A 55-year-old patient with a confirmed large saddle pulmonary embolism is undergoing the EKOS procedure for rapid thrombolysis. The patient is currently exhibiting signs of right ventricular strain and severe hypoxemia. As a nurse, which action should you prioritize to ensure the patient’s safety during this intervention?

B) Monitor the patient's neurological status for signs of intracranial hemorrhage every 15 minutes.

A) Increase the patient's oxygen flow rate to 20L/min to improve oxygenation.

B) Monitor the patient's neurological status for signs of intracranial hemorrhage every 15 minutes.

C) Administer an additional dose of Warfarin to ensure anticoagulation during the procedure.

D) Prepare for immediate transport to the Intensive Care Unit for closer monitoring.

A nurse is monitoring a patient with a large saddle pulmonary embolism undergoing the EKOS procedure for thrombolysis. Which assessment finding would most likely indicate a complication requiring immediate intervention?

B) Onset of hematuria and a drop in hemoglobin levels

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

B) Onset of hematuria and a drop in hemoglobin levels

C) A decrease in blood pressure from 110/70 mmHg to 100/65 mmHg

D) An increase in respiratory rate from 28 to 32 breaths per minute

A patient undergoing thrombolytic therapy for a pulmonary embolism has developed sudden confusion, a decreased Glasgow Coma Scale score, and unilateral weakness, along with a drop in hemoglobin levels. As the primary nurse, what is the most critical action to take to address these changes?

C) Immediately notify the healthcare provider of the neurological changes and potential intracranial hemorrhage.

A) Continue monitoring vital signs and prepare for potential intubation due to low oxygen saturation.

B) Administer a transfusion of packed red blood cells to address the drop in hemoglobin.

C) Immediately notify the healthcare provider of the neurological changes and potential intracranial hemorrhage.

D) Increase the high-flow oxygen delivery to improve the patient's oxygen saturation levels.

A patient undergoing thrombolytic therapy for a pulmonary embolism has developed new neurological symptoms, including confusion and a decrease in Glasgow Coma Scale score. The patient's hemoglobin levels have also dropped significantly. As the primary nurse, which immediate action should you prioritize to ensure the patient's safety while awaiting further diagnostic results?

D) Elevate the head of the bed to 30 degrees and initiate seizure precautions.

A) Increase the oxygen flow rate to further support respiratory function.

B) Prepare for the administration of a blood transfusion to address the drop in hemoglobin.

C) Collaborate with the healthcare team to discontinue the thrombolytic therapy.

D) Elevate the head of the bed to 30 degrees and initiate seizure precautions.

A patient with a confirmed pulmonary embolism and intracerebral hemorrhage is being stabilized in the ICU. Her hemodynamic status is fragile, and renal function is compromised. Which of the following nursing actions is the most appropriate to prioritize at this time?

B) Adjust the vasopressor infusion rate to maintain a mean arterial pressure (MAP) greater than 65 mmHg.

A) Initiate continuous renal replacement therapy to address rising creatinine levels.

B) Adjust the vasopressor infusion rate to maintain a mean arterial pressure (MAP) greater than 65 mmHg.

C) Administer a high-dose diuretic to manage potential fluid overload due to renal impairment.

D) Resume anticoagulation therapy to prevent further thrombotic events.

A patient with a pulmonary embolism and a confirmed intracerebral hemorrhage is being managed in the ICU. The patient's renal function is compromised, and her blood pressure is supported by vasopressors. Her oxygen saturation is critically low, and she's on non-invasive positive pressure ventilation. As the nurse, which intervention is the priority to prevent further neurological deterioration?

C) Adjust the settings on the non-invasive ventilator to optimize oxygenation.

A) Increase the vasopressor dosage to maintain a higher blood pressure target.

B) Administer diuretics to manage fluid status and prevent cerebral edema.

C) Adjust the settings on the non-invasive ventilator to optimize oxygenation.

D) Initiate dialysis to address rising creatinine levels and improve renal function.

A patient with acute kidney injury and intracranial hemorrhage is receiving continuous renal replacement therapy (CRRT) and hypertonic saline to manage cerebral edema. Which nursing intervention is most crucial to prioritize in this scenario?

B) Performing frequent neurological assessments to monitor for changes in the patient's level of consciousness.

A) Adjusting the CRRT settings to ensure adequate fluid removal and prevent fluid overload.

B) Performing frequent neurological assessments to monitor for changes in the patient's level of consciousness.

C) Administering hypertonic saline at a faster rate to quickly reduce intracranial pressure.

D) Increasing the frequency of vital sign monitoring to detect any hemodynamic instability.

A patient with acute kidney injury and fluctuating neurological status is being managed with continuous renal replacement therapy (CRRT) and hypertonic saline. Which nursing intervention is most critical to prioritize in this scenario to prevent further complications?

B) Perform frequent neurological assessments for any changes in consciousness or signs of increased intracranial pressure.

A) Monitor and document hourly urine output to assess renal function.

B) Perform frequent neurological assessments for any changes in consciousness or signs of increased intracranial pressure.

C) Adjust the CRRT settings to ensure adequate fluid removal without compromising blood pressure.

D) Administer antihypertensive medications to maintain optimal blood pressure levels.

A nurse in the ICU is caring for a patient with severe right heart failure, complicated by cardiogenic shock and decreased cerebral perfusion. The patient is receiving norepinephrine to support blood pressure. During the assessment, the nurse notes an increase in heart rate to 140 bpm, a blood pressure of 85/50 mmHg, and a further decline in Glasgow Coma Scale (GCS) score to 7. Based on these findings, what is the nurse's priority action?

B) Prepare for immediate intubation and mechanical ventilation to protect the airway.

A) Increase the norepinephrine infusion rate to further support blood pressure.

B) Prepare for immediate intubation and mechanical ventilation to protect the airway.

C) Notify the physician for potential adjustment of fluid management and consider diuretic therapy.

D) Initiate a rapid bolus of hypertonic saline to improve cerebral perfusion.

Pulmonary Embolis with right heart strain, treated with EKOS procedure - Nursing Case Study

Pathophysiology

• Primary mechanism: A pulmonary embolism (PE) occurs when a thrombus obstructs a pulmonary artery, causing a sudden increase in pulmonary vascular resistance. This obstruction impairs blood flow to lung tissue, leading to ventilation-perfusion mismatch and hypoxemia.

• Secondary mechanism: The increased pressure in the pulmonary artery causes right ventricular (RV) strain as the RV struggles to maintain cardiac output against the elevated afterload. Over time, this can lead to RV dilation, decreased contractility, and ultimately right heart failure.

• Key complication: Severe RV strain from a large PE can lead to decreased cardiac output and systemic hypotension, which are life-threatening. The EKOS procedure utilizes ultrasound-assisted catheter-directed thrombolysis to rapidly dissolve the clot, reducing RV strain and improving hemodynamics by decreasing pulmonary artery pressure.

Patient Profile

Demographics:

54-year-old female, office manager

History:

• Past medical history: Deep vein thrombosis, hypertension, chronic obstructive pulmonary disease

• Current medications: Warfarin, Lisinopril, Albuterol inhaler

• Allergies: Penicillin, shellfish

Current Presentation:

• Chief complaint: Sudden onset of severe shortness of breath and chest pain

• Key symptoms: Tachycardia, hypotension, cyanosis, elevated jugular venous pressure

• Vital signs: Heart rate 128 bpm, blood pressure 82/54 mmHg, respiratory rate 28 breaths per minute, oxygen saturation 82% on room air, temperature 37.2°C

Section 1

As the clinical team conducted the initial assessment, the patient's condition appeared to deteriorate rapidly. Her tachycardia persisted at 130 bpm despite initial stabilization efforts, and her blood pressure remained critically low at 78/50 mmHg. Her respiratory rate increased to 34 breaths per minute, and she continued to exhibit profound cyanosis with oxygen saturation dropping further to 78% even on 15L of supplemental oxygen via non-rebreather mask. The jugular venous pressure was markedly elevated, indicating worsening right heart strain. Auscultation revealed diminished breath sounds in the lower lobes and the presence of a third heart sound, suggestive of right ventricular dysfunction.

New diagnostic results provided additional insights into the severity of her condition. A bedside echocardiogram showed significant right ventricular dilation and hypokinesia, with a severely reduced ejection fraction of 25%. The interventricular septum was noted to be flattened, consistent with pressure overload. A CT pulmonary angiogram confirmed the presence of a large saddle pulmonary embolism occluding the main pulmonary artery bifurcation, with significant clot burden extending into both the right and left pulmonary arteries. Laboratory results showed a markedly elevated D-dimer level and arterial blood gas analysis revealed severe respiratory acidosis with a pH of 7.25, PaCO2 of 60 mmHg, and PaO2 of 55 mmHg.

The patient's management plan was adjusted to address these critical findings. The decision was made to proceed with the EKOS procedure to facilitate rapid thrombolysis and alleviate the right heart strain. However, the team remained vigilant for potential complications such as bleeding due to the combination of thrombolytic therapy and her existing anticoagulation with Warfarin. Continuous monitoring of her hemodynamic status was essential, as was frequent assessment of her neurological status to promptly identify any signs of intracranial hemorrhage, a known risk associated with thrombolytic therapy. The patient's journey now hinged on her response to this intervention and the meticulous balance of managing her complex clinical picture.

Section 2

Following the initiation of the EKOS procedure, the clinical team observed the patient closely for any changes in her condition. In the immediate aftermath, her vital signs showed some initial signs of improvement. Her heart rate gradually decreased to 110 bpm, and her blood pressure improved slightly to 85/55 mmHg. Despite these positive indicators, her oxygen saturation remained stubbornly low at 82% on high-flow oxygen, and her respiratory rate persisted at 32 breaths per minute, indicating ongoing respiratory distress. The team noted that her jugular venous pressure remained elevated, and the diminished breath sounds persisted, suggesting that the right heart strain had not yet fully resolved.

However, within a few hours, the patient's condition took an unexpected turn. She developed new neurological symptoms, including sudden confusion and disorientation, raising concerns about possible intracranial hemorrhage, a complication of the thrombolytic therapy. A rapid neurological assessment revealed a decrease in her Glasgow Coma Scale score to 12, with noted weakness on the left side of her body. The medical team promptly ordered a CT scan of her head to investigate the cause of these alarming symptoms. Concurrently, her laboratory results showed a significant drop in her hemoglobin levels from 12 g/dL to 9 g/dL, indicating potential bleeding.

The unfolding situation required the team to re-evaluate their management strategy. The potential for serious bleeding complications forced the clinicians to weigh the risks and benefits of continuing the thrombolytic therapy. It was imperative to stabilize the patient's neurological status while managing the embolic event effectively. This new complication introduced a complex layer to her treatment plan, demanding a multifaceted approach that balanced the urgency of resolving the pulmonary embolism with the critical need to prevent further hemorrhagic episodes. The patient’s journey now hinged on the careful integration of multidisciplinary expertise, as the team navigated these perilous complications to optimize her outcomes.

Section 3

As the medical team waited for the CT scan results, they initiated a series of interventions to address the patient's deteriorating condition. The priority was to stabilize her hemodynamics while minimizing further neurological decline. The decision was made to temporarily halt the thrombolytic therapy to mitigate the risk of further bleeding, particularly given the drop in hemoglobin and the signs of potential intracranial hemorrhage. The team started the patient on a low-dose vasopressor infusion to support her blood pressure, which had dipped again to 80/50 mmHg. Despite these efforts, the patient's oxygen saturation remained critically low at 80%, necessitating the initiation of non-invasive positive pressure ventilation in an attempt to improve her respiratory status.

Meanwhile, the CT scan confirmed a small intracerebral hemorrhage in the right parietal lobe, correlating with her left-sided weakness and confusion. This finding demanded a careful reassessment of her anticoagulation needs. The neurology consult recommended close monitoring in the intensive care unit with serial neurological examinations and repeat imaging if her condition worsened. In light of these findings, the team faced the complex challenge of managing both the pulmonary embolism and the intracranial hemorrhage, requiring a delicate balance between anticoagulation and hemorrhage control.

Further complicating the situation, the patient's renal function began to show signs of compromise, with her creatinine rising from 1.0 mg/dL to 1.8 mg/dL, potentially as a consequence of the contrast used in imaging or the underlying hemodynamic instability. This posed additional hurdles in managing fluid status and medication dosing, particularly in the context of her recent thrombolytic therapy. The critical care team, in collaboration with nephrology and neurology, needed to devise a comprehensive plan that would address her multifaceted needs while minimizing the risk of additional complications. The unfolding scenario required meticulous monitoring and agile decision-making to navigate the intricate web of her clinical challenges.

Section 4

As the medical team continued to manage the patient, new complications emerged, demanding further clinical adjustments. The patient's renal function deterioration was confirmed by an increase in BUN and creatinine levels, now at 35 mg/dL and 2.3 mg/dL respectively, indicating acute kidney injury likely exacerbated by contrast nephropathy and hypotension. This required immediate intervention to prevent further renal damage while considering her delicate hemodynamic status. The nephrology team advised beginning a low-dose continuous renal replacement therapy (CRRT) to manage fluid overload and electrolyte imbalances without compromising the patient's blood pressure stability.

Simultaneously, the patient's neurological status fluctuated; she became increasingly lethargic with a decreased level of consciousness, raising concerns of expanding intracranial hemorrhage or increased intracranial pressure (ICP). A repeat CT scan was expedited, revealing slight progression of the hemorrhage with surrounding edema. In response, the neurology team recommended initiating hypertonic saline to manage the cerebral edema, balancing this with the renal team's fluid restrictions. Serial neurological assessments were intensified, with strict monitoring for signs of herniation or further neurological decline.

Despite these mounting challenges, the patient's oxygenation showed subtle improvement with non-invasive ventilation, with her saturation rising to 85%. This incremental progress highlighted the importance of continued respiratory support while cautiously managing her anticoagulation needs. The team's next step involved a multidisciplinary meeting to reassess the patient's overall status, prioritizing interventions that would stabilize her condition without exacerbating the intracranial hemorrhage or renal impairment. This complex case evolved into a test of advanced clinical reasoning, demanding strategic planning and precise execution to navigate the intertwined complications effectively.

Section 5

As the team gathered for a multidisciplinary meeting, a sudden change in the patient's status prompted immediate attention. During routine monitoring, her heart rate spiked to 130 bpm with frequent premature ventricular contractions (PVCs), and her blood pressure dropped to 80/45 mmHg. Her respiratory rate increased to 28 breaths per minute, and her oxygen saturation fell to 78% despite the non-invasive ventilation support. These alarming changes suggested a potential exacerbation of right heart strain or further pulmonary compromise. The ICU nurse noted that the patient appeared increasingly diaphoretic and her skin was cool and clammy, indicating possible cardiogenic shock. The critical care team swiftly performed a point-of-care ultrasound, revealing a severely dilated right ventricle with reduced systolic function, consistent with worsening right heart failure.

In response to these developments, the medical team decided to optimize the patient's hemodynamics carefully. They initiated a low-dose norepinephrine infusion to support her blood pressure while maintaining vigilance over her renal status. The nephrology team adjusted the CRRT settings to accommodate the hemodynamic changes, aiming to prevent further renal insult. Concurrently, the cardiology team considered the possibility of catheter-directed thrombectomy or revisiting thrombolytic therapy, weighing the risks of bleeding against the benefits of resolving the pulmonary obstruction.

Despite these interventions, the patient's neurological status continued to be precarious. Her pupils were sluggishly reactive, and she exhibited diminished response to verbal stimuli, raising further concerns about cerebral perfusion. The neurology team recommended close monitoring of her Glasgow Coma Scale (GCS) score, which had dropped to 8, and reiterated the importance of balancing hypertonic saline administration with fluid management. The case now hinged on meticulous coordination among specialties to stabilize the patient, with each team member contributing their expertise to navigate this intricate clinical landscape. The team's next steps would involve reevaluating the efficacy of the interventions and determining whether surgical or advanced interventional procedures might be necessary to address the root causes of her critical condition.