Nursing Care Plan (NCP) for Pulmonary Embolism

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Outline

Pathophysiology

A pulmonary embolism  can occur when a blood clot or other substance  such as fat or air travels to the lungs. The clot that travels through the venous system and lodges in the pulmonary artery. This results in an occlusion of the pulmonary artery. Gas exchange is prevented at the alveolar level resulting in hypoxemia.

Etiology

PE is most commonly caused by a DVT that breaks off and migrates . They can also be caused by fat from long bone fracture, air, and tumors.

Desired Outcome

The most important desired outcome is to keep PE from growing in order to restore lung perfusion.

Subjective Data

  • Dyspnea and accessory muscle use
  • Pleuritic Chest Pain
  • Dizziness

Objective Data

  • Respirations > 20
  • Tachycardia
  • Hemoptysis
  • Lung Crackles
  • Wheezing
  • Fever (100.4 or higher)
  • Cough
  • Decreased SpO2
  • Hypotension
  • Right HF signs on ECG
  • ST at rest or new Afib

Nursing Interventions

Intervention

Rationale

Collect ABG

Respiratory Alkalosis may occur due to tachypnea; PaO2 is reduced due to increased dead space ventilation; (Late stages) ABG may progress to Metabolic Acidosis due to prolonged hypoxia

Closely monitor vital signs

BP may decrease due to decreased LV preload; Heart rate may increase due to hypoxemia; SpO2 decreases because of decreased blood perfusion in lungs.

CT scan

A CT scan is ordered to diagnose PE. The CT scan can also detect peripheral blood clots such as DVT. 

If CT Scan is not readily available, a Ventilation-Perfusion scan (V/Q scan) can be used. A test with a
“High probability” result means that there is an obstruction in the pulmonary vasculature. Please note that this test is not specific to diagnosing PE’s.

Place the patient on bleeding precautions

Anticoagulants and thrombolytics increase risk of bleeding.

  • Minimize  laboratory draws
  • Assess for new bruises
  • Assess sputum and urine for blood.

Keep patient NPO

If a patient becomes hemodynamically unstable, they  may need to go to surgery for an embolectomy. Oftentimes after clot is successfully removed, an IVC filter may be placed to prevent recurrent pulmonary embolisms.

Start Anticoagulation or Thrombolytic Therapy

Anticoagulants are administered to prevent the PE from growing, but it  does not break up or reduce the clot. Patients must be bridged  over to oral Warfarin for home anticoagulation.

 

Hemodynamically unstable patients may be candidates for thrombolytics which break up and dissolve the clot. There are absolute contraindications to thrombolytic therapy that must be considered.

  • History of hemorrhagic stroke.
  • Active cranial neoplasm
  • Recent surgery
  • Trauma within last 2 months
  • Active or recent intracranial bleeding 

Draw labs

Lactic Acid

  • An increase in lactic acid indicates anaerobic metabolism in the absence of oxygen.
  • D-dimer can indicate presence of thrombus in body.

Lesson Details

Writing a Nursing Care Plan (NCP) for Pulmonary Embolism

A Nursing Care Plan (NCP) for Pulmonary Embolism starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.

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Transcript

All right. Today, we are going to be talking about pulmonary embolism. Let’s take a look at the patho. Pretty much, Pulmonary embolism is your gas exchange as impaired because there’s a blockage in the lung. It can be from a blood clot, fat, or air, some things that we want to consider as nurses. So, first we want to look at all the vital signs. What are some vital signs that you think we would see? What are some changes? I definitely think that maybe we’ll have some increased respirations, Uh, we’ll have a heart rate increase, so it will be a little tachy, And also, we may have a fever, or some low BP. The next thing we want to consider is starting some anticoagulation therapy. So, we want to start anticoagulation therapy, or we want to start some thrombolytics. We want to monitor bleeding and we want to initiate bleeding precautions because of those thrombolytics and anticoagulants, and we want to make sure we educate the patient about bleeding risk, and some things that they can do at home. The most important thing that we want to focus on with PEs is we want to stop the PE from growing in order to restore lung perfusion. 

 

So this right here is Virchow’s triad, and it’s just a fancy way of saying that these three things together are going to increase a patient’s risk at having the thrombus. So, right here we have hypercoagulability, which is pretty much how thick the blood is. Venous Stasis is just what it sounds, It is the blood that is stopped. So, this can increase with people who are immobile, or if they’re obese or have a more sedintary lifestyle. And finally, the last portion of the Virchow’s triad is the, uh, damaged blood vessels, so, that comes from IV drug, user atherosclerosis. All of these things together create the perfect environment for a thrombus to form and break off into the lungs, and that’s when you get the PE. 

 

So some suggestive data, what is the patient going to tell you that they’re feeling, they may complain about some pleuritic chest pain, so they want to complain about some pain, or they may also talk about some difficulty breathing or dyspnea, so, um, they may complain about that. And then you may also notice that they complain about dizziness, weakness, those types of things. 

 

Some things that we may observe as nurses remember objective data, objective observed. We may observe some respiration, so their respirations are going to be way up over 20. Okay, they’re going to have some tachycardia, so they’re going to have increased heart rate. They may have a temperature, a fever that’s a hundred and four or greater. Um, we may have some bloody sputum, some hemoptysis, some crackles when we listen. Some wet lungs is what I call it. We may also have a cough, uh, decreased SATs, decreased o2 SATs, so that may be anywhere, um, in the eighties, anything less than eighty-eight, we definitely want to be concerned about. And then we’re going to have, uh, increased D dimer. Some nursing interventions, so we are going to focus on a few things. 

A lot of things that we’re going to focus on are going to work on the clot, but we’re going to also want to take a look. So, the first thing we’re going to say here is monitoring vital signs. So, we’re going to want to monitor vital signs. So again, you’re going to have some hypoxia. So, you’re going to have some increased heart rate, increased respirations. This is going to be low SATs, so we can maybe, uh, administer some supplemental oxygen, um, if their saturations are low. So, we want to administer o2. The next thing we want to focus on is we want to go ahead and start that anticoagulation therapy or a thrombolytic. So, anticoagulants such as heparin and then there’s also a Alteplase, which is the thrombolytic. Anticoagulation heparin is going to stop the clot from growing, Alteplase is going to actually bust that clot up. 

The next thing we want to focus on is, uh, we are going to actually place that patient on bleeding precautions. So, we want to make sure that we minimize our blood sticks. So, bleeding precautions, we’re going to, uh, minimize blood, uh, lab sticks. We’re going to ensure that they use electric trimmers, soft bristled toothbrushes, things like that. The labs that we’re going to look at, we’re going to focus primarily on lactic acid and D dimer. Um, and D dimer is just telling you that there’s a thrombus or something in the blood, um, and that lactic acid is going to show some hypoxia. Um, we’re going to order a CT scan. CT scan is the way to diagnose a PE. There’s also something called VQ perfusion scan. We’re not going to get into too much detail with that, but pretty much that’s just to let you know that there is a clot or thrombus somewhere in the body. So, um, but CT scan is the gold standard. 

 

Finally, we want to collect the ABG. That ABG is going to get us a lot of good information, uh, with the patient’s respiratory status. So ABG, remember, they have the increased respiration rate. So, that is going to, um, show maybe some alkalosis and then they may progress, uh, to, uh, acidosis just based off of, uh, prolonged hypoxia. Uh, there are just a couple things here on this slide that I want to let you know about, and this is the thrombolytic, the absolute contraindication, so if they have anything in the last few months, any trauma in the last couple of months in the, uh, active, uh, recent intracranial bleeding, any surgery, active, a neoplasm or some tumor or cancer in the cranium. And then also if they have a history of hemorrhagic stroke, we want to stay away from thrombolytics because that’s going to also increase their, uh, chance and risk of bleeding. 

Uh, finally, these are our key points. Know this, okay. know this, remember the patho. PE is a block in the lungs that’s keeping your air from getting into your blood. Okay. They may complain of some dyspnea, some difficulty breathing, chest pain. They’re going to have some increased respirations. They’re going to be tachycardia, they’re going to have some, uh, bloody sputum, hemoptysis, decrease, uh, o2 SATs. Remember, we’re going to start them on anticoagulation or thrombolytics right away. Remember, those anticoagulants are going to keep it from growing thrombolytics or clot busters as I like to call them are going to break up and dissolve that clot. And then finally, we’re going to place them on bleeding precautions, because they are at increased risk of bleeding because of the medications that we’ve given them. We’re going to use a soft-bristle toothbrush, and we’re also going to advise them to follow these measures at home as long as they are on those anticoagulants. So we love you guys here. Go out and be your best self today and as always, happy nursing.

 

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