathing and deep breathing exercises.||To strengthen the respiratory muscles, reduce shortness of breath, and lower the risk for airway collapse.|
|Prepare the patient for surgery if indicated.||To prepare the patient physically and mentally for an embolectomy or vein filter.|
Pulmonary Embolism Nursing Care Plan 3
Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion
Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.
|Pulmonary Embolism Nursing Interventions||Rationales|
|Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels and mental status related to fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.||To gradually increase the patient’s tolerance to physical activity. To enable the patient to pace activity versus rest.|
|Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.|
|Refer the patient to physiotherapy / occupational therapy team as required.||To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.|
Pulmonary Embolism Nursing Care Plan 4
Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective Breathing Pattern related to hypoxia secondary to pulmonary embolism as evidenced by abnormal arterial blood gases (ABG’s), dyspnea, tachypnea and the use of accessory muscles of breathing.
Desired Outcome: The patient will be able to maintain effective and adequate breathing as shown by relaxed breathing characterized by normal rate, depth and the absence of dyspnea.
|Pulmonary Embolism Nursing Interventions||Rationale|
|Take note of the patient’s anxiety levels.||Pulmonary embolism oftentimes has associated anxiety to the patient due to the sudden and acute nature of the condition. Patients with anxiety can show rapid, shallow breathing with associated increasing dyspnea. It can also be a clinical manifestation of decreasing hypoxemia.|
|Take note of the patient’s respirations, including the rate, rhythm and depth. Evaluate for the presence of increased and labored breathing such as shortness of breath, use of accessory including predisposing and precipitating factors muscles, etc.||Imminent and early respiratory distress may be characterized as having changes in the patient’s respiratory rate and rhythm. In pulmonary embolism, tachypnea is a classic clinical manifestation. These rapid and shallow respirations would result in hypoxia. The resulting hypoxia would slowly develop into hypoventilation (slow respiratory rate) and ultimately respiratory failure, if left unattended.|
|Evaluate the associated pain within the patient’s respiratory cycle. Take note of its defining characteristics, predisposing and precipitating factors alike.||Pain associated with pulmonary embolism oftentimes presents as sharp and stabbing pain that worsens with deep breathing and coughing. Due to this, the patient is inclined to have shallow respirations that in turn negatively impact the lung’s gas exchange capabilities.|
|Observe and monitor the patient’s arterial blood gasses (ABGs).||Patients with pulmonary embolism usually present with hypoxemia and respiratory alkalosis due to decreased carbon dioxide levels. Developing respiratory acidosis is indicative of respiratory failure for these patients that would necessitate immediate ventilator support.|
|Observe and check for oxygen saturation as indicated.||The normal oxygen saturation is 95% and above in room air. Utilizing a pulse oximeter is a valuable tool in order to detect significant changes in the patient’s oxygenation.|
|Offer reassurance and reduce anxiety by staying with the patient, especially during episodes of respiratory distress.||The healthcare provider being calm and providing comfort to an anxious patient is helpful in reducing anxiety episodes.|
|Assist the patient to a sitting position. Assist in position changes every 2 hours as the patient tolerates.||A sitting position allows for the proper chest expansion and good diaphragmatic excursion that will facilitate better breathing of the patient. Frequent position changes will enable movement and drainage of tenacious secretions in the respiratory tract.|
|Advise the patient to do deep breathing and coughing exercises. Facilitate suctioning as tolerated and as indicated.||Coughing is the most effective method in facilitating the movement and expulsion of tenacious secretions on the patient’s respiratory tract. However, in instances wherein the patient is unable to cough effectively, the healthcare provider may do suctioning. Suctioning is a healthcare provider technique with the intention of keeping the patient’s airways open by removing secretions.|
|Prepare the patient for planned imaging and diagnostic procedures such as: Chest x-rayCT scanVentilation-perfusion scanPulmonary arteriogramD-dimer assay||Procedures such as chest x-ray and D-dimer assay (a blood test marker for clot lysis) are oftentimes done to initially confirm or rule out a pulmonary embolism (PE) diagnosis. A CT scan is also done for patients highly suspected of having PE. Performing a pulmonary arteriogram is the definitive test for confirming a pulmonary embolism diagnosis.|
|Provide supplemental oxygen as ordered and indicated.||Oxygen support is necessary for these patients in order to maintain adequate oxygen in the body that consequently decreases labored breathing, relieves dyspnea and promotes comfort. Oxygen support is given continuously at an appropriate amount in order to maintain oxygen levels, thus preventing desaturations.|
|Prepare for the need for establishing advanced airway support through intubation and mechanical ventilation.||Advanced airway techniques such as intubation and mechanical ventilation are methods that may be utilized to stabilize a person’s respirations in light of impending respiratory failure. These methods aim to support the patient’s breathing and ventilation that may be compromised for unrelieved dyspnea.|
Pulmonary Embolism Nursing Care Plan 5
Risk for Bleeding
Nursing Diagnosis: Risk for Bleeding related to anti-coagulant therapy secondary to pulmonary embolism treatment regimen.
- The patient will be free from episodes of hidden or frank bleeding.
- The patient will be able to maintain within normal range the following bleeding parameters: prothrombin time (PT), partial thromboplastin time (PTT), and international normalized ratio (INR) while on anticoagulant therapy for pulmonary embolism.
|Pulmonary Embolism Nursing Interventions||Rationale|
|Evaluate the patient’s history for bleeding conditions such as: liver disease, kidney issues, severe hypertension, cavitary tuberculosis (presence of gas-filled space in the lung due to tuberculosis), bacterial endocarditis, heparin-induced thrombocytopenia.||Assessing for any bleeding history that the patient may have previously experienced is necessary before treating for pulmonary embolism. This is due to the reason that anticoagulation therapy is the treatment of choice in managing PE.|
|Evaluate for clinical manifestations of bleeding such as: Bleeding from catheter insertion sitesBleeding from mucous membranesDepressed hematocrit and hemoglobin levelsGastrointestinal bleeding (e.g., melena)Genitourinary bleeding (e.g., hematuria)Integumentary bleeding (e.g., hematoma, petechiae, purpura)Respiratory tract bleeding (e.g., blood tinged sputum)||Early assessment for the occurrence of any bleeding symptoms will help prevent irreversible episodes and the application of appropriate management.|
|Observe platelet counts and take note for heparin-induced thrombocytopenia.||Since heparin therapy is utilized to treat pulmonary embolism, the patient will be susceptible in developing heparin-induced thrombocytopenia (HIT). With this treatment side effect, the patient experiences severe platelet level depression that causes bleeding. HIT is more common in the use of unfractionated heparin therapy than on low molecular-weight heparin.|
|Observe for the bleeding and coagulation sensitive laboratory tests such as: Platelet countINRPTaPTThemoglobin hematocrit||Close monitoring of bleeding parameters is essential to reduce bleeding episodes while the patient is on anticoagulation therapy. The type of test for monitoring will depend on the kind of anticoagulant medication provided for the patient.|
|Observe for the correct IV dosage and manner of delivery (i.e., use if infusion pumps)||Administering of IV anticoagulants is best done through the use of electronic infusion pumps to ensure adequate and timely administration of medication and to reduce risks of over or under treatment.|
|Administer prescribed anticoagulant therapy, through IV bolus, continuous IV infusion, subcutaneous route, or oral form.||Anticoagulant therapy is indicated for patients with PE to prevent further formation of thrombus. Protocol may vary depending on the medication administered. For those patients with heparin intolerance, other non-heparin agents (e.g. factor Xa inhibitors) are utilized to address PE.|
|Stop all heparin products and seek consultation with a hematologist if the patient is positive for Heparin-induced platelet aggregation (HIPA).||Heparin-induced platelet aggregation or HIPA is a laboratory test wherein the blood is tested for clotting reaction on the presence of heparin. A positive result would indicate that the patient is highly susceptible in developing heparin-induced thrombocytopenia (HIT), a medical condition triggered by heparin use with associated clumping of platelets and presence of bleeding episodes.|
|Anticipate the following interventions for heparin-induced bleeding episodes: Stop the infusionRe-evaluate immediately aPTT levels and heparin dosagesFrequent vital signs monitoringChecking with the blood bank for blood availability.||Due to the high risk of bleeding, close watch of the patient’s aPTT should be prioritized. The aPTT guide while on therapy should be within 1.5 to 2 times the normal. Anticipating blood transfusion is necessary for highly deviated aPTT levels.|
|Anticipate shifting IV anticoagulants to the oral form after the appropriate length of therapy has elapsed. Observe the patient’s INR, PT and aPTT levels.||The anticoagulation effects of warfarin set in after 2-3 days of treatment. Because of this, it is crucial that overlapping of the IV and the oral anticoagulants is done to ensure acceptable PT or INR levels before discontinuing heparin infusion.|
|Administer thrombolytic medications as prescribed by the physician.||Thrombolytic medications are warranted for patients with substantial PE that compromises hemodynamic stability. Because of this, it is prudent to monitor for contraindications and complications of such therapy such as: recent surgery, recent organ biopsy, pregnancy, recent stroke, or recent or active bleeding (internal).|
Pulmonary Embolism Nursing Care Plan 6
Nursing Diagnosis: Anxiety related to respiratory distress secondary to pulmonary embolism as evidenced by restlessness, dyspnea and tachypnea.
Desired Outcome: The patient will be able to demonstrate reduction in anxiety levels experienced by exhibiting a peaceful demeanor and cooperative behavior.
|Pulmonary Embolism Nursing Interventions||Rationale|
|Evaluate the patient for clinical manifestations of anxiety such as: Feelings of panic, fear and uneasinessTachycardiaCold or sweaty hands or feetShortness of breathRestlessness||Pulmonary embolism can worsen, particularly when the patient is suffering from anxiety, for it causes rapid and shallow respirations. Early detection of impending anxiety attacks can result in better care management and outcomes.|
|Observe the patient’s oxygen levels.||The normal oxygen saturation is 95% and above. Increasing anxiety can be an early indication of developing or worsening hypoxia.|
|Provide comfort measures such as: Maintaining a calm and quiet environmentPlaying of soft music of not contraindicatedUse of a calm voice in a reassuring tone.||Ensuring and maintaining calmness will prevent worsening of the patient’s anxiety by reducing oxygen demand of the body and the respiratory effort associated with anxiety episodes.|
|Describe therapeutic procedures and information in simple and concise terms. Avoid the use of complicated terminologies and medical jargon.||Simplification of instructions allows the patient to easily understand the information relayed by the healthcare worker. Enlightening the patient of pertinent information related to his care will decrease his anxiety levels.|
|Make sure to update the patient’s significant others of the progress and therapeutic regimen.||Anxiety can be easily transferred from the patient to their family and vice versa. Updating the patient’s significant others ensure that they understand the current progress and will relieve feelings of uncertainty.|
|Stay with the patient, particularly during episodes of acute anxiety. Instruct the patient to do slow, deep breathing exercises. Reassure the patient and significant others that continuous and prompt monitoring is done to ensure prompt intervention.||The presence of a familiar and reliable person, such as the healthcare worker working with the patient, will give a sense of security to both the patient and family. Anxious persons would oftentimes need external reassurance from others in order to work around and manage their apprehension.|
|Educate on the significance of relaxation techniques such as: Progressive muscle relaxationDiaphragmatic and pursed lip breathingUse of imagery, repetitive phrases (restating a phase that triggers a physical relaxation such as “relax and let go”).||Some effective ways of managing anxiety are relaxation techniques. Effectivity of relaxation techniques vary from person to person but are generally helpful as other avenues for managing anxiety.|
|Support the patient in reinforcing their problem-solving strategies. Focus on the logical strategies that the patient used in the past and discover and employ new methods in order to address anxious feelings.||Assisting the patient in discovering and rediscovering anxiety-reducing strategies helps the patient manage his anxiety, thereby allowing him to cope with the situation.|
|Offer massage and backrubs to the patient’s if requested and if not contraindicated.||Utilizing therapeutic touch such as massages may help the patient cope with anxious feelings. It helps in reducing apprehensive thoughts by means of tactile distraction and promotion of relaxation to the patient.|
|Instruct the patient and family on the clinical manifestations of anxiety.||Equipping the patient and family of the knowledge regarding manifestations of beginning anxiety will assist them in recognizing these early on in order to apply the necessary interventions to manage such situations.|
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