Nursing Care Plan | NCP Pulmonary Embolism
Pulmonary embolism (PE) is a potentially life-threatening condition in which a free-flowing blood clot (embolism) becomes lodged within the pulmonary vasculature. Approximately 650,000 cases of PE are reported yearly and approximately 60% of patients who die in a hospital are found to have a PE on autopsy. It is viewed as the most commonly missed diagnosis in the elderly.
When an embolism becomes lodged within a pulmonary vessel, platelets accumulate around the thrombus and trigger the release of potent vasoactive substances. The pulmonary vasculature constricts, which leads to an increased pulmonary vascular resistance, increased pulmonary arterial pressure, and increased right ventricular workload. Blood flow abnormalities result in a ventilation/perfusion mismatch that is initially dead-space ventilation (ventilation with no perfusion). As atelectasis occurs, shunting (perfusion without ventilation of the alveolus) results. If the right side of the heart (accustomed to pumping out against a relatively low-resistance pulmonary circuit) cannot empty its volume against the increased pulmonary vascular resistance, right-sided heart failure occurs. Ultimately, cardiac function may deteriorate with decreased cardiac output, decreased systemic blood flow, and shock.
A PE usually occurs when a thrombus in the deep veins of the lower extremities loosens or dislodges and begins to move in the bloodstream. The thrombus (now an embolus because it is moving in the bloodstream) floats to the heart, moves through the right side of the heart, and enters the pulmonary circulation through the pulmonary artery. Major risk factors for the development of PE include any condition that produces venous stasis, increased blood coagulability, or venous endothelial (vessel wall) changes. Situations resulting in these pathological changes include immobility, dehydration, injury, or decreased venous return. Conditions associated with these risk factors include varicosities, pregnancy, obesity, tumors, thrombocytopenia, atrial fibrillation, multiple trauma, presence of artificial heart valves or vessels, sepsis, and congestive heart failure.
Nursing care plan assessment and physical examination
Many patients with PE report a history of DVT, surgery, or some other condition that results in vascular injury or increased blood coagulability. Patients may describe a sudden onset of dyspnea and chest pain for no apparent reason. Some patients report severe symptoms, such as severe pain, wheezing, diaphoresis, and a sense of impending doom. The severity of the symptoms partly depends on the size, number, and location of the emboli.
Patients often appear short of breath, diaphoretic, weak, fearful, and anxious. They may be febrile, or their skin may be cold and clammy. Those in critical condition may develop severe chest pain, syncope, and chest splinting and may cough up bloody sputum. Not all patients become hypoxemic because the increased respiratory rate increases their minute volume and thereby maintains gas exchange. However, some patients have signs of hypoxemia, such as confusion, agitation, and central cyanosis.
When you auscultate the patient’s chest, you may note decreased breath sounds, wheezing, crackles, or a transient pleural friction rub. You may also note tachycardia, a third heart sound, or a loud pulmonic component of the second heart sound. You may note a warm, tender area in the leg. Ongoing monitoring during an acute episode of PE is essential for patient recovery. Monitor the patient’s vital signs, including temperature, pulse, blood pressure, and respiratory rate, every hour or as needed. Observe the patient continuously for signs of right ventricular failure as evidenced by neck vein distension, rales, peripheral edema, enlarged liver, dyspnea, increased weight, and increased heart rate. Monitor the patient for signs of shock, such as severe hypotension, mottling, cyanosis, cold extremities, and weak or absent peripheral pulses.
Depending on the severity of symptoms, patients and their families usually display some degree of anxiety. Because PE is life-threatening, their fears are justified and appropriate. Assess the patient’s and family’s ability to cope.
Nursing care plan primary nursing diagnosis: Impaired gas exchange related to impaired pulmonary blood flow and alveolar collapse.
Nursing care plan intervention and treatment plan
Massive PE is a medical emergency. Make sure that the patient’s airway, breathing, and circulation are maintained. Administer oxygen immediately to support gas exchange and prepare for the possibility of intubation and mechanical ventilation. Obtain intravenous (IV) access for administration of fluids and pharmacologic agents. Before administration of thrombolytic agents, draw a coagluation profile and complete blood count to obtain a baseline.
Although it is rare, severe cases of PE that are unresponsive to anticoagulant or thrombolytic therapy may require surgery. The least invasive technique is the insertion of a transvenous catheter into the pulmonary vasculature. If the procedure is unsuccessful, however, a thoracotomy may be required to remove the obstructing embolism. Patients prone to PE seeded from deep vein thrombi may have a prosthetic umbrella inserted into the inferior vena cava to trap the emboli.
The primary concern for the nurse who is caring for a patient with PE includes the maintenance of airway, breathing, and circulation by support of the cardiopulmonary system. The most important independent measure before PE formation is prevention of thrombus formation. To prevent PE in high-risk patients, encourage early chair rest and ambulation as the patient’s condition allows. Even patients who are intubated and mechanically ventilated with multiple catheters can be gotten out of bed without physiological risk for periods of chair rest. Provide active and passive range-of-motion at least every 8 hours for all patients on bedrest. Teach the family and significant others of an immobile patient how to perform passive range-of-motion exercises. If the patient is not on fluid restriction, encourage drinking at least 2 L of fluids a day to decrease blood viscosity. Use compression boots for patients who are on bedrest to increase venous return.
During anticoagulant therapy, protect patients from injury. Report any signs of increased bleeding, such as ecchymosis, epistaxis, hematuria, mucous membrane bleeding, decreasing hemoglobin or hematocrit, and bleeding from puncture sites. Restrict parenteral injections and venipunctures to essential procedures only. If the patient is ambulatory, provide a safe environment.
Provide information about the diagnosis and prognosis of PE, and explain all procedures and diagnostic tests. Set aside time each day to talk with the patient and family to allow for expression of their feelings. If the patient is a child, monitor the patterns of growth and development using age-appropriate milestones and developmental tasks. Provide age-appropriate play activities for children.
Nursing care plan discharge and home health care guidelines
Teach the patient and family methods of prevention. Because of the association of DVT and PE, instruct patients to avoid factors that cause venous stasis. Explain that patients should avoid prolonged sitting, crossing of their legs, placing pillows beneath the popliteal fossae, and wearing tight-fitting clothing such as girdles. Encourage hospitalized patients to ambulate as soon as possible after surgery and to wear antiembolic hose or pneumatic compression boots while they are bedridden. Encourage patients to drink at least 2 L of fluid a day unless they are on fluid restriction. Suggest that obese patients limit calorie intake to reduce their weight.
Discuss all medications with the patient and family. Patients are usually discharged on warfarin. Remind the patient to keep appointments with the healthcare professional. Note that the patient needs periodic blood specimens to monitor drug levels. Explain that warfarin is continued unless the patient consults with the healthcare professional. Explain that the patient cannot take any over-the-counter drug preparations that contain salicylates without consulting the healthcare provider. Encourage the patient to avoid foods that are rich in vitamin K, such as dark green vegetables, which counteract the effects of warfarin. Encourage the patient to wear a medical identification bracelet that shows she or he is on anticoagulant therapy. Describe the complications of anticoagulant therapy. Instruct the patient to avoid activities that might predispose to injury or bleeding. Children may require helmets and other protective equipment. Encourage the patient to use a soft toothbrush and an electric razor for shaving. Instruct the patient to report any orange or pink-red urine discoloration, blood in the stool, excessive bruising, heavy menses, excessive gum bleeding, hemoptysis, bloody vomitus, and abdominal or flank pain. Encourage the patient to inspect her or his back in the mirror each day to check for bruising. Instruct the patient to inform dentists and other healthcare providers about the anticoagulant therapy before any procedure.
Instruct the patient and family about possible complications. If leg pain or swelling, decreased pulses in the lower extremities, shortness of breath, chest pain, or anxiety occurs, the patient or family should report to an emergency department as soon as possible.
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