22.27: Pulmonary Embolism III: Nursing Management

A pulmonary embolism occurs when a thrombus, amniotic fluid, tumor tissue, fat, or air embolus blocks one or more pulmonary arteries. Effective nursing management and patient education are crucial for improving outcomes and preventing recurrence.

Nursing management starts with obtaining a comprehensive patient history, particularly noting any history of deep vein thrombosis (DVT). Assess for clinical manifestations, including dyspnea, chest pain, crackles, heart murmurs, and signs of right-sided heart failure like peripheral edema and jugular vein distention (JVD). Evaluate laboratory values, focusing on arterial blood gas (ABG) results, which may show hypoxemia, and D-dimer levels, which, when elevated, can suggest the presence of a pulmonary embolism (PE).

Nursing care for PE focuses on acute care, ongoing assessment, and preventive strategies.

Acute Care

Prompt recognition and treatment are essential in the acute phase. Nurses should frequently monitor vital signs, especially respiratory rate, oxygen saturation, and blood pressure. Administering oxygen therapy to maintain adequate oxygenation is often necessary.

Patients should stay on bed rest during thrombolytic infusion, and vital signs must be frequently monitored for adverse reactions. Invasive procedures are avoided to prevent bleeding. Tests like international normalized ratio (INR) or activated partial thromboplastin time (aPTT) are conducted 3-4 hours after the infusion to confirm fibrinolytic system activation.

Ongoing Assessment

Regular respiratory and cardiovascular status assessment is crucial, including monitoring for signs of hypoxemia, respiratory distress, and hemodynamic instability. Continuous oxygen therapy is essential, and nurses should regularly assess patients for hypoxemia and monitor pulse oximetry to gauge therapy effectiveness. Deep breathing exercises and incentive spirometry are recommended to prevent atelectasis and improve ventilation. In some cases, nebulizer therapy or percussion and postural drainage may be necessary to manage secretions.

Managing Pain

Patients with PE often experience pleuritic chest pain. Placing them in a semi-Fowler position can ease breathing discomfort. Nurses should frequently turn and reposition patients to enhance ventilation and perfusion. For severe pain, administer prescribed opioid analgesics.

Patient Education on Preventing the Recurrence of DVT and PE

The nurse should instruct the patient regarding the following:

• Continue wearing anti-embolism stockings (compression hose) as directed.
• Avoid sitting with legs crossed or remaining in one position for prolonged periods.
• Change positions regularly, walk occasionally, and perform leg and ankle exercises when sitting for extended periods, especially during travel.
• Stay hydrated, particularly during travel and in warm weather, to prevent hemoconcentration due to fluid deficit.
• Proper instruction on anticoagulant therapy is crucial. Patients need to understand the purpose of the medication, the importance of adherence, and the potential side effects. They should be informed about the need for regular blood tests on warfarin and dietary considerations that may affect anticoagulant efficacy.
• Lifestyle Modifications: Encouraging lifestyle changes that promote cardiovascular health is beneficial. Patients should maintain a healthy weight, avoid prolonged immobility, and stay hydrated. Smoking cessation is strongly recommended, as smoking increases the risk of blood clots. Regular physical activity and avoiding sedentary behavior are essential.
• Recognizing Symptoms of Recurrence: Patients should be educated on signs of lower extremity circulatory compromise and potential DVT, such as calf pain, leg swelling, pedal edema, and PE recurrence symptoms like sudden chest pain, shortness of breath, or coughing up blood. They should know when to seek immediate medical attention and have an action plan.
• Importance of Follow-Up Appointments: Patients should understand the importance of attending follow-up appointments to monitor recovery and adjust treatments as necessary.