Nursing Care Plan for Pulmonary Embolism

Pulmonary embolism (PE)

A pulmonary embolism is a sudden blockage in a lung artery. The cause is usually a blood clot in the leg called a deep vein thrombosis that breaks loose and travels through the bloodstream to the lung. Pulmonary embolism is a serious condition that can cause
  • Permanent damage to the affected lung
  • Low oxygen levels in your blood
  • Damage to other organs in your body from not getting enough oxygen
If a clot is large, or if there are many clots, pulmonary embolism can cause death.



Pulmonary Embolism
Signs and Symptoms
  • dyspnoea - suddenly and there is at 90% of cases
  • pleuritic chest pain
  • haemoptisis
  • fainting
  • tachycardia more than 100/menit
  • tachipnoe more than 20/menit
  • fever

Threat Signs of Life:
Symptoms of Pulmonary embolism:
  • severe dyspnea
  • chest pain
  • increased venous pressure
  • there is evidence of right heart failure
  • hypotension
  • shock

Assessment for Pulmonary Embolism

Assessment of the ABCD approach

Airway
  • Assess and maintain airway
  • Perform head tilt, chin lift if necessary
  • Use this tool to the airway if necessary
  • Consider referring to the anesthesiologist to do intubation if unable to maintain airway

Breathing
  • Assess oxygen saturation using pulse oximeter, to retain more than 92% saturation.
  • Give high-flow oxygen via non re-breath mask.
  • Consider getting a breathing using bag-valve-mask ventilation
  • Make checks to assess arterial blood gas PaO2 and PaCO2
  • Assess breathing
  • Perform examination of respiratory system
  • Listen to the sound of the pleura
  • Make checks thoracic images - may be normal, but look for:
  • Evidence of a wedge shaped shadow (infarct)
  • Linear atelectasis
  • Effuse pleural
  • Hemidiaphragm increased
  • If the clinical signs show the presence of pulmonary embolism, ventilation perfusion scan done (VQ) or CT pulmonary angiogram (CTPA) in accordance with local policy

Circulation
  • Assess heart rate and rhythm, the possibility of sound gallops
  • Assess increased JVP
  • Record blood pressure
  • ECG examination may show:
  • Sinus tachycardia
  • The existence of S1 Q3 T3
  • Right bundle branch block (RBBB)
  • Right axis deviation (RAD)
  • P pulmonale
  • Perform IV access
  • Perform a complete blood

Disability
  • Assess level of consciousness by using AVPU
  • Decreased awareness of incoming patients showed early signs of extreme conditions and require immediate medical attention and requires treatment in the ICU.

Exposure
  • Always examine the possibility of using a test Pulmonary embolism, if the patient is stable and health history examinations do other physical examination.
  • Do not forget to check for signs of DVT

Risk Factors of Pulmonary embolism
  • DVT exist in 50% of patients
  • Previous surgery
  • Previous trauma
  • Immobilization for various reasons
  • Malignancy
  • Patients taking oral contraceptives
  • Patients received hormone therapy
  • Long gestation
  • Obesity
  • Patients get Estregen Selective Receptor Modulator therapy (SERM)
  • Hyperviskositas Syndrome
  • Childbed
  • Nephrotic syndrome
  • Antithrombin III deficiency
  • Deficiencies of protein C and S
  • Lupus anticoagulant

Nursing Care Plan for Pulmonary Embolism

Komentar

Posting Komentar

Postingan populer dari blog ini

Nursing Care Plan for Dehydration

Gambar
Dehydration Definition Dehydration is a condition in which a person who is not fasting experiencing or at risk of dehydration vascular, interstitial or intra-vascular (Sell Lynda Carpenito, 2000: 139). Classification Classification of dehydration by Donna D. Ignatavicus there are 3 types: a. Isotonic dehydration Isotonic dehydration is lost water followed by the electrolyte so that the density remained normal, then this type of dehydration is usually not result in ECF fluid move to the ICF. b. Hypotonic dehydration Hypotonic dehydration is the loss of solvent from the ECF exceeds fluid loss, resulting in blood vessels become more concentrated. ECF osmotic pressure decreases, resulting in fluid moves from the ECF to ICF. Vascular volume also decreased, as well as cell swelling occurs. c. Hypertonic dehydration Hypertonic dehydration is ECF fluid loss exceeds the solvent is non-osmotic dehydration ECF decreased, resulting in fluid moves from ICF to ECF. Etiology Various causes dehydratio...
Baca selengkapnya

NCP Post Traumatic Stress Disorder

DSM-IV 309.81 Posttraumatic stress disorder (specify acute, chronic, or delayed onset) 308.3 Acute stress disorder An anxiety disorder resulting from exposure to a traumatic event in which the individual has experienced, witnessed, or been confronted with an event or events that involve actual or threatened death/serious injury or a threat to the physical integrity of the self or others. The
Baca selengkapnya

Nursing Care Plan for Impaired Verbal Communication

Impaired verbal communication is defined as decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols. Related to : Physiologic conditions Alteration of central nervous system Impaired neurologic development or dysfunction Disturbance in attachment/bonding with the parent/caregiver Characterized by : Language delay or total absence of language Immature grammatic structure; pronoun reversal; inability to name objects Stereotyped or repetitive use of language (echolalia, idiosyncratic words, inappropriate high-pitched squealing/giggling, repetitive phrases, sing-song speech quality) Lack of response to communication attempts by others Outcome : Communicate in words/gestures that are understood by others Interventions and Rationales Use one-on-one interactions to engage the client in nonverbal play. R/: The nurse enters the client’s world in a nonthreatening interaction to form a trusting relationship. Recognize subtle cues indicating the client is ...
Baca selengkapnya