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Concept map #1 Pulmonary Embolism
Transcript of Concept map #1 Pulmonary Embolism
VS: T 97.6, P 75, BPM 102/62, 16 RPM, 96% on RA O2, Weight 68.10 kgs, Height 64 in
General: Pt is alert, pleasant, acute illness with cough and distress.
HEENT: Nothing markable. Her throat is red and sore, but no exudate. Pupils equal, large, round, and reactive to light.
Neck: No lymphadenopathy.
CVS: heart sounds normal sinus rhythm
Chest: Lungs clear to auscultation. No sounds of crackles /wheezing or rhonchi.
Abdomen: sounds present in all quadrants. Distended and firm.
Urinary: No troubles with urine 500 mls in 6 hrs.
Extremities: capillary refill <2 sec., skin tugor - norm. No edema present. Strong pedal and radial pulses. Mild swelling, tender in calf and left medial thigh.
60 year old Caucasian female
Never Smoked and occasional glass of wine.
Spouse travels with his job frequently, she functions well being able to perform her own ADLs., as well as care for the household and business.
Has grown children both up here and in the valley that are very concerned with her welfare.
Moved up from the valley (Phoenix) in 2010.
Past Medical History
Date of birth: 09/10/1954
Date of Hospital admission: 1/25/2015
Assessment: 01/29/14 from 0600 - 1230
Patient T.H. is 60 year old female
Admitted for: Large Pulmonary Embolism (P.E.) and a large Deep Vein Thrombosis (D.V.T) in left leg.
Code Status - Full Code
Allergies - NKA
Chief Complaint- P.E and 2nd D.V.T.
Pulmonary embolism occurs when material, usually a blood clot, gets wedged into an artery in someone's lungs. These blood clots most often originate in the deep veins of the patient's legs, but they can also come from other parts of the body. Condition is deep vein thrombosis (DVT).
Sometimes, blockages within the blood vessels inside the lungs come from air bubbles, fats with the marrow of a long bone that becomes broken.
Nursing Diagnosis #1 Impaired Gas Exchange
Interventions: Nursing Diagnosis #2: Pain r/t decreased pulmonary tissue perfusion associated with obstructed pulmonary blood flow.
Intervention: Nursing Diagnosis # 3: Ineffective Breathing Pattern
Intervention: Nursing Diagnosis #4: Risk for bleeding r/t anticoagulant therapy.
Intervention: Nursing Diagnosis #5: Risk for Anxiety and Fear in relation to new Pulmonary Embolus
Vallerand, A., Deglin, J., Sanoski, C., (2011) Davis’s Drug Guide for Nurses. F. A. Davis Company.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans: Guidelines for individualizing client care across the life span (8th Ed.). Philadelphia: F.A. Davis Company.
Wilkinson, J., Ahern, N. (2009), Prentice Hall Nursing Diagnosis Handbook, Ninth Edition.
Mckesson, Summit Healthcare Medical Center
Mildly elevated cholesterol and advised by her physician to go on red yeast rice.
2012 - Colonoscopy
2010 - Hysterectomy with bladder suspension.
2006 - Rotator cuff repair.
Past Surgical History
Red Yeast rice
Use to take Estrogen, but has not for some time.
Daily Women's Vitamins
Never told to take aspirin
Sodium Chloride 0.9% Syringe 10ml Saline.
Warfarin 5mg tablet at 1700 daily.
Heparin in D5w IV (25,000 unit/500ml) parenteral Solution 500ml
Hospital Meds cont.
Aceaminophren = Dose 325mg tablet - 2 tablets every 6 hrs as needed
Heparin 5000 unit /ml - 54888 unit/ 1.097ml
Laboratory / Diagnostic Test
1. Impaired Gas Exchange r/t decreased pulmonary perfusion due to pulmonary obstruction of pulmonary arterial blood flow by emboli.
2. Pain r/t decreased pulmonary tissue perfusion associated with obstructed pulmonary blood flow.
3. Ineffective breathing Pattern due to pulmonary emboli pain and dypsnea
4. Risk for bleeding r/t anticoagulant therapy.
5. Anxiety and fear r/t newness of pulmonary embolism.
1. Monitor vital signs and noting any changes.
2. Assess for hypoxia.
3. Administer Anticoagulant.
4. Assess the embolism daily.
5. Assess for s/s of pulmonary infarction.
1. Initially Blood Pressure, heart rate, and respiratory rate will increase.
2. Gas exchange effectiveness is reduced with s/s of restlessness, diaphoresis.
3. Heparin and Lovenox used to treat and prevent reoccurring emboli.
4. To determine the effectiveness of the meds and care.
5. A large pulmonary embolus of lung can cause ischemic infarction of the lung.
Patient maintain at good gas exchange with +90 O2 with normal heart rate and breathing.
Met. Patient was 96 on room air and her heart rate was at 75 during day of assessment.
1. Assess for severity of the pain.
2. Determine the patients history with pain tolerance.
3. Administer meds for pain.
4. Teach the patient comfortable positions for breathing and breathing techniques.
5. Stay with the patient when she is struggling with dyspnea or any other breathing problems.
1. To know the severity can help to manage pain, which in turn controls the shallowness of breathing and improve gas exchange.
2. Helps in the planning of pain relief for the patient.
3. Relief of pain and helps to take the tension and anxiety to a more manageable position.
4. Helps to facilitate and teach effective breathing techniques.
5. Reduce the anxiety of the patient , which helps to keep the patient calm.
Patient achieves a pain level <4 on a 0-10 scale and that patient exhibit signs of comfort ant that her vitals resemble comfort.
1. Assess respiratory rate, rhythm, and depth of breathing.
2. Implement measures to improve breathing by assisting patient with semi-high Fowler's position.
3. Assess for random sounds in the breathing.
4. Assess pain in relation to breathing.
5. Monitor the Oxygenation.
1. Tachypnea is a normal finding with pulmonary embolism. Changes in respiratory is a warning of impending problems.
2. High Fowler's enhances lung exchanges allowing for pulmonary expansion without diaphragm interference.
3. It is possible to be normal sounds, but crackles are a common sound as well..
4. Sharp and stabbing pain may get worse with deep breathing and coughing, so effects breathing pattern.
5. Pulse oximetry is a great way to determine oxygenation.
Patient will experience a effective and relaxed breathing pattern having no signs of dyspnea.
1. Educate Patient about the risk of bleeding. Example: explain to communicate therapy to any Doctor or Dentist before any invasive procedure.
2. Establish baseline prothrombin time (PT) and partial thromboplastin time.
3. Report any PTT /INR below or above the therapeutic range of 1.5-2.0
4. Have Vitamin K available.
5. Monitor for signs of bleeding (gums, bruises, tarry stools, hematuria, nose bleeds.
Patient to be educated concerning effects of anticoagulant therapy, and that patient stays safe from bleeding prior to discharge.
1. Patient will more than likely be release with continued treatment and needs to be informed about potential bleeding.
2. To look for baseline for continued therapy if there is not too high of a PTT reading.
3. In order for the Doctor to determine any changes that need to be made in Heparin and Warfarin use.
4. Protamine Sulfate is antidote for Heparin.
5. Important while under therapy to watch for bleeding, because of the anticoagulant use could create much bleeding.
Unmet. Patient had no signs of bleeding the day of assessment, but she was educated on the possibilities of bleeding.
1. Assess for severity of her anxiety regarding PE and DVT
2. Provide reassurance and comfort to to the patient.
3. Decrease any stimuli that could cause worse anxiety.
4. Educate on how to deal with present PE and DVT as well as the future prevention.
5. Listen to Patient fears and anxiety.
1. Find a starting point in dealing with patient' anxiety helps determine starting point for the nurse.
2. patient experiences the better and more efficient the results of the care will be. Of course no false hope.
3. Stimuli just heightens the anxiousness of the patient.
4. Knowledge of what is going on helps to relieve anxiety. Unknown is scarey for patients and creates anxiety.
5. Active listening shows the patient that the nurse really cares about her experience.
Patient will have minimal fears and anxiety, but she has realistic and educated concerns in order to be pro-active in her recovery.
Partially met. Patient did not have any anxious look by the end of the shift as much as she did at the beginning (family support helped a lot with that). .
Spouse brings 60 year old female to Doctor's office because of shortness of breath and pain in her left leg, and sent to hospital.
Her complaints - Shortness of breath, chest pain, and cough.
Also, Swelling, pain, tenderness,in left leg.
She states she had "the flu" couple weeks ago.
Signs and Symptoms
Respiratory-Dyspnea, tachypnea, tachycardia, pleuritic chest pain, dry cough, hemoptysis
Cardiac -Distended neck veins, syncope, cyanosis, systemic hypotension, abnormal heart sounds, abnormal ECG
Low grade fever, petechiae, flu-like symptoms
Pain - one or both legs
Tenderness and Swelling - leg(s)
Warmth - leg(s)
S/S for Pulmonary Embolism
Teaching: PE and DVT care, medication compliance, take it easy until doctor says otherwise. Have INR and PTT checked weekly. Report any chest pains and increase in difficulty of breathing.
By: Lance Powell and Cameo Johnson
S/S for Deep Vein Thrombosis
Na - 138
K+ - 4.0
Cl - 100
CO2 - 26
AGAP - 16
Gluc - 119
BUN - 10
Crea - 0.9
INR - 1.1
Large saddle embolus in the left and right main pulmonary arteries extending from right to left pulmonary hila., extending into upper and lower lobar and occasional segmental branch vessels of both lungs.
Large clot in lower left leg.
Ongoing.Patient maintained comfort throughout shift except when having to get out of bed to use bedside commode. Vitals otherwise stayed under control.
Met. Patient breathing had improved and had less signs of shortness of breath by the end of shift.