Nursing Care Plan for Pulmonary Embolism - 4 Nursing Diagnosis and Interventions

NCP for Pulmonary Embolism 
Nursing Interventions for Ineffective Breathing Pattern, Acute Pain, Impaired Gas Exchange, Activity Intolerance

Pulmonary embolism is a blockage of the pulmonary artery, which is caused by a thrombus in deep vein thrombosis in the lower limb that is released and follows circulation to the arteries in the lungs. After reaching the lungs, large thrombus is caught in the bifurcation of the pulmonary artery or lobar bronchus and results in hemodynamic disturbances, while small thrombus continues to reach the distal part, clogging small blood vessels in the peripheral lung (Goldhaber, 1998; Sharma, 2005).

Pulmonary embolism is a blockage of the pulmonary artery by an embolus, which occurs suddenly. An embolism can be a blood clot (thrombus), but it can also be fat, amniotic fluid, bone marrow, tumor fragments or air bubbles, which will follow the bloodstream until it finally clogs the arteries. (Brunner & Suddarth, 1996).

Pulmonary embolism is a major problem in world health, with high morbidity and mortality reaching 30% if not treated (Torbicki, 2000; Sharma, 2005).

Predisposing factors for pulmonary embolism include; men, old age, immobilization, trauma, long bone fractures, pregnancy, oral contraception, obesity, congestive heart failure and malignancy. If not treated, the mortality rate is quite high, estimated at 30% (10 times greater than those treated) and decreases by 2-10% with appropriate diagnosis and management (Torbicki, 2000; Fedullo, 2003; Riedel, 2004).

Symptoms of pulmonary embolism depend on the size of the thrombus and the area of the pulmonary artery that is blocked by the thrombus. Symptoms may not be specific. Chest pain is the most common symptom and usually has a sudden onset and is pleuritic. Sometimes it can be substernal and can resemble angina pectoris or myocardial infarction. Dyspnea is the second most common symptom followed by tachypnea, tachycardia, nervousness, cough, diaphoresis, hemoptysis, and syncope. (Brunner and Suddarth, 2001)

Massive embolism that clogs the pulmonary artery bifurcation can cause real dyspnea, sudden substernal pain, rapid and weak pulse, shock, syncope and sudden death. (Brunner and Suddarth, 2001)

Multiple small embolism can be involved in the terminal pulmonary artery, resulting in multiple small infarctions in the lungs. Clinical features can resemble bronchopneumonia or heart failure. (Brunner and Suddarth, 2001)

Diagnostic examinations of pulmonary embolism according to Brunner and Suddarth, (2001. 622) include:

1. Chest X-ray
   Chest radiographs in pulmonary embolism are usually normal but can show pneumoconstriction, infiltrates, atelectasis, diaphragmatic elevation in a diseased position, or dilated large pulonal arteries and pleural effusion.
2. ECG
   The ECG usually shows sinus tachycardia, atrial flutter or fibrillation and possible right axis deviation, or right ventricular strain.
3. Plethysmography impedance
   Plethysmography impedance is performed to determine the presence of troimbosis in the deep vein.
4. Arterial blood gas
   Arterial blood gas in pulmonary embolism can show hypoxemia and hypocapnea.

The aim of management of pulmonary embolism is to reduce symptoms, prevent death, reduce the risk of developing chronic pulmonary hypertension, and prevent recurrence. Current management of pulmonary embolism does not only use anticoagulants. (Torbicki, 2000; Lee, 2005).

Nursing Diagnosis

1. Ineffective Breathing Pattern r / t decreased lung ability
2. Acute pain: chest r / t lung infarction
3. Impaired gas exchange r / t ventilation and perfusion imbalances
4. Activity intolerance r / t decreases oxygen supply in tissues

Nursing Interventions

1. Ineffective Breathing Pattern r / t decreased lung ability
   • Goal: Effective breathing pattern
   • Outcomes:
     
     • Shows normal / effective breathing patterns with normal blood gas analysis.
     • No cyanosis and signs of hypoxic symptoms
   • Intervention:
     
     1. Identify causes or trigger factors
        R /: Knowing etiology and trigger factors
     2. Evaluate respiratory function (rapid breathing, cyanosis, changes in vital signs)
        R /: Can assess respiratory function
     3. Auscultation of breath sounds
        R /: Can listen to normal breath sounds or not
     4. Note the development of the chest wall and trachea position, fremitus review
        R/ : Can know accumulation of secretions or other foreign objects
     5. Maintain a comfortable position usually elevating the head of the bed
        R /: To make it easier to breathe
     6. Give oxygen through cannula / mask
        R /: Maximize breathing and reduce breath work


2. Acute pain: chest r / t lung infarction
   
   • Goal: Pain is lost or reduced
   • Outcomes:
     
     • The patient says the pain is reduced or can be controlled
     • The patient looks calm
   • Interventions:
     
     1. Assess for pain, scale and intensity of pain
        R /: Can know the scale of pain in patients
     2. Teach the patient about pain management with distraction and relaxation
        R /: The patient can understand pain management by distraction and relaxation
     3. Assess the effectiveness of pain relief measures
        R /: Can reduce the pain suffered by patients
     4. Give analgesics as indicated
        R /: Can be used to reduce pain


3. Impaired gas exchange r / t ventilation and perfusion imbalances
   
   • Goal: the patient will show normal gas exchange.
   • Outcomes: The patient will show normal gas exchange and pink skin color.
   • Interventions:
     
     1. Assess the frequency, rhythm, sound and depth of breathing.
        R /: Knowing normal or not breathing.
     2. Give oxygenation
        R /: Maximize breathing and reduce breathing
     3. Monitor oxygen saturation
        R /: Balance oxygen between inspiration and expiration
     4. Correction of acid base balance.
        R /: Knowing whether gas exchange is normal or not
     5. Give a position that makes it easy to increase lung expansion.
        R /: To facilitate breathing
     6. Give effective coughing exercises and deep breathing
        R /: Can reduce or issue a secret


4. Activity intolerance r / t decreases oxygen supply in tissues
   
   • Goal: Tolerance activity
   • Outcomes:
     
     • Participate in desired activities
     • Shows a decrease in physiological intolerance signs
   • Intervention:
     
     1. Assess activity response
        R /: Knowing the extent of the patient's activities
     2. Encourage the patient about energy saving techniques
        R /: The patient can save energy
     3. Give encouragement to do activities or self-care gradually if intolerance returns
        R /: The patient and family can do self-care if intolerance returns

Tag : Activity Intolerance, Acute pain, Impaired Gas Exchange, Ineffective Breathing Pattern, Medical-Surgical Nursing, Nursing Care Plan, Nursing Diagnosis, Nursing Interventions, Pulmonary Embolism