A patient with a suspected pulmonary embolism is experiencing significant respiratory distress and has a subtherapeutic INR level while on Warfarin therapy. Which of the following interventions should the nurse anticipate as a priority to improve the patient's condition?

B) Prepare the patient for thrombolytic therapy to dissolve the clot.

A) Increase the flow rate of the high-flow nasal cannula to deliver more oxygen.

B) Prepare the patient for thrombolytic therapy to dissolve the clot.

C) Administer a bolus of intravenous fluids to support blood pressure.

D) Request a repeat INR test to confirm the initial subtherapeutic result.

A patient with a suspected pulmonary embolism is showing signs of respiratory distress and right ventricular strain. The patient's INR is subtherapeutic at 1.8 despite being on Warfarin. What is the most appropriate nursing intervention to prioritize at this time?

C) Prepare for thrombolytic therapy as ordered, given the subtherapeutic INR and signs of instability.

A) Administer a bolus of intravenous fluids to improve blood pressure.

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

C) Prepare for thrombolytic therapy as ordered, given the subtherapeutic INR and signs of instability.

D) Request an order for a higher dose of Warfarin to reach therapeutic INR levels.

A patient with multiple bilateral pulmonary emboli and right ventricular strain is being managed with intravenous heparin due to a subtherapeutic INR. Despite increased supplemental oxygen, the patient exhibits significant tachypnea and hypoxemia. Which nursing intervention is most appropriate to address the patient's current condition?

C) Initiate non-invasive positive pressure ventilation (NIPPV) to improve oxygenation.

A) Increase the oxygen flow rate to 8 L/min via nasal cannula.

B) Elevate the head of the bed to 45 degrees to facilitate breathing.

C) Initiate non-invasive positive pressure ventilation (NIPPV) to improve oxygenation.

D) Prepare the patient for intubation and mechanical ventilation.

A patient with multiple bilateral pulmonary emboli is currently on intravenous heparin therapy with a subtherapeutic INR and displays elevated respiratory rate and low oxygen saturation. What is the primary nursing intervention to address the patient's current respiratory status while continuing anticoagulation therapy?

A) Increase oxygen supplementation and place the patient in a high Fowler's position

B) Administer a bronchodilator to alleviate bronchospasm and improve oxygenation

C) Initiate thrombolytic therapy to rapidly dissolve the emboli

D) Reduce the heparin infusion rate to prevent further respiratory compromise

A patient with a diagnosed pulmonary embolism is experiencing hemodynamic instability and worsening respiratory acidosis despite being on intravenous heparin. The healthcare team is considering escalating to thrombolytic therapy. As a nurse, what is the most appropriate initial intervention to address the patient's current condition?

B) Administer an increased dose of supplemental oxygen to enhance oxygenation.

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

B) Administer an increased dose of supplemental oxygen to enhance oxygenation.

C) Prepare for immediate administration of thrombolytics to dissolve the emboli.

D) Elevate the head of the bed to reduce respiratory distress.

A patient with a significant pulmonary artery occlusion is experiencing signs of hemodynamic instability, including tachycardia, hypotension, fatigue, and dizziness. Despite being on intravenous heparin with therapeutic aPTT levels, the patient exhibits worsening hypoxemia and respiratory acidosis. Given these findings, what is the most appropriate initial nursing intervention to prioritize for this patient?

C) Administer additional oxygen and ensure the patient is in a semi-Fowler's position.

A) Increase the rate of intravenous fluid administration to address hypotension.

B) Prepare for immediate thrombolytic therapy to dissolve the emboli.

C) Administer additional oxygen and ensure the patient is in a semi-Fowler's position.

D) Obtain a stat echocardiogram to assess right heart function.

A patient with acute cor pulmonale is receiving thrombolytic therapy. Which nursing intervention is most critical to implement during the administration of this medication?

C) Check vital signs every 15 minutes for the first hour.

A) Monitor the patient's oxygen saturation continuously.

B) Assess the patient's neurological status every 2 hours.

C) Check vital signs every 15 minutes for the first hour.

D) Evaluate the patient's pain level regularly.

A patient with acute cor pulmonale is receiving thrombolytic therapy. Which of the following nursing actions is most critical in the first hour of administration to ensure patient safety?

A) Assess for signs of bleeding every 15 minutes.

B) Monitor serum potassium levels closely.

C) Encourage the patient to ambulate to prevent deep vein thrombosis.

D) Administer prescribed antihypertensive medication immediately.

A patient receiving thrombolytic therapy for a pulmonary embolism begins to experience hemoptysis. What is the most appropriate initial nursing action?

C) Notify the healthcare provider and prepare for potential discontinuation of thrombolytic therapy.

A) Administer a prescribed hemostatic agent immediately.

B) Inform the patient that hemoptysis is a common side effect and continue monitoring.

C) Notify the healthcare provider and prepare for potential discontinuation of thrombolytic therapy.

D) Increase the patient's oxygen flow to manage potential hypoxia.

A patient undergoing thrombolytic therapy for a pulmonary embolism develops hemoptysis and prolonged coagulation times. Which nursing intervention is most appropriate to implement first?

D) Reassess the patient's vital signs and physical status

A) Administer a hemostatic agent as prescribed

B) Increase the oxygen flow rate

C) Notify the healthcare provider of the bleeding

D) Reassess the patient's vital signs and physical status

Pulmonary embolism - Nursing Case Study

Pathophysiology

• Primary mechanism: A pulmonary embolism (PE) occurs when a blood clot, often originating from deep veins in the legs (deep vein thrombosis), travels to the lungs and lodges in the pulmonary arteries, obstructing blood flow and impairing gas exchange.

• Secondary mechanism: The blockage in the pulmonary artery increases pressure in the right ventricle of the heart, leading to right ventricular strain or failure, as the heart struggles to pump blood through the obstructed pulmonary circulation.

• Key complication: Reduced blood flow in the lungs decreases oxygenation of blood, potentially leading to hypoxemia and, if untreated, can result in respiratory distress, decreased cardiac output, or sudden death due to circulatory collapse.

Patient Profile

Demographics:

52-year-old male, office manager

History:

• Key past medical history: Hypertension, Deep Vein Thrombosis (DVT) 2 years ago

• Current medications: Lisinopril, Warfarin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of shortness of breath

• Key symptoms: Chest pain, rapid heartbeat, light-headedness, cough with occasional hemoptysis

• Vital signs: Blood pressure 110/70 mmHg, heart rate 120 bpm, respiratory rate 28 breaths per minute, oxygen saturation 88% on room air, temperature 98.6°F

Section 1

Change in Patient Status

As the medical team begins to address the suspected pulmonary embolism, the patient's condition starts to evolve, highlighting the complexity of his case. Despite initial oxygen supplementation, his oxygen saturation remains suboptimal at 90% with a high-flow nasal cannula delivering 10 liters per minute. The patient continues to experience significant respiratory distress, evidenced by increased accessory muscle use and audible wheezing upon auscultation. His heart rate remains elevated at 122 bpm, and his blood pressure has dropped slightly to 105/68 mmHg, indicating a potential compromise in cardiac output due to increased strain on the heart's right side.

The patient's clinical presentation prompts further evaluation, and an electrocardiogram (ECG) is performed, revealing sinus tachycardia with signs of right ventricular strain, including an S1Q3T3 pattern. Given his history of DVT and current anticoagulation therapy with Warfarin, concerns rise regarding the adequacy of anticoagulation management. A rapid point-of-care INR test shows a subtherapeutic level of 1.8, suggesting ineffective anticoagulation, possibly exacerbating the current thromboembolic event.

In response to the emergent nature of the situation, the team considers escalating anticoagulation therapy while also addressing the possibility of thrombolytic intervention. The patient's hemodynamic stability remains a concern, prompting the need for continuous monitoring and preparation for potential advanced interventions should his condition deteriorate further. This transitional phase in the patient's journey highlights the critical balance between maintaining adequate oxygenation and addressing the underlying thrombotic process, setting the stage for further diagnostic evaluations and therapeutic decisions.

Section 2

As the team progresses with the management plan, new diagnostic results emerge that provide further insight into the patient's condition. A contrast-enhanced CT pulmonary angiography is performed, confirming the presence of multiple bilateral pulmonary emboli predominantly affecting the right lung, with significant occlusion noted in the right pulmonary artery. This finding correlates with the observed signs of right ventricular strain on the ECG, reinforcing the severity of the embolic event and the increased workload on the heart's right side. Additionally, a venous Doppler ultrasound of the lower extremities reveals an extension of the deep vein thrombosis in the left leg, suggesting ongoing thrombus formation despite the current anticoagulation therapy.

In light of these findings, the medical team opts to initiate a bridging strategy with intravenous heparin, given his subtherapeutic INR and the acute nature of the embolic burden. The decision is made to monitor the patient's activated partial thromboplastin time (aPTT) closely to ensure therapeutic anticoagulation levels are achieved promptly. Meanwhile, the patient continues to exhibit significant tachypnea with a respiratory rate now elevated to 32 breaths per minute, and his oxygen saturation remains concerning at 88% despite increased supplemental oxygen. Arterial blood gas analysis reveals a respiratory alkalosis with mild hypoxemia, underscoring the patient's heightened respiratory drive and impaired gas exchange.

This critical juncture calls for careful assessment of the patient's response to the intensified anticoagulation regimen and vigilant monitoring for any signs of bleeding or hemodynamic instability. The team remains prepared to escalate to thrombolytic therapy if the patient's status does not improve or deteriorates further. These steps emphasize the delicate balance required in managing the acute and potentially life-threatening complications of pulmonary embolism, setting the stage for ongoing evaluation and adjustment of the therapeutic approach.

Section 3

As the medical team continues to monitor the patient closely, a change in his clinical status becomes apparent. Despite the initiation of intravenous heparin and diligent titration to maintain therapeutic aPTT levels, the patient begins to exhibit signs of hemodynamic instability. His heart rate increases to 128 beats per minute, and his blood pressure drops to 92/58 mmHg, raising concerns about possible right heart failure due to the significant pulmonary artery occlusion. The patient also reports feeling increasingly fatigued and lightheaded, with episodes of dizziness upon attempting to sit up.

In response to these developments, the team conducts a repeat arterial blood gas analysis, which now shows worsening hypoxemia with a PaO2 of 60 mmHg and a progression to respiratory acidosis, indicating impaired ventilation and oxygenation. The patient's lactate level is also elevated at 3.1 mmol/L, suggesting tissue hypoperfusion and raising the suspicion of impending shock. Given these alarming signs, the team considers the possibility of escalating to thrombolytic therapy to rapidly dissolve the emboli and relieve the burden on the right ventricle. However, they must carefully weigh the risks of bleeding against the potential benefits, taking into account the patient's current anticoagulation regimen and overall stability.

The nursing staff remains vigilant, continuously monitoring the patient's vital signs and providing supplemental oxygen to maintain adequate saturation levels. They also prepare for potential advanced interventions, such as the administration of thrombolytics or transfer to the intensive care unit if his condition deteriorates further. This scenario underscores the importance of timely decision-making and interdisciplinary collaboration in managing complex cases of pulmonary embolism with evolving complications. The next steps hinge on the patient's response to the current treatment plan and the careful balancing of therapeutic options to optimize outcomes.

Section 4

As the medical team deliberates on the next steps for managing the patient’s condition, they decide to conduct a bedside echocardiogram to assess the status of the right ventricle and evaluate the extent of hemodynamic compromise. The echocardiogram reveals significant right ventricular dilation and hypokinesis, confirming the suspicion of right heart strain due to the pulmonary artery occlusion. These findings, combined with the patient's worsening clinical status and elevated lactate levels, strongly suggest the onset of acute cor pulmonale, a complication that could rapidly progress to cardiogenic shock if not promptly addressed.

In light of these diagnostic results, the medical team urgently consults with a cardiologist to evaluate the appropriateness of initiating thrombolytic therapy, given the high risk of further hemodynamic decline. The patient’s risk of bleeding is thoroughly assessed, considering his current anticoagulation with heparin and the absence of contraindications such as recent surgery or a history of hemorrhagic stroke. After careful consideration, the decision is made to proceed with thrombolytic therapy, aiming to quickly dissolve the emboli and alleviate the burden on the right side of the heart.

The nursing staff plays a crucial role during this critical intervention, ensuring continuous monitoring of the patient's vital signs and readiness to manage potential complications such as bleeding or allergic reactions. They also provide emotional support to the patient, who is understandably anxious about the escalation of treatment. As the thrombolytic therapy is administered, the team remains vigilant, observing for any signs of clinical improvement or deterioration. The hope is that this aggressive approach will stabilize the patient's condition, improve oxygenation, and ultimately prevent further deterioration, allowing for a smooth transition to the next phase of recovery and care management.

Section 5

As the thrombolytic therapy progresses, the nursing staff observes the patient closely for any changes in clinical status. Within the first hour, there are subtle signs of improvement; the patient reports a slight decrease in chest pain and a marginal improvement in breathing comfort. Vital signs are monitored continuously, and there is a gradual stabilization of blood pressure, which begins to rise from a concerning 85/55 mmHg to a more reassuring 100/65 mmHg. Heart rate remains elevated but shows a slight decrease, moving from 120 beats per minute to 105 beats per minute. Oxygen saturation improves slightly, going from 88% to 92% on high-flow oxygen, suggesting enhanced gas exchange as the emboli begin to break down.

However, as the therapy proceeds, the patient begins to experience a new onset of hemoptysis, raising concerns about bleeding complications. The nursing team promptly reports this to the medical team, who orders an immediate repeat of coagulation studies. The lab results reveal a significant prolongation of the patient's prothrombin time (PT) and activated partial thromboplastin time (aPTT), indicating the need for cautious monitoring and possible adjustment of anticoagulation therapy. Despite this, the team decides to continue with the thrombolytic treatment, judging that the risk of hemodynamic collapse outweighs the bleeding risk at this moment.

This development necessitates a comprehensive reassessment of the patient's condition and the potential need for additional interventions. As the medical team weighs the benefits and risks, they consider the introduction of a hemostatic agent to manage the bleeding while maintaining the therapeutic effectiveness of the thrombolytics. The patient remains under close surveillance, with the nursing team prepared to provide immediate care and psychological support, reassuring the patient throughout this critical phase. Moving forward, the patient will require further diagnostic imaging to assess the resolution of the emboli and ongoing evaluation of his response to therapy, ensuring timely adjustments to the treatment plan as needed.