Nursing Care Plan for Pulmonary Embolus

Pulmonary embolism is a condition in which the pulmonary vasculature is blocked by foreign matter such as blood clot, air, tumor tissue, bone, or by needle or catheter. Usually the result of peripheral venous thrombosis, it may lead to pulmonary infarction and pulmonary hypertension. This plan, which includes intervention specific to this condition, may be used in association with thrombophlebitis/thrombosis.

Nursing Diagnoses: Ineffective breathing pattern related to chest pain, decreased lung expansion caused by emboli with severity depending on size and number of vessels occluded. Impaired gas exchange related to altered blood flow caused by obstruction of circulation to the pulmonary vascular bed.

Expected Outcomes: Adequate ventilation evidenced by reduction in dyspnea, hypoxia, respiration within normal baseline limits for rate depth, and ease, ABGs within normal range.

Nursing Intervention
I. Assess for:
A. Respiratory status including history and physical examination especially thrombus/thrombophlebitis of both peripheral and deep veins.
Rationale: Provides data base and baselines.

B. Respiratory rate, depth, ease, dyspnea, tachypnea, tachycardia, cough, chest pain, hemoptysis; crackles, and accentuated pulmonic heart sound on auscultation.
Rationale: Changes indicate whether emboli are small, medium, or massive-sized.

II. Monitor, descibe, record:
A. Vital signs, chest sounds evey 2 to 4 hours, respiratory rate, quality.
Rationale: Indicates any changes in status leading to possible complications.

B. Chest X-ray.
Rationale: May indicate infarction, pulmonary effusion, consolidation.

C. Perfusion and ventilation scanning.
Rationale: Reflects pulmonary circulation and gas movement through lungs; size of clot.

D. Pulmonary angiography.
Rationale: Determines emboli in pulmonary vascular system; filling defect in pulmonary vessels.

E. Arterial blood gas.
Rationale: Decreasd PaO2 level indicates hypoxemia caused by inadequate oxygen supply.

III. Administer:
A. Oxygen via cannula or mask at rate based on ABGs.
Rationale: Provides oxygen to maintain oxygenation of tissues.

IV. Perform/Provide:
A. Bedrest in semi-Fowlers position.
Rationale: Reduces oxygen demand and facilitates chest expansion.

B. Deep breathing exercises, coughing, postural drainage if needed.
Rationale: Promotes adequate breathing pattern and air intake; prevents atelectasis.

C. Stay with patient, give reassurance and emotional support.
Rationale: Reduces anxiety and fear caused by pain and dyspnea.