What is the nurses priority intervention for a client diagnosed with a pulmonary embolism?

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Quick diagnosis can save a patient’s life.
Nursing Diagnosis:
Subjective Data:
Objective Data:
Nursing Outcomes:
Nursing Interventions:
What is the nurse's priority intervention for a client diagnosed with a pulmonary embolism?
What is the first thing to do for a pulmonary embolism?
What is the best management to a patient suspected with pulmonary embolism?
What is the management of pulmonary embolism?

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FEATURES: Emergency

Quick diagnosis can save a patient’s life.

Koschel, Mary Jo MSN, RN

Author Information

Mary Jo Koschel is a flight nurse and paramedic for AirLife in Greeley, CO, and is on the clinical faculty at the University of Northern Colorado School of Nursing, also in Greeley. She is also the coordinator of Emergency: [email protected].

AJN, American Journal of Nursing: June 2004 - Volume 104 - Issue 6 - p 46-50

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In Brief

This nursing care plan include a diagnosis, and many interventions for the following conditions: Pulmonary Embolism, PE

What are nursing care plans? How do you develop a nursing care plan?

What nursing care plan book do you recommend helping you develop a nursing care plan?

This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.

Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.

Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.

If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.

Scenario:

A 65 year old female presents to your floor from the ER. The patient is admitted for dyspnea. You note that the patient presents with extreme dyspnea on an type of activity, especially during ambulation. You note the patient’s O2 saturation drops during activity to 82% on room air. While resting the patient oxygen saturation is 88-89%. You place the patient on 2L nasal cannula. The patient states she does not wear any oxygen at home. She states she started feeling very short of breath and having “chest like pain” on inspiration ever since she got back from her church mission trip from China which was 2 days ago. She said she thought it was pneumonia but she hasn’t been coughing up anything. Patient’s history includes: Breast Cancer 2000, double mastectomy 2001, Appendectomy 1983, Rhinoplasty 1999. VS: HR 105, BP 115/82, O2 Saturation 93% 2L nasal cannula, Temp. 98.6, RR 21, pain 2 on 1-10 scale. D-Dimer 920, Troponin 0.01. Pt had a CT scan with PE protocol performed before arrival to your floor and the results showed positive for Pulmonary Embolism. Pt is started on Lovenox 1mg/kg BID subq and Coumadin 5mg PO daily. Current INR 1.2.

Nursing Diagnosis:

Impaired gas exchanged related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolus as evidence by dyspnea, positive for Pulmonary Embolism, and abnormal pulse oximetry.

Subjective Data:

The patient states she does not wear any oxygen at home. She states she started feeling very short of breath and having “chest like pain” on inspiration ever since she got back from her church mission trip from China which was 2 days ago. She said she thought it was pneumonia but she hasn’t been coughing up anything.

Objective Data:

A 65 year old female presents to your floor from the ER. The patient is admitted for dyspnea. You note that the patient presents with extreme dyspnea on an type of activity, especially during ambulation. You note the patient’s O2 saturation drops during activity to 82% on room air. While resting the patient oxygen saturation is 88-89%. You place the patient on 2L nasal cannula. Patient’s history includes: Breast Cancer 2000, double mastectomy 2001, Appendectomy 1983, Rhinoplasty 1999. VS: HR 105, BP 115/82, O2 Saturation 93% 2L nasal cannula, Temp. 98.6, RR 21, pain 2 on 1-10 scale. D-Dimer 920, Troponin 0.01. Pt had a CT scan with PE protocol performed before arrival to your floor and the results showed positive for Pulmonary Embolism. Pt is started on Lovenox 1mg/kg BID subq and Coumadin 5mg PO daily. Current INR 1.2.

Nursing Outcomes:

-Pt’s oxygen saturation will be 90-100% during hospitalization.-Pt will be free from any injuries due to bleeding side effects of anti-coagulation therapy.

-Pt will demonstrate 2 breathing techniques to use during dyspneic episodes to help prevent hypoxia.

-Pt will verbalize 5 important things she must monitor while taking the anti-coagulate Coumadin.

Nursing Interventions:

-The nurse will titrate oxygen supplementation to keep patient’s oxygen saturation 90-100%.-The nurse will educate the patient about using the call light before ambulation to help prevent fall injuries.

-The nurse will teach and demonstrate to the patient 2 breathing techniques to use during dyspneic episodes.

-The nurse will provide the patient will Coumadin education materials and ask the patient to verbalize 5 important things she must monitor while taking Coumadin.

What is the nurse's priority intervention for a client diagnosed with a pulmonary embolism?

Nursing care for a patient with pulmonary embolism includes: Prevent venous stasis. Encourage ambulation and active and passive leg exercises to prevent venous stasis. Monitor thrombolytic therapy.

What is the first thing to do for a pulmonary embolism?

Treatment.

Blood thinners (anticoagulants). These drugs prevent existing clots from enlarging and new clots from forming while your body works to break up the clots. ... .

Clot dissolvers (thrombolytics). While clots usually dissolve on their own, sometimes thrombolytics given through the vein can dissolve clots quickly..

What is the best management to a patient suspected with pulmonary embolism?

Anticoagulation therapy is the primary treatment option for most patients with acute PE. The utilization of factor Xa antagonists and direct thrombin inhibitors, collectively termed Novel Oral Anticoagulants (NOACs) are likely to increase as they become incorporated into societal guidelines as first line therapy.

What is the management of pulmonary embolism?

The treatment approach for acute PE should always consists of three major components: cardiopulmonary support, anticoagulation to prevent extension and recurrence, and reperfusion of the PA. Cardiopulmonary support should first be initiated with methods such as supplemental oxygen and inotropic agents.