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.
Risk factors of PE include the following:
- Reduced mobility/bed rest
- History of venous thromboembolism
- Recent surgery
- Oral contraceptives
- Varicose veins
- Clotting disorders
Clinical manifestations of PE may be varied and nonspecific, making it difficult to diagnose. The symptoms will depend on the size, type, and extent of the emboli.
Small emboli may often go undetected and cause transient symptoms. However, if the emboli are large enough, it can cause the following symptoms:
- Mild to moderate hypoxemia
- Chest pain
- Mental status alterations
D-dimer testing measures the presence of cross-linked fibrin fragments, which are the result of clot degradation. CT scans, pulmonary angiograms, and MRIs can visualize the lungs and blood vessels.
The 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 Care Plans Related to Pulmonary Embolism
Impaired Gas Exchange Care Plan
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
- Pulmonary embolism
- Ineffective gas exchange
- Alveolar-capillary membrane changes
- Ventilation-perfusion imbalance
As evidenced by:
- Abnormal ABGs
- Abnormal skin color
- Altered respiratory depth
- Altered respiratory rhythm
- The patient will demonstrate adequate oxygenation and improved ventilation as evidenced by improving ABGs
- The patient will maintain effective gas exchange as evidenced by O2 saturation and respiratory rate within normal limits
Impaired Gas Exchange 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.
Impaired Gas Exchange 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.
Acute Pain Care Plan
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
- Blockage of blood flow
- Lack of oxygen in cells
As evidenced by:
- Clutching chest
- Distraction behavior
- Facial grimacing
- Guarding behavior
- Positioning to ease pain
- Reports pain in the chest area
- The patient will report decreased sharp/stabbing/burning pain in the chest area
- The patient will demonstrate a relaxed appearance without facial grimacing, dyspnea, or restlessness behavior
Acute Pain 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.
Acute Pain 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.
Fear/Anxiety Care Plan
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
- Severe pain
- Possibility of death
- Unfamiliar situation
- Threat to health
As evidenced by:
- Increased blood pressure
- Increased heart rate
- Increased respiratory rate
- Concentration on the source of fear
- Decreased self-assurance
- Expresses alarm
- Expresses fear
- Expresses intense dread
- The patient will express fears and demonstrate coping techniques that will help reduce fear
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.
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.
References and Sources
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Pulmonary Embolism. Cleveland Clinic. February 26, 2019. https://my.clevelandclinic.org/health/diseases/17400-pulmonary-embolism
- Pulmonary Embolism. John Hopkins Medicine. 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/pulmonary-embolism
- Pulmonary Embolism. Mayo Clinic. June 13, 2020. https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/symptoms-causes/syc-20354647
- Pulmonary Embolism and Gas Exchange. Respiration.Fernandes CJ, Luppino Assad AP, Alves-Jr JL, Jardim C, de Souza R. 2019;98(3):253-262. doi: 10.1159/000501342. Epub 2019 Aug 7. PMID: 31390642. https://pubmed.ncbi.nlm.nih.gov/31390642/
- The psychological impact of pulmonary embolism: A mixed-methods study. Research and practice in thrombosis and haemostasis, Tran, A., Redley, M., & de Wit, K. (2021). 5(2), 301–307. https://doi.org/10.1002/rth2.12484