A patient with a suspected pulmonary embolism exhibits increased shortness of breath, a drop in oxygen saturation to 88%, and sharp chest pain on inhalation. Which initial nursing intervention is the highest priority to stabilize the patient's respiratory status?

A) Administer a higher concentration of supplemental oxygen.

B) Position the patient in a high Fowler's position.

C) Initiate a rapid response team call.

D) Administer prescribed anticoagulant therapy immediately.

A patient with suspected pulmonary embolism is experiencing increased shortness of breath, tachycardia, and chest pain. Despite supplemental oxygen, her oxygen saturation remains low. What is the priority action the nurse should take next?

C) Administer prescribed anticoagulant therapy

A) Increase the oxygen flow rate on the nasal cannula

B) Prepare the patient for a CT pulmonary angiogram

C) Administer prescribed anticoagulant therapy

D) Call the healthcare provider to report the changes

A patient with a confirmed diagnosis of substantial pulmonary embolism is receiving low molecular weight heparin therapy. The nurse is monitoring the patient’s response to treatment. Which of the following findings should prompt the nurse to immediately notify the healthcare provider?

A) A decrease in oxygen saturation from 90% to 85% despite oxygen therapy

B) A heart rate that remains elevated at 100 beats per minute

C) A blood pressure reading of 110/70 mmHg

D) A respiratory rate that remains stable at 20 breaths per minute

A patient with a confirmed pulmonary embolism is receiving anticoagulation therapy with low molecular weight heparin. The healthcare team is monitoring for complications related to the therapy. Which of the following nursing interventions should be prioritized to detect the most common complication associated with this treatment?

B) Assess the patient for signs of bleeding, such as hematuria or melena

A) Monitor the patient's oxygen saturation levels regularly

B) Assess the patient for signs of bleeding, such as hematuria or melena

C) Evaluate the patient's pain level and administer analgesics as needed

D) Check the patient's electrolyte levels for any imbalances

A patient with a pulmonary embolism has developed signs of gastrointestinal bleeding after starting anticoagulation therapy. The healthcare team is considering the next step in managing the patient's hemodynamic instability. Which of the following interventions should the nurse prioritize to address the patient's current condition?

A) Administer intravenous fluids to stabilize blood pressure.

C) Prepare the patient for an urgent surgical intervention.

D) Initiate a blood transfusion immediately without further assessment.

A patient who was started on anticoagulation therapy for a pulmonary embolism is now exhibiting signs of gastrointestinal bleeding, including coffee-ground emesis, abdominal tenderness, and a drop in hemoglobin levels. The healthcare team has temporarily held the anticoagulation therapy. What is the most appropriate immediate nursing action to prioritize in this situation?

C) Administer intravenous fluids to stabilize the patient's hemodynamic status

A) Increase the supplemental oxygen to improve oxygen saturation

B) Prepare the patient for an urgent endoscopy to identify the bleeding source

C) Administer intravenous fluids to stabilize the patient's hemodynamic status

D) Resume anticoagulation therapy to prevent worsening of the pulmonary embolism

A patient in the intensive care unit is experiencing decreased responsiveness, hypotension, tachycardia, and hypoxemia despite supplemental oxygen. After an endoscopy reveals multiple bleeding gastric ulcers, which of the following interventions should the nurse prioritize to address the patient's hemodynamic instability?

A) Administer intravenous fluids to maintain blood pressure.

B) Initiate continuous cardiac monitoring to assess for arrhythmias.

C) Prepare for immediate surgical intervention to repair ulcers.

D) Increase the oxygen flow rate to improve oxygen saturation.

A patient in the ICU with gastric ulcers exacerbated by anticoagulation therapy is receiving a blood transfusion and intravenous proton pump inhibitors. Which nursing assessment finding would be the most concerning and require immediate intervention?

A) Decreased urine output of 20 mL/hr

B) Temperature increase to 38.5°C (101.3°F)

D) Slightly improved oxygen saturation at 91%

A patient who recently received a blood transfusion is showing signs of respiratory distress with bilateral infiltrates on a chest X-ray. Which nursing intervention should be prioritized to address the patient's acute condition?

A) Administer diuretics to reduce potential fluid overload.

B) Increase the oxygen flow rate to improve oxygen saturation.

D) Prepare to administer anticoagulation therapy to prevent further embolic events.

A patient who recently received a blood transfusion is now exhibiting signs of respiratory distress, including tachypnea, use of accessory muscles, and wheezing. An arterial blood gas (ABG) analysis shows worsening hypoxemia and respiratory acidosis. A chest X-ray reveals bilateral infiltrates. What should be the nurse's priority intervention in this situation?

B) Initiate non-invasive positive pressure ventilation to improve gas exchange.

A) Administer a diuretic to address potential fluid overload.

B) Initiate non-invasive positive pressure ventilation to improve gas exchange.

C) Increase the patient's oxygen flow rate to 100% via non-rebreather mask.

D) Prepare the patient for immediate intubation and mechanical ventilation.

pulmonary embolism following a fracture - Nursing Case Study

Pathophysiology

• Primary mechanism: Venous thromboembolism (VTE) formation occurs after a fracture due to immobilization and injury to blood vessels, leading to stasis and hypercoagulability, which are part of Virchow's triad, increasing the risk of clot formation.

• Secondary mechanism: Fat embolism can develop when fat globules from the bone marrow enter the bloodstream during a fracture, leading to obstruction of pulmonary vessels and contributing to embolism.

• Key complication: These emboli can travel to the lungs, causing a pulmonary embolism, which obstructs blood flow, impairs gas exchange, and increases pulmonary artery pressure, potentially leading to respiratory distress and hemodynamic instability.

Patient Profile

Demographics:

55-year-old female, office manager

History:

• Key past medical history: Hypertension, osteoporosis, recent left tibial fracture

• Current medications: Lisinopril, calcium supplements, vitamin D, ibuprofen as needed

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath and chest pain

• Key symptoms: Dyspnea, pleuritic chest pain, swelling in the left leg, mild cough

• Vital signs: Blood pressure 145/90 mmHg, heart rate 110 bpm, respiratory rate 24 breaths per minute, temperature 99.5°F, oxygen saturation 91% on room air

Section 1

Change in Patient Status:

As the nursing team continues to monitor the patient, her condition begins to show signs of deterioration. Approximately two hours after initial presentation, her shortness of breath intensifies, and her oxygen saturation drops further to 88% on room air, prompting the immediate application of supplemental oxygen via nasal cannula. Despite this intervention, her respiratory rate increases to 28 breaths per minute, and her heart rate climbs to 120 bpm. The patient now appears visibly anxious and diaphoretic, and she reports an increased intensity in her chest pain, which she describes as sharp and stabbing, especially upon inhalation. The swelling in her left leg has also progressed, becoming more pronounced and tender to the touch.

Recognizing the potential for worsening pulmonary embolism, the healthcare team quickly initiates a more comprehensive assessment. Lung auscultation reveals diminished breath sounds in the lower lobes bilaterally, along with the presence of fine crackles, suggesting potential atelectasis or fluid accumulation. The cardiac examination shows no new murmurs, but the elevated heart rate and blood pressure of 150/95 mmHg indicate a compensatory response to hypoxia and increased pulmonary vascular resistance. The patient's escalating symptoms and vital signs reinforce the urgency for further diagnostic testing and potential therapeutic interventions to prevent further complications.

This change in status necessitates immediate clinical reasoning to prioritize interventions aimed at stabilizing the patient's respiratory status while investigating the underlying cause of her deterioration. The healthcare team considers the need for advanced imaging, such as a CT pulmonary angiogram, to confirm the presence of a pulmonary embolism, alongside laboratory tests including D-dimer and arterial blood gases to assess the severity of her respiratory compromise. This progression in the patient's journey highlights the critical importance of timely intervention in managing pulmonary embolism and preventing further morbidity.

Section 2

Following the patient's worsening condition, the healthcare team swiftly arranges for advanced imaging and laboratory tests. The CT pulmonary angiogram confirms the presence of multiple emboli in the pulmonary arteries, affirming the diagnosis of a substantial pulmonary embolism. Concurrently, laboratory results reveal an elevated D-dimer level, supporting the clotting activity in the body. Arterial blood gas analysis shows a pH of 7.32, PaCO2 of 50 mmHg, and PaO2 of 60 mmHg, indicating respiratory acidosis and significant hypoxemia. These findings corroborate the clinical suspicion of impaired gas exchange and increased pulmonary vascular resistance, necessitating immediate therapeutic adjustments.

In response to these diagnostic results, the healthcare team prioritizes stabilizing the patient's respiratory and hemodynamic status. The patient is transitioned from a nasal cannula to a non-rebreather mask to enhance oxygen delivery, aiming to improve her oxygen saturation levels above 92%. Anticoagulation therapy is promptly initiated with low molecular weight heparin to mitigate further clot propagation. Additionally, the team considers the potential use of thrombolytics, given the severity of the embolic burden and the patient's hemodynamic instability. Continuous monitoring of vital signs and oxygenation status is implemented to gauge the effectiveness of these interventions and guide further treatment decisions.

As the interventions begin, the patient's status is closely monitored for any signs of improvement or new complications. While her heart rate remains elevated, there is a slight improvement in oxygen saturation to 90% with the non-rebreather mask. However, the team remains vigilant for potential complications such as bleeding due to anticoagulation therapy or worsening hemodynamic instability. This phase of the patient's care underscores the need for diligent clinical reasoning and rapid adaptation of the treatment plan to address the complex and evolving nature of pulmonary embolism and its associated risks. The healthcare team prepares for potential escalation of care, including transfer to a higher acuity unit, should the patient's condition not stabilize promptly.

Section 3

As the healthcare team continues to monitor the patient's response to interventions, a new complication arises. Approximately six hours after the initiation of anticoagulation therapy, the patient begins to exhibit signs of gastrointestinal bleeding. She reports abdominal discomfort, and upon examination, her abdomen is slightly distended with tenderness in the epigastric region. The nursing staff notes the presence of coffee-ground emesis, an alarming indicator of potential upper gastrointestinal bleeding. Additionally, her vital signs show a concerning trend: her heart rate has increased to 120 bpm, blood pressure has dropped to 90/60 mmHg, and her oxygen saturation remains at 89% despite supplemental oxygen.

The healthcare team is faced with a complex situation requiring immediate clinical reasoning to balance the management of the pulmonary embolism and the emergent bleeding risk. They decide to hold the anticoagulation therapy temporarily to address the bleeding complication. Simultaneously, a gastroenterology consult is requested for further evaluation and possible endoscopic intervention. The team also orders a complete blood count, which reveals a significant drop in hemoglobin levels from 13 g/dL to 9 g/dL, confirming the suspicion of active bleeding.

In light of these developments, the patient is transferred to the intensive care unit for closer monitoring and advanced support. The team implements a plan to stabilize her hemodynamic status with intravenous fluids and considers the need for a blood transfusion if her hemoglobin levels continue to decline. As they navigate this critical phase, the healthcare team remains focused on reassessing the balance between treating the pulmonary embolism and managing the new complication, understanding that timely and well-coordinated interventions are crucial to improving the patient's outcomes. This situation underscores the importance of adaptive clinical reasoning in response to rapidly evolving conditions and potential complications.

Section 4

As the patient settles into the intensive care unit, the healthcare team continues its vigilant assessment and management of her condition. Approximately two hours after her transfer, her condition presents a new challenge. The patient becomes increasingly lethargic, responding only to verbal stimuli. Her vital signs indicate further instability: heart rate remains elevated at 125 bpm, blood pressure drops to a concerning 85/55 mmHg, and her respiratory rate increases to 24 breaths per minute. Despite receiving higher levels of supplemental oxygen, her oxygen saturation struggles to maintain above 88%. These findings suggest that her hemodynamic status is deteriorating, likely due to ongoing blood loss and compromised oxygenation.

The team quickly orders a repeat hemoglobin test, which shows a further decline to 7.5 g/dL. Recognizing the urgency, they proceed with a blood transfusion to address the anemia and support her hemodynamic stability. Concurrently, the gastroenterology team arrives to perform an emergent endoscopy, which reveals multiple bleeding gastric ulcers, possibly exacerbated by the anticoagulation therapy. Endoscopic intervention is performed to control the bleeding, and proton pump inhibitors are administered intravenously to aid in ulcer healing.

The patient's response to these interventions will be critical in determining the next steps. The healthcare team must carefully monitor her response to the blood transfusion and endoscopic measures to ensure stabilization. Additionally, they continue to weigh the risks and benefits of resuming anticoagulation therapy, considering the necessity of preventing further embolic events against the potential for recurrent bleeding. This delicate balance requires ongoing clinical reasoning and collaboration among the multidisciplinary team to optimize the patient’s complex care needs and improve her chances of recovery.

Section 5

As the team closely monitors the patient’s response to the interventions, they observe a gradual improvement in her hemodynamic status. Her heart rate begins to stabilize, decreasing to 110 bpm, and her blood pressure rises slightly to 95/60 mmHg, indicating a positive response to the blood transfusion. Her oxygen saturation also improves to 91% with continued supplemental oxygen, suggesting a partial restoration of her respiratory function. However, the team remains vigilant, aware that her condition could change rapidly.

Approximately four hours post-intervention, the patient exhibits a new complication: she becomes increasingly tachypneic, with a respiratory rate of 30 breaths per minute, and begins to exhibit signs of respiratory distress, including the use of accessory muscles and audible wheezing. A repeat arterial blood gas (ABG) analysis reveals worsening hypoxemia, with a PaO2 of 55 mmHg, and a developing respiratory acidosis, with a pH of 7.30 and PaCO2 of 50 mmHg. These findings suggest a potential acute respiratory compromise, possibly due to pulmonary edema or a progression of the initial embolic event.

Recognizing the severity of these findings, the healthcare team initiates non-invasive positive pressure ventilation to support her breathing and improve gas exchange. They also order a STAT chest X-ray, which reveals bilateral infiltrates, raising the possibility of acute respiratory distress syndrome (ARDS) or fluid overload secondary to the transfusion. The team must now engage in clinical reasoning to differentiate between these potential causes and determine the most appropriate management strategy. This involves revisiting the patient's fluid status, evaluating the need for diuretics, and considering the timing and necessity of resuming anticoagulation therapy to prevent further embolic complications. The multidisciplinary team continues its collaboration, balancing the need for aggressive intervention with the risks of exacerbating her delicate condition.