Pulmonary embolism (PE) is a blockage of one or more pulmonary arteries by a blood clot. Large emboli obstruct pulmonary blood flow, causing reduced oxygenation, reduced gas exchange, decreased perfusion, pulmonary tissue hypoxia, and even death.
Most PEs occur due to deep vein thrombosis (DVT) in the lower extremities when a thrombus breaks off and travels to the lungs. Less common causes of PEs include fat emboli from fractured bones, air emboli from intravenous therapy, and amniotic fluid emboli.
In this article:
Nursing Process
Early diagnosis and prompt treatment are essential to reduce the risk of mortality. The goals of treatment in PE include promoting adequate tissue perfusion, promoting adequate pulmonary function, and preventing further thrombi, complications, and the recurrence of PE.
Nurses assist with life-saving ventilatory and surgical support, administer medications, and educate patients on reducing their risk of PE.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section we will cover subjective and objective data related to pulmonary embolism.
Subjective Data
Review of health history and complaints
1. Assess the patient’s complaints and general symptoms.
Document the following:
- Dyspnea
- Tachypnea
- Fever
- Cough
- Chest pain
- Hemoptysis
- Crackles
- Wheezing
- Syncope
- Mental status alterations
- Hypotension
- Pain in the lower extremities (usually calf pain)
- Cold clammy skin
- Bluish discoloration of the skin (cyanosis)
2. Determine the patient’s risk.
Risk factors of PE include the following:
- Reduced mobility/bed rest
- History of venous thromboembolism
- Cancer
- Recent surgery
- Obesity
- Oral contraceptives
- Varicose veins
- Pregnancy
- Smoking
- Clotting disorders
3. Identify family history.
There would be an increased risk if the patient’s blood relatives (like a parent or sibling) had a pulmonary embolism or venous blood clot.
4. Revisit the patient’s past and present medical history.
Obtain a relevant medical history to determine risk factors for PE. Gather history from the patient and family members if the patient is confused. Examine the patient’s records, notes, family history, surgical history, and most current test results. Review the patient’s prescriptions.
5. Use Pulmonary Embolism Rule-out Criteria (PERC).
The Pulmonary Embolism Rule-out Criteria (PERC) is used for emergency department (hospitalized) patients to identify those with minimal risk of PE. Patients who are negative for all eight requirements have a <2% chance of PE, and additional testing is unnecessary.
Eight criteria under PERC:
- Age 50 or older
- Rapid heart rate (more than 100 bpm)
- Oxygen saturation of < 95% on room air
- Hemoptysis
- Hormone replacement or oral contraceptives
- Prior DVT or PE
- Unilateral leg edema
- Surgery or trauma within the previous four weeks
Objective Data
Physical assessment
1. Quickly assess for unexplained symptoms.
When a blood clot obstructs oxygen-rich blood flow in one of the prominent arteries of the lungs, pulmonary embolism occurs. Due to the lack of oxygen, PE is a medical emergency that may result in long-term harm to the lungs or other organs. In severe circumstances, pulmonary embolism may result in death. Seek immediate medical care if the patient experiences unexplained dyspnea, chest pain, or fainting.
2. Monitor vital signs.
Depending on the size of the clot and how much lung tissue is compromised, vital signs may be normal or abnormal. Vital signs decrease and become unstable with large clots. It can manifest as tachycardia, tachypnea, hypotension, and hypoxia.
3. Systemic assessment approach:
- Neck: distended jugular veins
- CNS: decreased level of consciousness
- Cardiovascular: chest pain on inspiration, arrhythmias, and tachycardia
- Circulatory: palpable cords, palpitation
- Respiratory: dyspnea, cough, hemoptysis, tachypnea, persistent cough, rales upon auscultation, decreased breath sounds, loud pulmonic closure sound (P2), and right side gallop, hypoxemia
- Lymphatic: swelling of the lower extremities and pedal edema
- Musculoskeletal: syncope, calf pain, fatigue, and muscle weakness
- Integumentary: erythema, cyanotic or pale skin, and excessive sweating
Diagnostic procedures
Note: Since chest pain and shortness of breath can also be the primary symptom of heart attack, pneumonia, pneumothorax (lung collapse), dissection of an aortic aneurysm (damage in the aorta), and other disorders, the physical examination will initially focus on the heart and lungs.
1. Hook the patient to an ECG machine.
ECG may be normal but may also indicate indirect indications of PE. The most common findings are:
- Tachycardia
- Nonspecific ST-segment
- T-wave changes
- S1Q3T3 pattern
- Right ventricular strain
- New incomplete right bundle branch block
2. Obtain a D-dimer blood test.
The D-dimer blood test measures the presence of cross-linked fibrin fragments, resulting from clot degradation.The risk of a pulmonary embolism is minimal if the findings are normal. This test does not explicitly detect lung blood clots but can reduce the need for imaging tests and the risk of radiation exposure.
3. Investigate other blood tests.
- Complete blood count with differential indicates the presence of anemia, blood coagulation, and infection.
- INR and PTT determine blood clotting capabilities.
3. Review chest X-ray findings.
The chest X-ray in pulmonary embolism is frequently normal. However, they can rule out other disorders with similar symptoms to pulmonary embolism.
4. Prepare for CTPA.
The preferred diagnostic technique for patients with suspected PE is a multidetector CT Pulmonary Angiogram (CTPA). It enables accurate imaging of the segments of pulmonary arteries and can detect blood clots.
5. Investigate further.
- Ventilation/perfusion scan (V/Q scan) is a diagnostic procedure for suspected PE for whom CTPA is contraindicated or when additional testing is required. Before V/Q scanning, a standard chest x-ray is necessary. The test of choice for identifying PE in pregnancy is still V/Q scanning.
- Echocardiogram detects right heart strain as a pulmonary embolism side effect.
- Venous Doppler ultrasound visualizes blood clots in patients with PE or deep vein thrombosis (DVT) with chest pain or dyspnea.
- Chest CT Scan is the recommended imaging scan for PE. It shows blood clots in the pulmonary arteries. Be cautious in using IV contrast (dye) in patients who are pregnant or have kidney problems. Also, note any allergies to seafood or iodine due to the risk of allergic reaction with the contrast.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section you’ll learn more about possible nursing interventions for a patient with pulmonary embolism.
Provide Supportive Measures
1. Administer supplemental oxygen.
Supplemental oxygen is recommended in individuals with oxygen saturation levels under 90%. Unstable patients may require mechanical ventilation.
2. Resuscitate volume aggressively.
The most prevalent cause of death in patients with hemodynamically unstable PE is acute right ventricular (RV) failure. Aggressive volume resuscitation can cause the RV to overextend and lower cardiac output (CO). Thus, only patients with collapsing prominent veins (inferior vena cava) should receive intravenous fluid resuscitation. Hemodynamic support may include the use of vasopressors.
3. Consider life-saving measures.
Extracorporeal membrane oxygenation (ECMO) is an example of a mechanical cardiopulmonary support device used in instances of high-risk, severe PE when other therapy has failed or if the patient cannot tolerate thrombectomy.
Promote Anticoagulation
1. Understand the need for anticoagulation.
It is crucial to understand that anticoagulation is the cornerstone of PE treatment. It also relieves chest and calf pain by promoting good blood flow to the affected area.
2. Administer anticoagulants as ordered.
PE can be treated with anticoagulation using:
- Low-molecular-weight heparin (LMWH)
- Unfractionated heparin (UFH)
3. Monitor for bleeding.
There is a risk of bleeding with any anticoagulant. Monitor for bloody stools, bruising, hemoptysis (coughing up blood), and epistaxis (bloody nose).
4. Consider NOACs.
Deep vein thrombosis (DVT) and PE are now treated and prevented with non-vitamin K antagonist oral anticoagulants (NOAC). Dabigatran, apixaban, and rivaroxaban are examples of NOACs. They are also called “DOACs,” or direct oral anticoagulants.
5. Monitor for PTT/INR.
The dosage of warfarin used daily to maintain proper blood thinning is determined by the INR (international normalized ratio). Blood tests are not required to check the effectiveness of the dosage of DOACs. IV unfractionated heparin is monitored through routine PTT (partial thromboplastin time) law draws to ensure therapeutic levels.
Dissolve the Clots
1. Assist in catheter-directed treatment.
With catheter-directed thrombolytic therapy, the clot-busting medication is delivered directly into the pulmonary artery at the location of the clot.
2. Surgically remove the clot.
The clot is removed using a catheter placed into the pulmonary artery. It is done through thrombectomy (removal of thrombus) or embolectomy (removal of embolus).
3. Consider vena cava filters.
The risk of recurrent PE decreases after placing a permanent vena cava filter. Vena cava filters are recommended for patients:
- With a contraindication to anticoagulants
- Still experiencing VTE, and anticoagulants are no longer working
Prevent Recurrence and Complications
1. Wear compression stockings.
In those with a prior history of a clot, compression stockings may aid in preventing recurrent DVT. Legs are steadily compressed by compression stockings, which improves blood flow via the veins and muscles of the legs. Compression stocks are a low-cost method for preventing blood from pooling in the legs before and after surgery.
2. Encourage early ambulation.
Following surgery, ambulation can aid in preventing pulmonary embolism and speed up recovery in general. Encourage the patient to get up and move around on the day of their surgery if not contraindicated.
3. Elevate the legs.
Elevating the patient’s legs at night and whenever sitting is therapeutic. Pillows can be used to elevate the legs and feet.
4. Use pneumatic compression.
Thigh-high or calf-high cuffs used in pneumatic compression therapy automatically inflate and deflate every few minutes. The legs’ veins are massaged and constricted, increasing blood flow and circulation.
5. Increase fluid intake.
Dehydration can lead to the formation of blood clots. Water is the best liquid to prevent blood clots. Avoid alcohol due to the effects of fluid loss.
6. Move periodically.
When on a long car ride, stop and stretch. On a plane, bend the knees and pump the feet to promote circulation.
7. Avoid sitting still.
Every 15 to 30 minutes, advise the patient to reposition, move the ankles in circles, and lift the toes when sitting for a long time. Emphasize the need to move even when sitting to promote circulation.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for pulmonary embolism, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for pulmonary embolism.
Acute Pain
Patients with PE often describe chest pain characterized as stabbing, sharp, burning, aching, or a dull sensation occurring under the breastbone or on one side of the chest. The pain usually occurs when breathing deeply, often hindering the ability to take a deep breath.
Nursing Diagnosis: Acute Pain
Related to:
- Blockage of blood flow
- Lack of oxygen in cells
- Hypoxia
As evidenced by:
- Diaphoresis
- Dyspnea
- Clutching chest
- Distraction behavior
- Facial grimacing
- Guarding behavior
- Positioning to ease pain
- Reports pain in the chest area
Expected outcomes:
- Patient will report decreased sharp/stabbing/burning pain in the chest area
- Patient will demonstrate a relaxed appearance without facial grimacing, dyspnea, or restlessness behavior
Assessment:
1. Conduct a comprehensive pain assessment.
Determining the characteristic of the pain, its location, intensity, and effects on function can support further assessments and planning of appropriate interventions.
Interventions:
1. Provide accurate information about the condition.
An educated explanation of the nature of the pain, present condition, and the treatment regimen can enhance pain control.
2. Administer medications as indicated.
Pain medication and anticoagulants are indicated for patients with PE to help improve the symptoms of the condition. Do not administer aspirin or NSAIDs that could further thin the blood.
3. Provide supplemental oxygen.
Pain in PE is associated with decreased oxygenation in the blocked areas in the lungs. Providing supplemental oxygen can help reduce hypoxia and pain.
4. Provide non-pharmacological pain relief.
Non-pharmacologic techniques for pain relief include relaxation, imagery, positioning, and distraction and can also work to decrease the work of breathing causing pain.
Anxiety
Patients diagnosed with PE are often fearful and anxious following their diagnosis due to the seriousness of the condition. Studies show that these patients also fear the recurrence of PE even after treatment.
Nursing Diagnosis: Anxiety
Related to:
- Severe pain
- Possibility of death
- Unfamiliar situation
- Threat to health
As evidenced by:
- Diaphoresis
- Increased blood pressure
- Increased heart rate
- Increased respiratory rate
- Apprehensiveness
- Concentration on the source of fear
- Decreased self-assurance
- Expresses alarm
- Expresses fear
- Expresses intense dread
Expected outcomes:
- Patient will express fears and demonstrate coping techniques that will help reduce fear.
Assessment:
1. Assess the source of fear.
Psychological distress is common in patients diagnosed with PE. Assess the exact factors of the patient’s fear to provide appropriate support.
Interventions:
2. Use therapeutic communication.
Using the following techniques: active listening, silence, offering self, and seeking clarification are a few ways the nurse can establish trust and effectively communicate with the patient about their fear.
3. Involve support systems.
Encourage family and friends to provide support to the patient.
4. Remain calm.
The patient who is experiencing panic or fear is unable to think logically. The nurse can be a source of calmness for the patient and provide reassurance.
5. Educate about prevention.
Fear may be associated with the recurrence of PE. Arm the patient with information to prevent a recurrence such as quitting smoking, taking medications as prescribed, wearing compression stockings, and being physically active.
Decreased Cardiac Tissue Perfusion
Decreased cardiac tissue perfusion associated with pulmonary embolism can be caused by a blood clot that disrupts the blood flow in the lungs resulting in decreased oxygenated blood and poor cardiac tissue perfusion.
Nursing Diagnosis: Decreased Cardiac Tissue Perfusion
Related to:
- Conditions that compromise the blood supply
- Structural impairment of the heart
- Difficulty of the heart muscle to pump
- Inability to contract and relax effectively
- Chaotic or irregular heart contraction
As evidenced by:
- Decreased cardiac output
- Decreased blood pressure
- Decreased peripheral pulses
- Increased central venous pressure (CVP)
- Increased pulmonary artery pressure (PAP)
- Tachycardia
- Dysrhythmias
- Ejection fraction less than 40%
- Decreased oxygen saturation
- Presence of abnormal heart sound S3 and S4 upon auscultation
- Chest pain
Expected outcomes:
- Patient will manifest pulse rate and rhythm within normal limits.
- Patient will demonstrate ejection fraction within normal limits.
- Patient will not develop right-sided heart failure.
Assessment:
1. Assess the cardiovascular status.
PE increases pulmonary pressures and may precipitate acute cor pulmonale. The nurse should assess for any underlying cardiac history that could complicate a PE.
2. Check for DVT.
If pulmonary embolism is suspected, examine the legs for deep vein thrombosis (DVT) symptoms, as this is usually where a PE originates. The presence of heart or lung disease and the size of the embolism will affect the type and severity of the symptoms.
3. Obtain ECG.
The nurse should quickly assess for dysrhythmias on ECG associated with PE.
Interventions:
1. Consider ECMO for hemodynamically unstable patients.
Mechanical cardiopulmonary support devices (such as extracorporeal membrane oxygenation (ECMO)) can be used in hemodynamically unstable patients. The heart and lungs may rest while the machine circulates and oxygenates blood outside the body.
2. Start anticoagulation therapy as ordered.
Anticoagulation therapy may include warfarin, non-vitamin K antagonist oral anticoagulants (NOACs), unfractionated heparin, and low-molecular-weight heparin (LMWH).
3. Administer thrombolytic therapy.
Thrombolytic therapy is reserved for massive PE as thrombolytics rapidly dissolve clots and reduce mortality.
4. Anticipate a possible removal of the clot.
In percutaneous thrombectomy, an X-ray-guided catheter is inserted into the blood vessel and advanced to the embolism location. It breaks, dissolves, or draws out the clot using thrombolytic medication.
Impaired Gas Exchange
Pulmonary embolism affects hemodynamics, lung mechanical capacity, and gas exchange. Patients with PE have problems with the transfer of carbon dioxide and oxygen across the lungs, increasing the risk of death from PE.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Pulmonary embolism
- Ineffective gas exchange
- Alveolar-capillary membrane changes
- Ventilation-perfusion imbalance
As evidenced by:
- Abnormal ABGs
- Hypoxemia
- Hypoxia
- Abnormal skin color
- Altered respiratory depth
- Altered respiratory rhythm
- Tachypnea
- Confusion
- Diaphoresis
- Restlessness
Expected outcomes:
- Patient will demonstrate adequate oxygenation and improved ventilation as evidenced by improving ABGs.
- Patient will maintain effective gas exchange as evidenced by O2 saturation and respiratory rate within normal limits.
Assessment:
1. Assess the patient’s ABG results.
Even though ABG analysis is not a diagnostic tool specific for PE, it is still important when assessing respiratory function. Patients with PE will show low PaO2 and pCO2 due to inadequate oxygenation, resulting from occlusion in the pulmonary vasculature.
2. Assess the patient’s breathing pattern and rate.
Patients experiencing PE are often short of breath. Breathing may be rapid, uneven, and labored. Immediate intervention is required.
3. Assess the patient’s breath sounds.
The presence of wheezes and crackles indicate airway obstruction and may or may not be heard on auscultation with a PE.
4. Assess the patient’s mental status and behavior.
Restlessness and mental status changes indicate impaired gas exchange. Lethargy is often indicative of severe impairment.
Interventions:
1. Administer medications as indicated.
Immediate anticoagulation is required for patients suffering from PE. Anticoagulants prevent clots from enlarging or new clots from forming but can’t dissolve existing clots. Thrombolytics are “clot busters” that can be given in severe cases.
2. Assist with V/Q scan.
A ventilation-perfusion scan (V/Q scan) evaluates air movement in the bronchi and bronchioles as well as the perfusion of blood within the lungs.
3. Administer supplemental oxygen.
Supplemental oxygen will help promote adequate oxygenation and relieve dyspnea.
4. Prepare for surgical intervention as indicated.
Embolectomy may be indicated for patients with massive PE who are hemodynamically unstable. Vena cava filters can also be placed to prevent clots from traveling to the lungs.
Ineffective Breathing Pattern
An ineffective breathing pattern associated with pulmonary embolism can be caused by a blood clot that blocks the blood flow in the lungs resulting in difficulty breathing.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Blood clot obstruction in the blood supply to the lungs
- Ineffective gas exchange in the lungs
- Insufficient oxygenated blood
- Difficulty of the heart muscle to pump
- Ventilation-perfusion imbalance
As evidenced by:
- Increased central venous pressure
- Increased pulmonary artery pressure
- Tachycardia
- Decreased oxygen saturation
- Chest pain
- Difficulty breathing (dyspnea)
- Rapid breathing (tachypnea)
- Accessory muscle use
- Cough
- Alteration in the level of consciousness
- Restlessness
- Fatigue
- Inadequate tolerance in activities
- Cyanosis
- Abnormal ABGs
Expected outcomes:
- Patient will maintain oxygen saturation within normal limits.
- Patient will present an alert, conscious, and coherent level of consciousness.
- Patient will maintain a respiratory rate of 12-18 breaths per minute without accessory muscle use or cyanosis.
Assessment:
1. Assess respiratory status.
The blood supply to the lungs is restricted by pulmonary embolism, which reduces oxygen levels and raises blood pressure in the pulmonary arteries. The lungs are affected based on the clot size and the presence of an underlying lung or heart disease. The symptoms of a pulmonary embolism can vary but usually result in chest pain with breathing, shortness of breath, and coughing.
2. Auscultate for lung sounds.
Bibasilar crackles or wheezing lung sounds are expected for patients with pulmonary embolism.
3. Review ABG analysis.
Suspicion for pulmonary embolism increases in patients with unexplained hypoxemia and a normal chest radiograph. The ABG analysis reveals respiratory alkalosis and hypocapnia.
4. Obtain chest X-ray.
A blood clot will not show on a chest X-ray, but this imaging is useful when a patient presents with acute dyspnea to rule out other possible diseases.
Interventions:
1. Administer oxygen as ordered.
Supplemental oxygen is recommended for individuals with oxygen saturation levels under 90%.
2. Consider mechanical ventilation for unstable patients.
In severe cases of PE, the patient who deteriorates to respiratory distress may require mechanical ventilation.
3. Position the patient in an upright position.
To encourage oxygenation, raise the head of the bed and maintain the patient in a semi- or high-Fowler’s position as tolerated.
4. Work with an RT.
Respiratory therapists titrate oxygen and ventilation settings, administer breathing treatments, obtain and assess ABGs, and assist the patient in promoting oxygenation.
References
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