Pulmonary embolism refers to the obstruction of the pulmonary artery or one of its branches by a thrombus that originates somewhere in the venous system or in the right side of the heart. The clinical symptoms depend on the size and location of the embolus. Careful analysis of risk factors aids in diagnosis; these include hypercoagulability, damage to the walls of the veins, prolonged immobility, recent surgery, deep vein thrombosis, postpartum state, and medical conditions such as polycythemia, heart failure, and trauma. Treatment approaches vary depending on the degree of cardiopulmonary compromise associated with the PE. They can range from thrombolytic therapy in acute situations to anticoagulant therapy and general measures to optimize respiratory and vascular status (e.g., oxygen therapy, compression stockings).
Pulmonary embolism is a frequent hospital-acquired condition and one of the most common causes of death in hospitalized clients. Preventing thrombus formation is a critical nursing role.
Nursing Care Plans
Nursing care planning and goals for a client with pulmonary embolism include managing pain, relieving anxiety, providing oxygen therapy, preventing the formation of a thrombus (ambulation and passive leg exercises), monitoring thrombolytic therapy, decreasing the risk of pulmonary embolism, and preventing possible complication.
Here are four (4) nursing care plans (NCP) and nursing diagnosis (NDx) for pulmonary embolism:
Impaired Gas Exchange
Nursing Diagnosis
- Impaired Gas Exchange
May be related to
- Decreased lung perfusion caused by the obstruction of pulmonary arterial blood flow by the embolus.
- Decreased bronchial airflow associated with bronchoconstriction
- Increased physiological shunting caused by collapse of alveoli resulting from surfactant loss
- Increased alveolar dead space
Possibly evidenced by
- Confusion
- Decreased PaO2 and increased PaCO2
- Desaturation (Oxygen saturation below 90%)
- Dyspnea
- Headache
- Hypercapnia
- Hypoxia
- Pale skin
- Restlessness/Irritability
- Tachypnea
Desired Outcomes
- Client will maintain adequate gas exchange, as evidenced by ABGs within the normal range, oxygen saturation of 90% or greater, alert response mentation or no further deterioration on the level of consciousness, relaxed breathing, and baseline HR for the client.
Nursing Interventions | Rationale |
---|---|
Assess the skin color, nail beds, and mucous membranes for color changes. | Cool, pale skin occurs as a compensatory response to hypoxemia. When oxygen and perfusion become impaired, peripheral tissues become cyanotic. |
Monitor for any changes in vital signs. | In initial hypoxia and hypercapnia, there is an increase in the respiratory rate, heart rate, and blood pressure. As the hypercapnia and hypoxia get worse, blood pressure may drop, heart rate tends to continue to be rapid and includes dysrhythmias, and respiratory failure ensues, with the client unable to maintain the rapid respiratory rate. |
Assess for the signs and symptoms of hypoxia (such as confusion, headache, diaphoresis, restlessness, tachycardia, and pale skin). | Hypoxia results from increased dead space (ventilation without perfusion) that reduces effective gas exchange. |
Auscultate lung sounds, noting areas of decreased ventilation and the presence of adventitious sounds. | Crackles are common clinical findings with pulmonary embolism. |
Assess for the signs and symptoms of pulmonary infarction (such as fever, cough, bronchial breathing, hemoptysis, pleuritic pain, pleural friction rub, and consolidation). | A large pulmonary embolus or multiple small clots in a specific area of the lung can cause ischemic necrosis or infarction of the lung area. |
Assess for calf tenderness, redness, swelling, and hardened areas. | Pulmonary embolism often arises from a deep vein thrombosis and may have been previously overlooked. |
Monitor for any changes in the ABGs. | ABG analysis can be normal or show hypoxemia and hypocapnia because of tachypnea. Later signs of respiratory failure include low PaO2 and elevated Paco2. Metabolic acidosis results from a lactic acid buildup from tissue hypoxia. |
Monitor oxygen saturation as indicated. | Pulse oximetry is a useful tool in the clinical setting to detect changes in oxygenation. Oxygen saturation should be at 90% or greater. |
Maintain client on bed rest. May resume activity gradually as tolerated. | This will decrease the oxygen demand during an episode of acute respiratory distress. |
Position the client properly to facilitate ventilation-perfusion matching. | Upright and sitting position optimize diaphragmatic excursions and lung perfusion. When the client is positioned on one side, the affected area should not be dependent. |
Administer oxygen as indicated. | Supplemental oxygen maintains adequate oxygenation, decreases the work of breathing, relieves dyspnea, and promotes comfort. The appropriate amount of oxygen needs to be continuously delivered so the client does not become desaturated. |
Anticipate the need to start anticoagulant therapy and, if there is massive thromboembolism, the use of thrombolytic therapy. | Heparin or enoxaparin (Lovenox) is used to prevent the recurrence of emboli. These medications do not dissolve clots that already exist. If a massive thrombus is present or the client is hemodynamically unstable, thrombolytic therapy (e.g, alteplase or reteplase [Retavase]) is used to directly lyse or dissolve the clot. |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023Â (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See Also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to respiratory system disorders:
- Asthma | 8 Care Plans
- Bronchiolitis | 5 Care Plans
- Bronchopulmonary Dysplasia (BPD) | 5 Care Plans
- Chronic Obstructive Pulmonary Disease (COPD) | 7 Care Plans
- Cystic Fibrosis | 5 Care Plans
- Hemothorax and Pneumothorax | 3 Care Plans
- Influenza (Flu) | 5 Care Plans
- Lung Cancer | 5 Care Plans
- Mechanical Ventilation | 6 Care Plans
- Near-Drowning | 5 Care Plans
- Pleural Effusion | 6 Care Plans
- Pneumonia | 11 Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans