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Nursing care plan

Medical Diagnosis: Pulmonary Embolism

Nursing Diagnosis: Impaired gas exchanged related to decrease pulmonary perfusion

associated with obstruction of pulmonary arterial blood flow by the embolus.

Expected outcome: Patient maintains optimal gas exchange as evidenced by:-

a. Normal arterial blood gases (ABGs)

b. Pulse oximetry results within normal range.
c. Usual mental status.
d. Normal respiration rate.

Nursing intervention Rationales

-Frequently assess respiratory status
including rate, depth, effort, lung sound
and SPO2.
-Assess the mental status of the client
(changes in orientation and behavior)
-Monitor ABGs and note changes
- Impaired ventilation affects gas exchange
and worsens hypoxemia (Tachypnea,
dyspnea). SPO2 can be used as a non-
invasive method to monitors oxygen
saturation.
- Restlessness is an early sign of hypoxia.
Hypoxemia often causes confusion and
agitation.
- ABGs used to assess gas exchange of
client

-Position the patient in high fowler’s
position
-Administered oxygen as ordered by
doctor
-Maintain bed rest
-Administer medications
(anticoagulants) as prescribed by
doctor. E.g low-molecular-weight
heparin, warfarin etc
-To facilitate maximal lung expansion/
improve ventilation and reduce venous
return to the right side of the heart.
-To improve oxygenation.
-Bed rest reduces metabolic demands for
oxygen
- Anticoagulant therapy is preventive by
inhibiting further clot formation.
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Nursing care plan

Medical Diagnosis: Pulmonary Embolism

Nursing Diagnosis: Risk for bleeding related to prolonged coagulation time associated
with anticoagulant therapy.

Expected outcome: the client will not experienced unusual bleeding as evidenced by:-

a. Skin and mucous membrane free of petechiae, purpura, ecchymosis and active
bleeding.
b. Absence of unusual joint pain
c. Exhibits no blood in feces, urine or emesis,
d. Stable Hematocrit and Haemoglobin level
e. Vital signs within normal range

Nursing intervention Rationales

-Assess frequently for signs of bleeding: Careful monitoring is necessary to identify
a. prolonged bleeding from invasive early signs of abnormal bleeding,
procedures, minor cuts
b. frank or occult blood in any body
excretion, emesis, sputum
c. joint pain
d. decreased in hameglobin or
hematocrit level
-Assess platelet count and coagulation -Platelet count less than 20,000 mm3
test results and report for any indicates severe risk of bleeding
abnormality.
-Avoid invasive procedures, injections - Invasive procedure increases the risk of
and venous punctures when possible tissue trauma and bleeding.

-Apply direct pressure to injection and - To minimize blood loss

venipuncture sites for at least 5 mins
-Maintain fluid intake of at least 3L/day - These measure help to prevent
unless contraindicated. Administer stool constipation and straining during defecation.
softers as ordered.
-Avoid medications that will interfere -Drug interaction can increase the risk fro
with clotting (e.g Aspirin) hemorrhage/ for their embolus formation.
-Keep protamine sulfate available for - Bleeding due to excess anticoagulant may
heparin therapy and Vit K available for require antidote administration to reverse
Warfarin (Coumadin) therapy anticoagulant effects rapidly.
-Caution client to avoid activities that - Minimizing the risk of bleeding
increase the risk for trauma e.g use soft
toothbrush for mouth care, avoid use
electric razor for shaving and
commercial mouthwashes
Nursing care plan
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Medical Diagnosis: Pulmonary Embolism
Nursing Diagnosis: Anxiety related to change in shortness of breath.
Expected outcome:
a. Patient is able to recognize signs of anxiety.
b. Patient may describe a reduction in the level of anxiety evidenced by normal
respiration rate.
Nursing intervention
-Assess the patient’s anxiety level
-Remain with the client during period of
acute respiratory distress
-Maintain a calm manner while
interacting with patient.
-Explain the treatment and diagnostic
procedure in simple and short
- Reduce sensory stimuli by maintaining
a quiet environment
-Allow family member to be with the
patient
-Encourage the patient to perform deep
breathing exercise
-Give oxygen supply as order by doctor
-Administer medications as order by
doctor
-Monitor oxygen saturation with pulse
oximeter and identity for the sign of
hypoxia
Rationales
- Appropriate interventions are
implemented.
- The presence of a caring nurse helps
reduces fear
- To established a therapeutic relationship
and gain cooperation through continuity of
care
- Providing a clear explanation to alleviate
anxiety.
- To reduce stress e.g excessive noise
-Give emotional support
- To relieve anxiety
-To improve the oxygenation and relieve the
shortness of breath
- To reduce anxiety
- To assess the oxygen level of the patient
and evaluate the effectiveness of the
nursing intervention