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.
Ineffective Breathing Pattern
May be related to
Possibly evidenced by
- Abnormal arterial blood gasses (ABGs)
- Desaturation (oxygen saturation below 90%)
- Impaired chest excursions
- Use of accessory muscles
- Client will maintain effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth, and absence of dyspnea.
|Assess the client’s anxiety level.||Pulmonary embolism is a sudden acute condition that can produce anxiety. Anxiety can result in rapid, shallow respirations and increase dyspnea. It can be a sign of decreasing hypoxemia.|
|Assess the respiratory rate, rhythm, and depth. Assess for any increase in the work of breathing: shortness of breath, and the use of accessory muscle.||Respiratory rate and rhythm changes are early signs of impending respiratory distress. Tachypnea is a typical finding of pulmonary embolism (PE). The rapid, shallow respirations results from hypoxia. The development of hypoventilation (slowing of respiratory rate) without improvement in the client’s condition indicates respiratory failure.|
|Assess the characteristics of pain, especially in association with the respiratory cycle.||Pain is usually sharp or stabbing and gets worse with deep breathing and coughing. It can result in shallow respirations, further impairing effective gas exchange.|
|Monitor arterial blood gasses (ABGs).||ABGs of these clients typically exhibit hypoxemia and respiratory alkalosis from a blowing off of carbon dioxide. The development of respiratory acidosis in this client indicates respiratory failure, and immediate ventilator support is indicated.|
|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 on room air.|
|Provide reassurance and allay anxiety by staying with the client during acute episodes of respiratory distress.||The presence of a trusted person may be helpful during periods of anxiety.|
|Position the client in a sitting position, and change the position every 2 hours.||If not contraindicated, a sitting position allows good lung excursion and chest expansion. Repositioning facilitates movement and the drainage of secretions.|
|Encourage deep breathing and coughing exercise. Suction as indicated.||Coughing is the most productive way to remove secretions. The client may be unable to perform independently. Suctioning is indicated when clients are unable to remove secretions from the airways by coughing. These maneuvers help keep airways open by clearing secretions.|
|Prepare the client for diagnostic studies:||Common tests such as a chest x-ray examination and D-dimer assay ( a marker for clot lysis) are readily available in acute care settings, especially to rule out PE. If there is a high suspicion for PE, then a CT scan and other scans are added to make a diagnosis. A pulmonary arteriogram is a definitive test.|
|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 for intubation and mechanical ventilation.||Intubation and positive-pressure ventilation are a means to stabilize breathing and ventilation and prevent decompensation of the client.|
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