A patient with suspected pulmonary embolism presents with worsening respiratory distress, increased heart rate, and chest pain. The latest ABG shows respiratory alkalosis with a pH of 7.48, PaCO2 of 30 mmHg, and PaO2 of 55 mmHg. What is the most appropriate initial nursing intervention to address the patient's hypoxemia?

A) Initiate high-flow oxygen therapy

B) Prepare for immediate thrombolytic therapy

D) Position the patient in a high Fowler's position

A patient with suspected pulmonary embolism is experiencing worsening respiratory distress and right ventricular strain. The patient is on high-flow oxygen therapy, and the medical team is considering anticoagulation adjustment due to a subtherapeutic INR. Which intervention should the nurse prioritize to address the patient's current respiratory compromise?

B) Increase the oxygen flow rate to improve oxygen saturation

A) Administer a bronchodilator to alleviate wheezing

B) Increase the oxygen flow rate to improve oxygen saturation

C) Prepare for thrombolytic therapy to dissolve the clot

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

A patient with a worsening pulmonary embolism is being treated with systemic thrombolysis. She exhibits jugular venous distension, tachycardia, and hypotension. Which nursing intervention should be prioritized to monitor and prevent further complications in this patient?

B) Initiate continuous cardiac monitoring

A) Administer oxygen at 2L/min via nasal cannula

B) Initiate continuous cardiac monitoring

C) Encourage deep breathing exercises

D) Administer intravenous fluids to address hypotension

A patient with a diagnosed pulmonary embolism is receiving systemic thrombolysis due to worsening right ventricular strain and hemodynamic instability. Which nursing intervention is the highest priority to monitor for potential complications during this treatment?

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

B) Assess for improvement in oxygen saturation levels

C) Evaluate pain levels and administer analgesics as needed

D) Check peripheral pulses for any signs of decreased perfusion

A patient with a pulmonary embolism has received systemic thrombolysis. Despite some improvement, her blood pressure remains low, and her heart rate is elevated. Which intervention should the nurse prioritize next to address these hemodynamic changes?

C) Prepare for the administration of inotropic agents to enhance cardiac output.

A) Increase the rate of intravenous fluids to improve blood pressure.

B) Administer an anxiolytic to decrease the patient's anxiety and heart rate.

C) Prepare for the administration of inotropic agents to enhance cardiac output.

D) Elevate the head of the bed to improve oxygenation.

A patient with a pulmonary embolism has received systemic thrombolysis. The nurse observes that the patient's oxygen saturation is 90%, respiratory rate is 24 breaths per minute, heart rate is 118 bpm, and blood pressure is 92/58 mmHg. Which nursing intervention is most appropriate to prioritize for this patient?

C) Administer a fluid bolus to address hypotension.

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

B) Prepare for immediate intubation due to respiratory distress.

C) Administer a fluid bolus to address hypotension.

D) Request an order for anti-anxiety medication to manage the patient's anxiety.

A patient with moderate right ventricular dilation and mild tricuspid regurgitation is receiving low-dose norepinephrine to manage hypotension. Her anticoagulation therapy has transitioned from thrombolytic therapy to a continuous heparin infusion. Which nursing intervention is a priority to ensure safe and effective management of this patient's condition?

A) Monitor the patient's heart rate and rhythm continuously.

B) Assess the patient's anxiety levels every 4 hours.

C) Encourage early ambulation to prevent deep vein thrombosis.

D) Administer prescribed anxiolytics to manage anxiety.

A patient with right ventricular dilation and persistent tachycardia is receiving low-dose norepinephrine for hypotension following thrombolytic therapy and is on a continuous heparin infusion. Which nursing intervention is most critical to ensure the safe management of this patient?

D) Evaluate hemoglobin and hematocrit levels every shift to detect any signs of bleeding.

A) Monitor the patient’s blood pressure every 15 minutes to assess the effectiveness of norepinephrine.

B) Check the patient's oxygen saturation every hour to ensure adequate respiratory function.

C) Assess the patient's mental status regularly for signs of decreased cerebral perfusion.

D) Evaluate hemoglobin and hematocrit levels every shift to detect any signs of bleeding.

A patient receiving heparin therapy has developed hemoptysis and hypotension, and their aPTT is significantly elevated. What is the most appropriate initial nursing intervention to prioritize in this situation?

A) Administer protamine sulfate as prescribed

B) Increase the supplemental oxygen delivery

C) Position the patient in a Trendelenburg position

D) Prepare the patient for an emergency bronchoscopy

A patient receiving heparin therapy for anticoagulation develops hemoptysis and hypotension, with lab results showing an elevated aPTT of 95 seconds. Which of the following nursing interventions is the most appropriate initial action?

C) Pause the heparin infusion and notify the healthcare provider.

A) Administer protamine sulfate to reverse heparin effects.

B) Increase the rate of the norepinephrine infusion.

C) Pause the heparin infusion and notify the healthcare provider.

D) Apply high-flow oxygen to improve oxygen saturation.

pulmonary embolism - Nursing Case Study

Pathophysiology

• Primary mechanism: A pulmonary embolism occurs when a blood clot, often originating from deep veins in the legs (deep vein thrombosis), travels to the pulmonary arteries, obstructing blood flow. This blockage prevents oxygen-rich blood from reaching lung tissues, impairing gas exchange.

• Secondary mechanism: The sudden obstruction increases pulmonary vascular resistance, leading to elevated right ventricular afterload. This strain can cause right ventricular dysfunction or failure, compromising cardiac output and potentially leading to systemic hypotension.

• Key complication: Reduced oxygenation and increased cardiac strain can result in acute respiratory distress and cardiovascular collapse, necessitating immediate intervention to restore perfusion and oxygen delivery.

Patient Profile

Demographics:

45, female, office manager

History:

• Key past medical history: History of deep vein thrombosis, hypertension

• Current medications: Warfarin, Lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath and chest pain

• Key symptoms: Tachycardia, cough, mild hemoptysis, dizziness

• Vital signs: Blood pressure 100/60 mmHg, heart rate 110 bpm, respiratory rate 24 breaths per minute, oxygen saturation 88% on room air, temperature 99.1°F

Section 1

As the medical team continues their assessment, they note a significant change in the patient's status indicating potential complications. Despite initial stabilization efforts, the patient begins to exhibit signs of worsening respiratory distress. Her respiratory rate increases to 30 breaths per minute, and her oxygen saturation drops further to 82% on room air. The patient appears increasingly anxious and diaphoretic, indicating heightened respiratory and cardiovascular strain. Upon auscultation, diminished breath sounds are noted in the lower lung fields, and scattered wheezes are present, suggesting evolving pulmonary compromise. The heart rate remains elevated at 118 bpm, and the patient reports intensified chest pain radiating to her back.

Concurrent with the physical assessment, laboratory results reveal a rising D-dimer level, consistent with ongoing thrombotic activity, and arterial blood gas analysis shows a significant respiratory alkalosis with a pH of 7.48, PaCO2 of 30 mmHg, and a PaO2 of 55 mmHg. These findings underscore an acute ventilation-perfusion mismatch and impaired gas exchange. An urgent bedside echocardiogram is performed, revealing signs of right ventricular strain, including moderate dilation and hypokinesis, corroborating the increased afterload and pressure burden on the heart.

These developments necessitate prompt intervention to address both the respiratory and hemodynamic components of the patient's condition. The team initiates high-flow oxygen therapy to improve oxygenation and considers anticoagulation adjustment under the guidance of a hematology consultant due to the subtherapeutic INR level of 1.8. Given the risk of further cardiovascular compromise, the team also prepares for potential escalation to advanced therapies, such as thrombolysis or mechanical ventilation, should the patient's condition not improve with initial interventions. This trajectory highlights the need for meticulous monitoring and timely clinical reasoning to avert further deterioration and guide the next steps in the patient's care plan.

Section 2

As the medical team implements high-flow oxygen therapy, there is an initial slight improvement in the patient's oxygen saturation, rising to 88%, but her respiratory rate remains elevated at 28 breaths per minute. The patient's anxiety persists, with continued diaphoresis and reports of sharp, stabbing chest pain that radiates to her shoulder blades. Despite these interventions, her heart rate continues to climb, now reaching 125 bpm, and jugular venous distension becomes more pronounced, suggesting worsening right heart failure.

A repeat arterial blood gas analysis shows a continued trend in respiratory alkalosis, with a pH of 7.46, PaCO2 of 32 mmHg, while the PaO2 remains critically low at 58 mmHg. The D-dimer level remains elevated, and a follow-up CT angiogram of the chest is urgently performed, revealing an increase in clot burden within the pulmonary vasculature, particularly affecting the right pulmonary artery. This finding indicates a progression of the pulmonary embolism and contributes to the deteriorating hemodynamic status.

Given the evidence of right ventricular strain and increasing risk of cardiovascular collapse, the team decides to proceed with systemic thrombolysis in an effort to rapidly reduce the clot burden and relieve the pressure on the heart. Concurrently, continuous cardiac monitoring is instituted to detect any arrhythmias, and vasopressor support is prepared should there be a need to stabilize her blood pressure, which is beginning to trend downward with readings of 90/60 mmHg. These decisions underscore the critical need for timely intervention and constant reassessment to prevent further complications and guide the patient's trajectory toward stabilization.

Section 3

Response to Interventions

Following the administration of systemic thrombolysis, the medical team monitors the patient closely for signs of improvement or potential complications. Within the first hour, her oxygen saturation shows a slight increase, reaching 90%, a modest but encouraging sign. Her respiratory rate decreases to 24 breaths per minute, indicating a partial reduction in respiratory distress. However, her heart rate remains elevated at 118 bpm, and her blood pressure continues to hover at concerning levels, with readings of 92/58 mmHg. Despite the thrombolytic therapy, the patient's anxiety persists, although she reports a marginal decrease in the intensity of her chest pain.

Continuous cardiac monitoring reveals occasional premature ventricular contractions, suggesting ongoing myocardial stress. The medical team remains vigilant, aware that the patient is still at risk for arrhythmias due to the strain on the right side of her heart. Repeat arterial blood gas analysis shows a slight improvement in respiratory alkalosis with a pH of 7.44 and PaCO2 of 34 mmHg. However, the PaO2 remains low at 62 mmHg, indicating that further intervention may be necessary to optimize oxygenation.

The team evaluates the need for additional supportive measures, such as inotropic support, to enhance cardiac output and stabilize blood pressure. They also consider escalating anticoagulation therapy once the acute phase of thrombolysis is managed, to prevent further clot formation. The patient's response to thrombolysis will be assessed continuously over the next critical hours, with the healthcare team prepared to adjust the treatment plan based on her evolving condition. This ongoing assessment and adaptation highlight the importance of dynamic clinical reasoning in managing complex cases like pulmonary embolism with complications.

Section 4

As the team continues to monitor the patient, new diagnostic results come in, shedding light on her current status. A follow-up echocardiogram reveals moderate right ventricular dilation and mild tricuspid regurgitation, indicating persistent strain on the right side of her heart. This finding aligns with the ongoing tachycardia and low blood pressure, suggesting that the thrombolytic therapy has not fully alleviated the pulmonary arterial pressure. Additionally, a repeat chest CT angiography shows partial resolution of the emboli but reveals residual clot burden in the pulmonary arteries, confirming the need for extended anticoagulation therapy.

In light of these findings, the medical team decides to initiate low-dose norepinephrine to address the patient's hypotension, aiming to improve perfusion without exacerbating cardiac workload. They also adjust her anticoagulation regimen, transitioning from thrombolytic therapy to a continuous heparin infusion, with plans to switch to oral anticoagulants as her condition stabilizes. The team remains attentive to the risk of bleeding, given the recent thrombolysis, and conducts regular hemoglobin and hematocrit assessments to monitor for any signs of hemorrhagic complications.

Throughout this phase, the patient's overall response remains cautiously optimistic. Her mental status remains alert, and she continues to communicate effectively, albeit with persistent anxiety. The nursing team employs non-pharmacological interventions, such as guided breathing exercises and reassurance, to manage her anxiety and support her breathing efforts. As her oxygen saturation stabilizes around 92% with supplemental oxygen, the team prepares to reassess her status in the coming hours, ready to modify the treatment plan as needed to navigate the complexities of her recovery journey.

Section 5

As the medical team continues to manage the patient's condition, a new complication arises. During routine monitoring, the patient develops a sudden episode of hemoptysis, raising immediate concerns about potential bleeding complications. Her vital signs reflect a subtle change, with a heart rate increasing to 110 beats per minute and a slight drop in blood pressure to 88/58 mmHg. Despite these changes, her oxygen saturation remains stable at 92% with supplemental oxygen. The interdisciplinary team promptly reviews her recent lab results, noting a decrease in hemoglobin from 13.5 g/dL to 11.2 g/dL, which corroborates the suspicion of a bleeding event linked to the anticoagulation therapy.

In response to the hemoptysis and altered hemodynamics, the team conducts an urgent assessment and orders a repeat coagulation profile, revealing an elevated activated partial thromboplastin time (aPTT) of 95 seconds, indicating supratherapeutic anticoagulation. Consequently, the heparin infusion is temporarily paused, and the patient is closely monitored for further signs of bleeding while the team consults with the hematology department for guidance on managing her anticoagulation regimen. To address her hypotension, the norepinephrine infusion is carefully titrated, ensuring adequate support for her blood pressure without exacerbating cardiac workload.

Throughout this period, the nursing team focuses on vigilant monitoring and supportive care. They provide continuous reassurance to the patient, explaining each step of the intervention to alleviate her anxiety. The team also prepares to reassess the patient's condition regularly, prioritizing the prevention of further complications. The goal is to stabilize her hemodynamics while cautiously balancing the anticoagulation therapy to mitigate the residual clot burden without increasing the risk of bleeding. This careful orchestration of interventions and assessments is critical as the team navigates the complexities of her recovery journey.