Issaiah Nicolle L.

Cecilia 3 BSN - A
RLE ACTIVITY 5
Assessment findings for Pulmonary Embolism
 Apprehension and restlessness
 Blood-tinged sputum
 Chest pain
 Cough
 Crackles and wheezes on auscultation
 Cyanosis
 Distended neck veins
 Dyspnea accompanied by anginal and pleuritic pain,
exacerbated by inspiration
 Feeling of impending doom
 Hypotension
 Petechiae over the chest and axilla
 Shallow respirations
 Tachypnea and tachycardia
Interventions and Priority Nursing Actions: (Pulmonary Embolism)
PRIORITY NURSING ACTIONS
SUSPECTED PULMONARY EMBOLISM
1. Notify the Rapid Response Team and health care provider (HCP).
2. Reassure the client and elevate the head of the bed.
3. Prepare to administer oxygen.
4. Obtain vital signs and check lung sounds.
5. Prepare to obtain an arterial blood gas.
6. Prepare for the administration of heparin therapy or other therapies.
7. Document the event, interventions taken, and the client’s response to treatment.

Reference: Saunders Comprehensive Review for the NCLEX-RN Examination, 7 th Edition