During the initial assessment of a patient with suspected thromboembolic event, which of the following findings should the nurse prioritize for immediate intervention?

A) Mild jugular venous distension

B) Clear lung sounds upon auscultation

During the initial assessment of a patient with suspected obstructive shock, which finding is most consistent with this condition?

C) Mild jugular venous distension

Which laboratory result is most indicative of a thromboembolic event in this patient?

C) Increased white blood cell count

A patient with a history of deep vein thrombosis is diagnosed with a pulmonary embolism and is started on low molecular weight heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of this anticoagulation therapy?

D) No specific routine lab test is needed for efficacy

B) Activated partial thromboplastin time (aPTT)

D) No specific routine lab test is needed for efficacy

What is the primary purpose of monitoring a patient for unusual bruising and bleeding while on low molecular weight heparin therapy?

C) To detect potential side effects of anticoagulation therapy

A) To assess for signs of infection

B) To evaluate the effectiveness of the medication

C) To detect potential side effects of anticoagulation therapy

D) To ensure patient comfort and satisfaction

What is the primary purpose of administering low molecular weight heparin to a patient with a thromboembolic event?

B) To prevent further clot formation

What is the most appropriate nursing intervention for a patient with slight jugular vein distention and increased respiratory rate?

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

A) Encourage the patient to increase fluid intake.

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

C) Administer oxygen at 2 liters per minute via nasal cannula.

D) Encourage the patient to ambulate frequently.

What is the most appropriate initial nursing intervention for a patient with slight jugular vein distention and an elevated BNP level?

B) Elevate the head of the bed to 90 degrees

D) Perform a focused respiratory assessment

What is the primary purpose of administering supplemental oxygen via nasal cannula to a patient with increased work of breathing and a respiratory rate of 25 breaths per minute?

B) To improve oxygenation and reduce respiratory distress

A patient with a respiratory rate of 25 breaths per minute and oxygen saturation of 93% on room air is now receiving supplemental oxygen via nasal cannula at 2 liters per minute. What is the primary reason for administering supplemental oxygen in this situation?

C) To improve oxygenation and alleviate increased work of breathing

A) To increase the patient's heart rate

B) To enhance the patient's respiratory rate

C) To improve oxygenation and alleviate increased work of breathing

D) To decrease the patient's blood pressure

obstructive shock for lvn students - Nursing Case Study

Pathophysiology

• Primary mechanism: Obstructive shock occurs when a physical barrier blocks blood flow through the heart and major vessels, leading to inadequate circulation and oxygen delivery to tissues. Common causes include cardiac tamponade, tension pneumothorax, or massive pulmonary embolism.

• Secondary mechanism: The obstruction increases pressure in the affected area, reducing the heart's ability to fill and pump effectively. This results in decreased cardiac output, leading to reduced blood supply to vital organs.

• Key complication: If unaddressed, obstructive shock can cause organ failure due to insufficient blood flow and oxygenation, emphasizing the need for prompt identification and treatment of the underlying cause to restore normal circulation.

Patient Profile

Demographics:

28-year-old male, construction worker

History:

• Key past medical history: History of deep vein thrombosis (DVT)

• Current medications: None

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Mild chest discomfort

• Key symptoms: Lightheadedness, shortness of breath with exertion, mild swelling in legs

• Vital signs: Blood pressure 120/80 mmHg, heart rate 90 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, oxygen saturation 96% on room air

Section 1

Initial Assessment Findings:

During the initial nursing assessment, the patient appears alert and oriented but expresses concern about his recent symptoms. The nurse performs a focused cardiac and respiratory assessment, noting mild jugular venous distension and clear lung sounds upon auscultation. The patient's skin is warm and dry, though there is noticeable mild pitting edema in both lower extremities. The nurse also observes that the patient has a slightly anxious demeanor, likely due to his discomfort and unfamiliarity with the situation.

The nurse conducts a thorough review of the patient's history, taking note of his past deep vein thrombosis. Given the patient's current symptoms and medical history, the nurse considers the possibility of a thromboembolic event, such as a pulmonary embolism, contributing to the obstructive shock. The nurse prioritizes monitoring the patient's oxygen saturation and respiratory status, as any significant decrease in oxygen levels or increase in respiratory distress would necessitate immediate intervention.

In collaboration with the healthcare team, the nurse ensures that the patient is prepared for further diagnostic testing to confirm the underlying cause of the obstructive shock. Blood tests, including D-dimer and arterial blood gases, are ordered alongside imaging studies such as a chest X-ray and potentially a CT pulmonary angiogram to evaluate for a pulmonary embolism. This comprehensive assessment aims to gather critical information to guide the next steps in the patient's management and ensure timely and effective treatment.

Section 2

New Diagnostic Results:

Shortly after the initial assessment, the nurse receives the results of the blood tests and imaging studies. The D-dimer test returns elevated, which, combined with the patient’s history of deep vein thrombosis, raises the clinical suspicion for a thromboembolic event. The arterial blood gas analysis indicates mild respiratory alkalosis, with a partial pressure of oxygen (PaO2) of 75 mmHg, suggesting some degree of impaired gas exchange. The chest X-ray shows no significant abnormalities; however, the CT pulmonary angiogram confirms the presence of a small pulmonary embolism in the right lower lobe.

These findings provide a clearer picture of the underlying cause of the patient's obstructive shock. The nurse reviews the results with the healthcare team, discussing the need for anticoagulation therapy to manage the pulmonary embolism and prevent further complications. The patient's vital signs remain stable, with a blood pressure of 110/70 mmHg, heart rate of 95 beats per minute, and respiratory rate of 22 breaths per minute, although the patient continues to exhibit mild anxiety.

The medical team decides to initiate low molecular weight heparin therapy, and the nurse ensures that the patient and his family understand the treatment plan and its importance. The nurse also educates the patient on signs and symptoms of potential complications, such as increased shortness of breath or chest pain, that would require immediate medical attention. This proactive approach aims to stabilize the patient's condition and facilitate a smooth transition to the next phase of care.

Section 3

Response to Interventions:

Following the initiation of low molecular weight heparin therapy, the patient shows signs of positive response to the treatment. Over the next few hours, the nurse monitors the patient's vital signs and clinical status closely. The patient's blood pressure remains stable at 115/72 mmHg, and the heart rate gradually decreases to 88 beats per minute, indicating a slight reduction in cardiac workload. The respiratory rate also decreases to 20 breaths per minute, suggesting a decrease in the patient's anxiety levels and an improvement in overall respiratory comfort.

The nurse performs a focused respiratory assessment, noting that the patient has less labored breathing and is able to speak in full sentences without difficulty. Auscultation of the lungs reveals clear breath sounds bilaterally, with no adventitious sounds such as wheezing or crackles. The patient's oxygen saturation improves slightly, reaching 94% on room air, which is encouraging given the previous PaO2 of 75 mmHg. The nurse continues to educate the patient on the importance of adhering to the anticoagulation regimen and encourages early ambulation and leg exercises to prevent further thromboembolic complications.

While the patient is stable, the nurse remains vigilant for any signs of bleeding, a potential side effect of anticoagulation therapy. The nurse checks for any unusual bruising, bleeding gums, or blood in the urine and stools, reassuring the patient and family that these assessments are part of routine care to ensure safety during treatment. The patient's family expresses relief and gratitude for the attentive care and clear communication provided by the healthcare team. The nurse's proactive interventions and ongoing assessments are critical in maintaining the patient's stability and preventing complications, setting the stage for a continued positive trajectory in the patient's recovery journey.

Section 4

The following morning, the nurse conducts a routine assessment and notes a few changes in the patient's condition that require attention. While the patient's vital signs remain stable, with a blood pressure of 118/75 mmHg and a heart rate of 86 beats per minute, the respiratory rate has slightly increased to 22 breaths per minute. The patient reports feeling a mild discomfort in the chest, described as a pressure sensation rather than pain, which prompts the nurse to perform a more focused cardiac assessment. The nurse checks the patient's capillary refill, which remains brisk at less than 2 seconds, indicating adequate peripheral perfusion. However, the nurse observes slight jugular vein distention when the patient is positioned at a 45-degree angle, which could suggest increased central venous pressure.

In light of these findings, the nurse reviews the latest lab results, which include a complete blood count (CBC) and coagulation profile. The CBC reveals a hemoglobin level of 13 g/dL and a platelet count within normal limits, suggesting no immediate concern for bleeding. However, the D-dimer level remains elevated, consistent with the previous thromboembolic event. The nurse also notes a slight increase in the patient's B-type natriuretic peptide (BNP) level, prompting consideration of mild fluid overload or cardiac strain.

The nurse collaborates with the healthcare team to adjust the patient's care plan, including the potential need for diuretic therapy to manage fluid status and reduce cardiac workload. The patient is reassured about the changes in their condition and is educated on the importance of reporting any new or worsening symptoms. Additionally, the nurse reinforces the significance of continued monitoring, emphasizing that these assessments are crucial for early detection of complications and ensuring the patient's recovery remains on track. By addressing these early signs proactively, the team aims to maintain the patient's stability and prevent further escalation of symptoms.

Section 5

As the day progresses, the nurse continues to monitor the patient's response to the care plan adjustments. Early in the afternoon, the nurse notices a change in the patient's respiratory status. The respiratory rate has further increased to 25 breaths per minute, and the patient now appears slightly tachypneic with an oxygen saturation of 93% on room air. While still within acceptable limits, the nurse decides to administer supplemental oxygen via nasal cannula at 2 liters per minute to improve oxygenation and alleviate the patient’s increased work of breathing.

Additionally, during a routine auscultation of the patient's lung fields, the nurse detects fine crackles at the bases, which were not present during the morning assessment. This finding, coupled with the elevated BNP level and slight jugular vein distention noted earlier, suggests the potential development of mild pulmonary congestion. The nurse promptly communicates these changes to the healthcare provider, who concurs with the initiation of low-dose diuretic therapy to address potential fluid retention and reduce cardiac preload.

The patient is informed about the new intervention and reassured that these measures are precautionary to prevent further complications. The nurse emphasizes the importance of early intervention and continuous monitoring, explaining that these steps are vital to maintaining the patient's stability. The patient is encouraged to report any changes in symptoms, such as increased shortness of breath or worsening chest discomfort, to ensure timely management. As the healthcare team implements these adjustments, they remain vigilant in their assessments, aiming to ensure a favorable outcome and prevent the progression of obstructive shock symptoms.