A patient with a suspected pulmonary embolism presents with increased respiratory distress, hypoxemia, and signs of right ventricular strain. After initial stabilization efforts, what is the nurse's priority intervention to address the patient's hemodynamic instability?

B) Prepare for potential thrombolytic therapy as prescribed.

A) Administer high-flow oxygen via non-rebreather mask.

B) Prepare for potential thrombolytic therapy as prescribed.

C) Initiate a large-bore IV for fluid resuscitation.

D) Position the patient in high Fowler's position to facilitate breathing.

A patient with suspected pulmonary embolism (PE) is showing signs of right heart strain and hemodynamic instability. The nurse is preparing to initiate anticoagulation therapy as per the healthcare provider's orders. Which assessment finding would require the nurse to withhold the anticoagulation therapy and immediately notify the healthcare provider?

A) Presence of hematuria and a recent history of heparin-induced thrombocytopenia (HIT).

B) A blood pressure reading of 90/60 mmHg with sinus tachycardia on ECG.

C) An oxygen saturation of 88% on 4L of supplemental oxygen.

D) Audible wheezing and use of accessory muscles for breathing.

A patient in the intensive care unit is experiencing significant right heart strain and cardiogenic shock after initiation of anticoagulation therapy. The medical team has decided to initiate thrombolytic therapy. What is the nurse's priority assessment following the administration of thrombolytics?

B) Assess neurological status for changes indicating a cerebral bleed.

A) Monitor for signs of bleeding, such as hematuria or hematemesis.

B) Assess neurological status for changes indicating a cerebral bleed.

C) Evaluate for improvement in oxygen saturation and respiratory status.

D) Check vital signs frequently for signs of improved hemodynamic stability.

A nurse is caring for a patient in the intensive care unit who has been diagnosed with acute right heart failure and is showing signs of cardiogenic shock. The medical team has decided to initiate thrombolytic therapy. What is the nurse’s priority action when preparing for thrombolytic therapy in this patient?

A) Ensure immediate availability of a defibrillator and resuscitation equipment.

B) Obtain a complete blood count (CBC) to monitor for bleeding risks.

C) Administer aspirin to prevent further clot formation before thrombolysis.

D) Position the patient upright to improve oxygenation.

A patient who recently received thrombolytic therapy presents with persistent acidosis, elevated lactate levels, and respiratory distress. Considering the current clinical scenario, which nursing intervention is most appropriate to prioritize at this moment?

D) Initiate mechanical ventilation to manage respiratory distress and correct acidosis

A) Administer sodium bicarbonate to correct the metabolic acidosis

B) Prepare for the initiation of inotropic support to improve cardiac output

C) Increase the patient's oxygen flow rate to address hypoxemia

D) Initiate mechanical ventilation to manage respiratory distress and correct acidosis

A patient who recently received thrombolytic therapy for a massive pulmonary embolism is showing signs of respiratory distress, persistent jugular venous distension, and mixed acidosis. The repeat echocardiogram indicates partial clot resolution, but the patient's lactate level is elevated, and arterial blood gases reveal significant hypoxemia and hypercapnia. What is the most appropriate nursing intervention at this time to address the patient's condition?

C) Prepare the patient for mechanical ventilation to correct respiratory failure.

A) Increase the oxygen flow rate to improve oxygenation.

B) Initiate inotropic support to improve cardiac output.

C) Prepare the patient for mechanical ventilation to correct respiratory failure.

D) Administer a bicarbonate infusion to correct metabolic acidosis.

A patient receiving dobutamine and NIPPV for cardiac and respiratory support shows a slight improvement in ABG results, but mixed acidosis persists. As the nurse, what is the most appropriate next step in the management plan to address the continuing respiratory distress?

B) Titrate the pressure settings on the NIPPV to improve ventilation.

A) Increase the rate of dobutamine infusion to further enhance cardiac output.

B) Titrate the pressure settings on the NIPPV to improve ventilation.

C) Initiate intravenous sodium bicarbonate to correct the acidosis.

D) Administer a diuretic to reduce fluid overload and improve respiratory status.

A patient with acute heart failure is receiving low-dose dobutamine and NIPPV. Her latest ABG shows a pH of 7.34, PaO2 of 65 mmHg, and PaCO2 of 50 mmHg. Which nursing intervention should be prioritized to address the current clinical findings?

A) Increase the NIPPV settings to improve oxygenation

B) Administer a bronchodilator to reduce respiratory effort

C) Encourage the patient to perform incentive spirometry exercises

D) Prepare for possible intubation and mechanical ventilation

A patient with a right-sided pneumothorax has a small-bore chest tube placed. The nurse observes that the patient's work of breathing has decreased and oxygen saturation has improved. Which of the following should the nurse prioritize to prevent further complications in this patient?

A) Monitor for signs of re-expansion pulmonary edema

B) Administer high-flow oxygen to maintain saturation above 95%

C) Encourage deep breathing exercises to promote lung expansion

D) Increase the pressure settings on the non-invasive positive pressure ventilation (NIPPV) to improve ventilation

A patient with a small right-sided pneumothorax is being managed with a small-bore chest tube and non-invasive positive pressure ventilation (NIPPV). Which nursing intervention is a priority to ensure effective management of this patient's condition?

C) Regularly assess for subcutaneous emphysema around the chest tube insertion site

A) Encourage the patient to take deep breaths to facilitate lung expansion

B) Monitor the chest tube drainage system for changes in color and consistency

C) Regularly assess for subcutaneous emphysema around the chest tube insertion site

D) Increase the NIPPV pressure settings to improve oxygenation

Pulmonary embolism - Nursing Case Study

Pathophysiology

• Primary mechanism: A pulmonary embolism (PE) occurs when a blood clot, often from deep veins in the legs (deep vein thrombosis), travels through the bloodstream and lodges in the pulmonary arteries, obstructing blood flow to lung tissue.

• Secondary mechanism: The obstruction increases pulmonary vascular resistance, leading to increased right ventricular workload. This can cause right ventricular strain or failure, affecting cardiac output and potentially leading to systemic hypotension.

• Key complication: The impaired blood flow results in decreased oxygenation of blood, causing hypoxemia and potentially leading to respiratory distress. This can progress to cardiopulmonary collapse if not promptly managed.

Patient Profile

Demographics:

45-year-old female, office administrator

History:

• Key past medical history: Hypertension, deep vein thrombosis 2 years ago

• Current medications: Lisinopril 10 mg daily, Warfarin 5 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of shortness of breath

• Key symptoms: Chest pain, cough with hemoptysis, lightheadedness, mild swelling in the right leg

• Vital signs: Blood pressure 98/60 mmHg, heart rate 112 bpm, respiratory rate 24 breaths per minute, temperature 98.7°F, oxygen saturation 90% on room air

Section 1

The initial assessment reveals worsening respiratory distress and signs of potential right heart strain. Upon further examination, the patient exhibits increased work of breathing, with accessory muscle use and audible wheezing upon auscultation. Her skin is cool and clammy, indicative of poor peripheral perfusion. The repeat vital signs show a heart rate that has increased to 128 bpm and a blood pressure that has further decreased to 88/54 mmHg. Oxygen saturation remains concerning at 85% despite supplemental oxygen administration via nasal cannula. These findings suggest a progression towards hemodynamic instability, likely due to increased right ventricular pressure and decreased cardiac output.

The healthcare team decides to perform a stat ECG and order a series of laboratory tests, including arterial blood gases (ABG), D-dimer, and cardiac biomarkers, to evaluate the extent of cardiac strain and rule out myocardial infarction. The ECG shows sinus tachycardia with signs of right ventricular strain, including an S1Q3T3 pattern. The ABG results indicate acute respiratory alkalosis with partial compensation, reflecting the patient's hyperventilation and hypoxemia. Elevated D-dimer levels support the suspicion of a significant thromboembolic event, and an increased troponin level suggests myocardial stress, likely due to right heart overload.

These clinical findings necessitate prompt intervention to stabilize the patient's condition. The primary interventions include initiating anticoagulation therapy with low molecular weight heparin, considering thrombolytic therapy for the severe PE, and closely monitoring the patient's hemodynamic status in the intensive care setting. The medical team discusses the potential need for advanced therapies, such as catheter-directed thrombolysis or surgical embolectomy, should the patient's condition not improve with initial treatments. This comprehensive approach aims to mitigate the current complications and prevent further deterioration, providing a critical juncture in the patient's care.

Section 2

Following the initiation of anticoagulation therapy with low molecular weight heparin, the patient's hemodynamic status is monitored closely in the intensive care setting. Despite initial interventions, the patient's condition continues to worsen, with signs of new complications emerging. Her respiratory distress remains significant, and she develops new onset of jugular venous distension. The repeat vital signs indicate further deterioration, with a heart rate now at 135 bpm and a blood pressure dropping to 82/50 mmHg. Oxygen saturation is persistently low at 82% despite escalating to high-flow oxygen therapy.

The medical team notes that the patient's skin has become increasingly cyanotic, with cool extremities, suggesting the progression of cardiogenic shock due to right heart failure. A bedside echocardiogram is performed, revealing significant right ventricular dilation and hypokinesis, consistent with acute right heart strain and decreased cardiac output. These findings raise concerns about the risk of cardiopulmonary collapse and necessitate an urgent reevaluation of management strategies.

Given the lack of improvement and the risk of further hemodynamic instability, the team decides to initiate thrombolytic therapy to rapidly reduce the clot burden and alleviate the strain on the right ventricle. The decision is made after careful consideration of the potential risks, as the patient's condition is critical and the benefits of thrombolysis are deemed to outweigh the risks. This intervention represents a pivotal moment in the patient's treatment plan, with the aim of reversing the acute life-threatening complications while stabilizing her for potential advanced therapies if necessary.

Section 3

Following the administration of thrombolytic therapy, the patient's condition begins to show subtle signs of improvement, yet vigilance remains paramount. Over the next few hours, her heart rate gradually decreases to 120 bpm, and her blood pressure shows slight improvement, now reading 90/60 mmHg. Oxygen saturation rises to 86%, although this still indicates significant hypoxemia. Despite these marginal gains, the patient continues to exhibit marked respiratory distress, and her jugular venous distension persists.

A repeat bedside echocardiogram reveals a slight reduction in right ventricular dilation, suggesting a partial clot resolution and decreased right heart strain. However, the lab results now indicate a rising lactate level of 4.2 mmol/L, pointing to ongoing tissue hypoperfusion and raising concerns about the adequacy of systemic circulation. Furthermore, arterial blood gas analysis shows a pH of 7.32, with a PaO2 of 60 mmHg and a PaCO2 of 55 mmHg, highlighting a mixed respiratory and metabolic acidosis that requires prompt correction.

Given these findings, the medical team deliberates on the next steps. While thrombolysis has provided some relief, the persistent acidosis and elevated lactate suggest that additional supportive measures are necessary. The team considers options such as inotropic support to enhance cardiac output and possibly transitioning to mechanical ventilation to better manage her respiratory status. This decision-making process underscores the complexity of the situation, requiring careful balancing of interventions to stabilize the patient while minimizing further complications. The evolving scenario sets the stage for potential escalation to more advanced therapies, emphasizing the need for continuous monitoring and adaptive clinical strategies.

Section 4

As the medical team moves forward with their management plan, they decide to initiate low-dose inotropic support with dobutamine to improve cardiac contractility and enhance systemic perfusion. The patient is also transitioned to non-invasive positive pressure ventilation (NIPPV) to better support her respiratory efforts and improve oxygenation. Over the next hour, there is a noticeable change in her clinical status. Her heart rate decreases further to 110 bpm, and her blood pressure stabilizes at 95/65 mmHg, suggesting improved cardiac function. Oxygen saturation increases to 91%, indicating a positive response to the NIPPV, although careful monitoring remains crucial.

Despite these encouraging signs, the patient's respiratory distress persists, and the medical team opts to repeat arterial blood gas analysis to assess the effectiveness of their interventions. The new ABG results show a pH of 7.34, PaO2 of 65 mmHg, and PaCO2 of 50 mmHg. While there is a slight improvement in both the respiratory and metabolic components, the mixed acidosis has not fully resolved. Additionally, the lactate level has decreased marginally to 3.8 mmol/L, reflecting some improvement in tissue perfusion, but still warrants ongoing attention.

As the team evaluates these results, they remain alert to the potential for new complications. The patient's jugular venous distension has reduced slightly, but she continues to display tachypnea and increased work of breathing. The nursing staff diligently monitors for any signs of worsening respiratory status or hemodynamic instability, prepared to escalate care if needed. The clinical scenario remains dynamic, with each intervention carefully weighed against its potential risks and benefits, underlining the importance of a coordinated, multidisciplinary approach to navigate the complexities of the patient's condition.

Section 5

As the medical team continues to monitor the patient, attention shifts to the potential development of new complications. Despite some improvement in cardiac output and oxygenation, the patient's persistent tachypnea and increased work of breathing raise concerns about a developing pneumothorax, particularly given the use of non-invasive positive pressure ventilation (NIPPV). In response, the team performs a bedside ultrasound to evaluate the lung fields for any signs of air leakage or pleural abnormalities. The ultrasound reveals a small right-sided pneumothorax, which explains the ongoing respiratory distress despite the current interventions.

In light of this new finding, the medical team reassesses their management plan. They decide to place a small-bore chest tube to evacuate the air and prevent further compromise of respiratory function. Additionally, they continue to support the patient with NIPPV cautiously, while closely monitoring for any signs of hemodynamic instability or worsening respiratory status. The patient's vital signs remain relatively stable, with a heart rate of 105 bpm, blood pressure of 92/60 mmHg, and oxygen saturation maintaining at 90% post-procedure.

With the chest tube in place, the patient's respiratory status gradually improves. The work of breathing decreases, and her oxygen saturation increases to 94%, indicating effective resolution of the pneumothorax. However, the medical team remains vigilant, aware of the potential for further complications such as infection or re-expansion pulmonary edema. Continuous monitoring and frequent reassessment are emphasized, ensuring that any changes in the patient's condition are promptly addressed. The interdisciplinary team collaborates closely, recognizing the importance of coordinated care in optimizing outcomes for this complex case.