A nurse is caring for a patient diagnosed with a pulmonary embolism causing obstructive shock. The patient is receiving a continuous infusion of heparin and supplemental oxygen, but their condition is deteriorating with persistent hypotension and altered mental status. What is the nurse's priority action at this time?

B) Prepare the patient for thrombolytic therapy administration.

A) Increase the infusion rate of the heparin drip.

B) Prepare the patient for thrombolytic therapy administration.

C) Place the patient in Trendelenburg position to improve cerebral perfusion.

D) Administer an additional dose of oxygen to increase saturation levels.

A nurse is caring for a patient diagnosed with a large saddle pulmonary embolism, currently receiving heparin infusion and supplemental oxygen. Despite these interventions, the patient remains hypotensive and shows signs of deteriorating mental status. Which nursing intervention is the priority to address the patient's hemodynamic instability?

C) Prepare for administration of thrombolytic therapy to dissolve the embolus.

A) Increase the rate of oxygen supplementation to improve oxygenation.

B) Administer an intravenous fluid bolus to improve circulatory volume.

C) Prepare for administration of thrombolytic therapy to dissolve the embolus.

D) Assist in intubation and mechanical ventilation to support respiratory function.

A patient receiving thrombolytic therapy for a pulmonary embolism develops acute pleuritic chest pain and hemoptysis. What is the priority nursing intervention?

B) Stop the alteplase infusion immediately and notify the healthcare provider

A) Increase the rate of norepinephrine infusion to raise blood pressure

B) Stop the alteplase infusion immediately and notify the healthcare provider

C) Administer an analgesic to relieve chest pain and ensure comfort

D) Prepare the patient for intubation due to potential respiratory failure

A patient with a pulmonary embolism has been administered thrombolytic therapy and is under vasopressor support. Shortly after, the patient develops acute pleuritic chest pain and hemoptysis. What is the nurse's priority action in this situation?

C) Stop the thrombolytic infusion and notify the physician immediately.

A) Increase the rate of norepinephrine infusion to manage hypotension.

B) Administer intravenous fluids to improve renal perfusion.

C) Stop the thrombolytic infusion and notify the physician immediately.

D) Prepare the patient for an emergency chest CT scan to assess further.

A patient with a recent pulmonary embolism is experiencing diffuse alveolar hemorrhage and is receiving reduced-dose alteplase therapy. The patient is also on norepinephrine and low-dose furosemide. The latest ABG shows a pH of 7.46, PaCO2 of 32 mmHg, and PaO2 of 60 mmHg. Which of the following interventions should the nurse prioritize to address the patient's current condition?

B) Prepare for potential intubation to enhance oxygenation.

A) Increase the norepinephrine dose to further improve blood pressure.

B) Prepare for potential intubation to enhance oxygenation.

C) Administer additional fluids to improve urine output.

D) Hold the alteplase dose and notify the healthcare provider.

A patient with a pulmonary embolism is experiencing diffuse alveolar hemorrhage and is receiving reduced-dose alteplase. The patient's recent arterial blood gas shows a pH of 7.46, PaCO2 of 32 mmHg, and PaO2 of 60 mmHg. The nurse notes low urine output and an elevated heart rate. Which intervention should the nurse prioritize to address the patient's current status?

C) Monitor for signs of bleeding and adjust thrombolytic therapy as needed

A) Increase the dose of norepinephrine to improve blood pressure

B) Administer a bolus of intravenous fluids to enhance renal perfusion

C) Monitor for signs of bleeding and adjust thrombolytic therapy as needed

D) Increase oxygen supplementation to improve PaO2 levels

A patient with a large pulmonary embolism and right ventricular strain is receiving alteplase and supportive measures, including high-flow nasal cannula and low-dose dobutamine. Laboratory results show a hemoglobin level of 8.5 g/dL. Which nursing intervention is most critical at this time to ensure patient safety?

B) Monitor for signs of bleeding and prepare for possible blood transfusion.

A) Increase the dobutamine infusion rate to improve cardiac output.

B) Monitor for signs of bleeding and prepare for possible blood transfusion.

C) Decrease oxygen delivery to prevent oxygen toxicity.

D) Request an increase in alteplase dosage to hasten embolism resolution.

A patient with a large pulmonary embolism and right ventricular strain is being managed with alteplase therapy and supportive care. The patient’s hemoglobin has dropped to 8.5 g/dL, indicating potential alveolar hemorrhage. What is the nurse’s priority action in this situation?

D) Assess the patient for signs of increased bleeding and notify the healthcare provider for potential adjustment of therapy.

A) Increase the rate of alteplase infusion to expedite embolism resolution.

B) Monitor the patient’s oxygen saturation and adjust the high-flow nasal cannula settings as needed.

C) Prepare for the immediate transfusion of packed red blood cells to address the drop in hemoglobin.

D) Assess the patient for signs of increased bleeding and notify the healthcare provider for potential adjustment of therapy.

A patient with a right-sided pleural effusion and evolving pulmonary edema is experiencing increased respiratory distress despite high-flow nasal cannula support. The medical team is considering various interventions, including pausing alteplase administration and preparing for blood transfusion. What is the most appropriate initial nursing action to address the patient's respiratory compromise?

B) Elevate the head of the bed to improve ventilation

A) Assist with thoracentesis to relieve pleural effusion

B) Elevate the head of the bed to improve ventilation

C) Administer diuretics as ordered to reduce fluid overload

D) Prepare the patient for repeat echocardiography

A patient with worsening respiratory distress has a new onset of right-sided pleuritic chest pain, diminished breath sounds, and a documented right-sided pleural effusion. Considering the current clinical situation and the latest laboratory findings, what is the most appropriate nursing intervention to prioritize?

B) Prepare the patient for thoracentesis to relieve pleural effusion and improve breathing.

A) Administer diuretics to manage fluid overload and improve respiratory function.

B) Prepare the patient for thoracentesis to relieve pleural effusion and improve breathing.

C) Increase the oxygen flow rate to maintain adequate oxygenation levels.

D) Initiate blood transfusion to address the significant drop in hemoglobin levels.

obstructive shock - Nursing Case Study

Pathophysiology

• Primary mechanism: Obstructive shock is primarily caused by a physical blockage in the circulatory system, such as a pulmonary embolism or cardiac tamponade, which impedes blood flow and reduces cardiac output, leading to inadequate tissue perfusion.

• Secondary mechanism: The obstruction leads to increased pressure in the affected area, such as elevated pressure in the right side of the heart in cases of pulmonary embolism, which can further compromise cardiac function and exacerbate decreased cardiac output.

• Key complication: If untreated, the continued low cardiac output and inadequate tissue perfusion can lead to organ dysfunction and failure, emphasizing the need for prompt identification and treatment to restore normal circulation.

Patient Profile

Demographics:

56-year-old male, construction worker

History:

• Key past medical history: Hypertension, hyperlipidemia, history of deep vein thrombosis

• Current medications: Lisinopril, Atorvastatin, Warfarin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Sudden onset of severe shortness of breath

• Key symptoms: Chest discomfort, hypotension, tachycardia, jugular venous distension, altered mental status

• Vital signs: Blood pressure 85/60 mmHg, heart rate 120 bpm, respiratory rate 28 breaths/min, SpO2 88% on room air, temperature 36.8°C

Section 1

As the medical team begins their initial assessment, they perform a focused physical examination and order critical diagnostic tests to further evaluate the underlying cause of the patient's obstructive shock. Upon auscultation, they note diminished breath sounds on the right side and a pronounced wheeze on the left, raising suspicions of an obstructive process such as a pulmonary embolism. The patient's extremities are cool and clammy, indicative of poor perfusion, and his skin exhibits a mottled appearance. The jugular venous distension remains prominent, suggesting increased central venous pressure, possibly due to a blockage in the pulmonary vasculature.

The team quickly orders a computed tomography pulmonary angiogram (CTPA) to confirm the presence of a pulmonary embolism. The results reveal a large saddle embolus obstructing the bifurcation of the pulmonary arteries, confirming the diagnosis of pulmonary embolism as the primary cause of the obstructive shock. Concurrently, laboratory tests show an elevated D-dimer level, further supporting the diagnosis. Troponin levels are slightly elevated, indicating potential myocardial strain due to the increased workload on the right ventricle. Arterial blood gas analysis reveals respiratory alkalosis with a pH of 7.48, PaCO2 of 32 mmHg, and PaO2 of 60 mmHg, reflecting the patient's respiratory distress and impaired gas exchange.

Recognizing the critical nature of the situation, the medical team initiates treatment with anticoagulation therapy, starting the patient on a continuous infusion of heparin to prevent further clot formation. Supplemental oxygen is administered to improve hypoxemia, and the patient is positioned in a semi-Fowler's position to enhance respiratory mechanics and venous return. Despite these interventions, the patient's blood pressure remains low, and his mental status continues to decline, indicating the need for more aggressive measures such as thrombolytic therapy or surgical intervention if hemodynamic stability is not achieved. The team prepares for potential transfer to a higher level of care, such as the intensive care unit, for closer monitoring and advanced management options.

Section 2

As the medical team continues to monitor the patient, they observe a concerning change in his status. Despite the administration of heparin and supplemental oxygen, the patient's blood pressure continues to decline, now reading 82/50 mmHg, and his heart rate remains tachycardic at 120 beats per minute. His mental status deteriorates further, becoming increasingly lethargic and less responsive to verbal stimuli. Repeat arterial blood gas analysis shows a worsening trend, with a pH of 7.45, PaCO2 of 30 mmHg, and PaO2 dropping to 55 mmHg, indicating a persistent respiratory alkalosis but worsening hypoxemia. The patient’s urine output has also decreased significantly, now less than 20 mL/hr, suggesting impaired renal perfusion and progressing shock.

Recognizing the need for urgent escalation, the team decides to initiate thrombolytic therapy to rapidly dissolve the large saddle embolus and restore pulmonary blood flow. Alteplase is administered, with careful monitoring for any signs of bleeding or adverse reactions. Simultaneously, vasopressor support with norepinephrine is started to improve mean arterial pressure and ensure adequate organ perfusion. The patient is transferred to the intensive care unit for continuous hemodynamic monitoring and advanced supportive care.

However, shortly after thrombolytic administration, the patient develops acute pleuritic chest pain and hemoptysis, raising concerns for potential pulmonary hemorrhage, a known complication of thrombolysis. A bedside chest X-ray is swiftly performed, revealing patchy infiltrates in the right lung, consistent with alveolar hemorrhage. The team is faced with a critical decision, balancing the need to manage potential bleeding complications against the life-threatening risks posed by the pulmonary embolism. This situation necessitates a nuanced approach, requiring ongoing assessment and adjustment of therapeutic strategies to stabilize the patient while minimizing adverse outcomes.

Section 3

As the medical team grapples with the patient's deteriorating condition, they focus on managing the new complication of potential pulmonary hemorrhage. To gain further insight, a decision is made to perform a bronchoscopy, allowing direct visualization of the airways and assessment of the extent of bleeding. The procedure reveals diffuse alveolar hemorrhage in the right lung, confirming the need to cautiously manage the thrombolytic therapy. Given the significant risk of ongoing bleeding, the team opts to reduce the dose of alteplase while maintaining close surveillance of the patient’s respiratory and hemodynamic status.

Meanwhile, the patient's vital signs show slight improvement with the initiation of norepinephrine, with blood pressure rising to 90/60 mmHg, though still below optimal levels. Heart rate remains elevated at 115 beats per minute. Repeat arterial blood gases indicate a pH of 7.46, PaCO2 of 32 mmHg, and PaO2 increasing slightly to 60 mmHg, suggesting marginal improvement in oxygenation but continued respiratory alkalosis. The urine output remains low, at 25 mL/hr, prompting the addition of low-dose furosemide to manage fluid balance and support renal perfusion.

The team regularly reassesses the patient, balancing the need to manage the life-threatening pulmonary embolism against the risks of hemorrhagic complications. This situation necessitates a dynamic approach, with frequent adjustments to medications and interventions based on the evolving clinical picture. The patient's course is closely monitored, with plans for serial imaging and laboratory evaluations to guide further management decisions. As the team navigates this complex scenario, they remain vigilant for signs of stabilization or further deterioration, ready to adapt their strategy to ensure the best possible outcomes.

Section 4

As the team continues to navigate the complexities of the patient’s condition, new diagnostic results provide critical insights into the evolving clinical picture. A follow-up CT scan of the chest reveals a persistent, large pulmonary embolism in the right pulmonary artery, with evidence of right ventricular strain, highlighting the ongoing obstruction and its impact on cardiac function. Concurrently, laboratory tests show a drop in hemoglobin levels to 8.5 g/dL, reflecting the potential impact of alveolar hemorrhage on the patient’s overall blood volume. These findings underscore the dual challenge of managing obstructive shock due to the embolism while addressing the risk of significant blood loss.

In response to these developments, the medical team revisits their therapeutic strategy, emphasizing the careful titration of alteplase to balance embolism resolution against bleeding risk. They also enhance supportive measures, including optimizing oxygen delivery with high-flow nasal cannula to address the moderate hypoxemia. Given the signs of right ventricular strain, the team initiates a low-dose dobutamine infusion aimed at improving cardiac output and reducing ventricular workload. The goal is to stabilize hemodynamics without exacerbating the risk of further hemorrhage.

This intricate scenario demands ongoing clinical reasoning to adjust treatments in real time. The team remains alert to any changes in the patient's status, such as signs of worsening respiratory distress or further drops in hemoglobin, which could indicate increased bleeding. They also plan for continued serial monitoring, including echocardiography to assess cardiac function and repeat laboratory evaluations to guide transfusion needs. As they proceed, the balance between aggressive management of the pulmonary embolism and careful monitoring of bleeding risk remains the cornerstone of their approach, with the aim of steering the patient towards stabilization and recovery.

Section 5

As the medical team continues to manage the patient's condition, a new complication emerges. During a routine assessment, the patient begins to exhibit signs of increased respiratory distress, with a respiratory rate climbing to 32 breaths per minute and oxygen saturation dropping to 88% despite high-flow nasal cannula support. Auscultation of the lungs reveals diminished breath sounds on the right side, raising concerns about potential pleural effusion or worsening pulmonary edema. Additionally, the patient reports a sudden onset of sharp, pleuritic chest pain on the right side, intensifying the clinical picture.

In response to these alarming changes, an urgent chest X-ray is ordered, revealing the presence of a moderate right-sided pleural effusion and signs suggestive of evolving pulmonary edema. Laboratory results show further decline in hemoglobin levels to 7.9 g/dL, indicating ongoing blood loss, possibly exacerbated by alveolar hemorrhage. These findings prompt immediate intervention adjustments. The medical team decides to temporarily pause alteplase administration to evaluate the bleeding risk more comprehensively. At the same time, diuretics are considered to manage the fluid overload contributing to the patient's respiratory compromise, while blood transfusion is prepared to address the significant drop in hemoglobin.

This development necessitates a reevaluation of the therapeutic strategy. The team remains vigilant, conducting repeat echocardiography to reassess right ventricular function and exploring thoracentesis as a potential intervention for the pleural effusion. The focus shifts to fine-tuning fluid management, ensuring that respiratory support is optimized without compounding the risk of bleeding. As the patient navigates this critical juncture, the team remains committed to closely monitoring vital signs, oxygenation status, and laboratory parameters to guide further interventions and support the patient's recovery trajectory.