A pulmonary embolism is a blood clot, usually from a leg vein, that travels to the lungs and blocks blood flow. It can cause sudden shortness of breath and can be fatal. Your priorities are oxygenation, starting anticoagulation, and preventing new clots.
Each care plan below follows the nursing process (ADPIE).
Impaired Gas Exchange
- Blocked blood flow to part of the lung
- Ventilation and perfusion mismatch
- Sudden shortness of breath
- Tachypnea and tachycardia
- SpO2 below the ordered goal
- Pleuritic chest pain and anxiety
- SpO2 at or above the ordered goal within 1 hour of treatment
- Client breathes comfortably on room air by discharge
- SpO2, respiratory rate, and work of breathing
- Heart rate and BP
- Lung sounds
- Blood gases and imaging as ordered
| INTERVENTION | RATIONALE |
|---|---|
| Raise the head of the bed and give oxygen as ordered | Upright positioning and oxygen improve breathing. |
| Start anticoagulants such as heparin as ordered | Anticoagulants stop the clot from growing and prevent new clots. |
| Stay with the client and report worsening right away | A large PE can quickly lead to shock. |
| Prepare for thrombolytics or other procedures as ordered for a massive PE | Breaking up the clot can be lifesaving. |
EVALUATION
- SpO2 meets the goal
- Breathing is easier and slower
- Vital signs stay stable
Risk for Bleeding
- Anticoagulant or thrombolytic therapy
- Client remains free of bleeding while on anticoagulants
- Client takes anticoagulants safely at home and knows bleeding signs to report
- aPTT, anti-Xa, or INR as ordered
- Platelet count and hemoglobin
- Gums, urine, stool, and IV sites for bleeding
- Neuro status
| INTERVENTION | RATIONALE |
|---|---|
| Check labs before adjusting anticoagulants per protocol | Labs show if the dose is safe and effective. |
| Keep reversal agents available, such as protamine for heparin and vitamin K for warfarin | Fast reversal is needed if major bleeding happens. |
| Use a soft toothbrush and electric razor | These lower the risk of minor bleeding. |
| Teach to avoid NSAIDs and keep vitamin K intake consistent on warfarin | NSAIDs raise bleeding risk and vitamin K changes affect warfarin. |
EVALUATION
- Labs stay in the therapeutic range
- No signs of bleeding
- Client states bleeding precautions
Practice this in Priority Care
Recognize the client with a sudden PE and act first.
Play Priority CareQuick answers
What is the classic sign of a pulmonary embolism?
Sudden shortness of breath with tachycardia and often sharp chest pain, especially in a client with risk factors like recent surgery or immobility.
How can nurses help prevent PE?
Early ambulation, sequential compression devices, leg exercises, and anticoagulants as ordered all help prevent leg clots.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.