Pulmonary Embolism Nursing Care Plan
Comprehensive Nursing Interventions and Management
Table of Contents
Introduction to Pulmonary Embolism Nursing Care
Pulmonary embolism (PE) requires thorough nursing assessment and timely interventions to ensure optimal patient outcomes. This comprehensive nursing care plan addresses the key aspects of care for patients with pulmonary embolism, focusing on evidence-based interventions, rationales, and expected outcomes.
The nursing care for pulmonary embolism patients centers around improving oxygenation, managing anticoagulation therapy, preventing complications, relieving symptoms, and providing education for long-term management. Each nursing diagnosis in this care plan is tailored to address the specific needs of patients with pulmonary embolism.
Nursing care for pulmonary embolism requires a multifaceted approach that addresses both physiological and psychological aspects of patient care. The following 12 nursing diagnoses provide a comprehensive framework for delivering effective care.
1. Impaired Gas Exchange
Related to: Ventilation-perfusion mismatch, alveolar-capillary membrane changes secondary to pulmonary embolism
As evidenced by: Hypoxemia, dyspnea, tachypnea, abnormal arterial blood gases, decreased oxygen saturation
| Nursing Interventions | Rationale |
|---|---|
| Monitor respiratory rate, depth, and effort every 2-4 hours and as needed | Allows for early detection of respiratory distress and assessment of response to therapy |
| Assess oxygen saturation via pulse oximetry continuously and arterial blood gases as ordered | Provides objective data about oxygenation status and acid-base balance |
| Administer oxygen therapy as prescribed and adjust flow rates based on oxygen saturation goals | Improves tissue oxygenation by increasing the oxygen content of inspired air |
| Position patient in semi-Fowler’s or high Fowler’s position | Facilitates lung expansion and decreases work of breathing by reducing pressure on the diaphragm |
| Encourage deep breathing exercises and incentive spirometry every 1-2 hours while awake | Promotes optimal lung inflation and prevents atelectasis |
Expected Outcomes:
- Patient will maintain oxygen saturation ≥ 94% or at prescribed parameters
- Patient will demonstrate improved arterial blood gas values within normal limits
- Patient will report decreased dyspnea and improved comfort with breathing
- Patient will maintain respiratory rate within 12-20 breaths per minute
2. Ineffective Breathing Pattern
Related to: Pain, anxiety, decreased lung expansion, inflammatory process
As evidenced by: Dyspnea, tachypnea, altered chest excursion, use of accessory muscles, abnormal breathing patterns
| Nursing Interventions | Rationale |
|---|---|
| Assess respiratory rate, rhythm, depth, and use of accessory muscles every 2-4 hours | Provides baseline data and allows for tracking changes in breathing pattern |
| Teach and demonstrate pursed-lip breathing and diaphragmatic breathing techniques | Helps slow breathing rate, increase alveolar ventilation, and decrease air trapping |
| Coach patient on timing medications with activities to optimize breathing comfort | Ensures maximum benefit from medications when activity demands are highest |
| Assist patient to assume positions that optimize ventilation (e.g., semi-Fowler’s, leaning forward on overbed table) | Different positions can reduce work of breathing by optimizing diaphragmatic function |
| Provide calm, reassuring environment and teach anxiety-reduction techniques | Anxiety increases oxygen consumption and can worsen breathing difficulties |
Expected Outcomes:
- Patient will demonstrate effective breathing pattern with normal rate, rhythm, and depth
- Patient will demonstrate reduced or absent use of accessory muscles for breathing
- Patient will verbalize understanding of breathing techniques
- Patient will report improved ability to breathe comfortably
3. Acute Pain
Related to: Inflammatory process, tissue hypoxia, pleural irritation
As evidenced by: Verbal reports of pain, guarding behavior, facial grimacing, changes in vital signs during pain episodes
| Nursing Interventions | Rationale |
|---|---|
| Perform comprehensive pain assessment using a standardized scale every 4 hours and as needed | Establishes baseline and allows for evaluation of pain management effectiveness |
| Administer prescribed analgesics on schedule and as needed, evaluating effectiveness | Maintains therapeutic blood levels of medication for optimal pain control |
| Assist with position changes to minimize chest discomfort | Proper positioning can reduce strain on painful areas and improve comfort |
| Teach non-pharmacological pain management techniques (guided imagery, relaxation breathing) | Complementary approaches can enhance pain relief and reduce reliance on medications |
| Apply heat or cold therapy as appropriate with physician approval | Thermal therapy can reduce pain by altering pain transmission and improving circulation |
Expected Outcomes:
- Patient will report pain at a level of 3 or less on a 0-10 scale
- Patient will demonstrate use of at least two non-pharmacological pain management techniques
- Patient will participate in necessary care activities with minimal discomfort
- Patient will show improved vital signs during pain episodes
4. Anxiety
Related to: Breathlessness, change in health status, threat of death, unfamiliar environment
As evidenced by: Expressed concerns, restlessness, increased heart rate and respiratory rate, difficulty concentrating
| Nursing Interventions | Rationale |
|---|---|
| Assess anxiety level using a standardized scale and identify triggers | Provides objective measurement and helps identify specific factors to address |
| Create a calm environment (minimize noise, limit visitors if needed, dim lights) | Environmental stressors can increase anxiety and physiological stress responses |
| Teach progressive muscle relaxation and guided imagery techniques | These techniques activate the parasympathetic nervous system to counter anxiety response |
| Explain all procedures, medications, and treatments in simple terms | Knowledge reduces fear of the unknown and increases sense of control |
| Administer anti-anxiety medications as prescribed and evaluate effectiveness | Pharmacological intervention may be necessary during acute anxiety episodes |
Expected Outcomes:
- Patient will demonstrate reduced physical symptoms of anxiety
- Patient will verbalize feeling less anxious, with improved ability to cope
- Patient will use learned relaxation techniques when experiencing anxiety
- Patient will maintain vital signs within normal limits during periods of anxiety
5. Activity Intolerance
Related to: Imbalance between oxygen supply and demand, reduced cardiac output, pain, fatigue
As evidenced by: Exertional dyspnea, abnormal heart rate response to activity, fatigue, weakness
| Nursing Interventions | Rationale |
|---|---|
| Assess activity tolerance by monitoring vital signs before, during, and after activity | Provides objective data about physiological response to increased oxygen demand |
| Implement progressive activity plan starting with low-level activities and gradually increasing as tolerated | Gradual progression prevents overexertion while promoting increased stamina |
| Teach energy conservation techniques (prioritizing activities, using assistive devices) | Helps patient manage limited energy resources more effectively |
| Schedule activities during periods of highest energy; provide rest periods between activities | Timing activities to match energy patterns optimizes performance and reduces fatigue |
| Collaborate with physical therapy for individualized exercise plan | Expert guidance ensures safe, appropriate activity progression |
Expected Outcomes:
- Patient will demonstrate increased activity tolerance with vital signs returning to baseline within 5 minutes post-activity
- Patient will perform ADLs with minimal assistance and reduced fatigue
- Patient will verbalize understanding of energy conservation techniques
- Patient will participate in progressive activity plan as prescribed
6. Risk for Decreased Cardiac Output
Related to: Increased pulmonary vascular resistance, right ventricular strain, arrhythmias, hypoxemia
Risk factors: Large or multiple pulmonary emboli, pre-existing cardiac disease, hemodynamic instability
| Nursing Interventions | Rationale |
|---|---|
| Monitor vital signs, including heart rate, blood pressure, and hemodynamic parameters if available | Early detection of hemodynamic compromise allows for prompt intervention |
| Assess for signs of right heart failure (JVD, peripheral edema, hepatomegaly) | Pulmonary embolism can lead to right ventricular failure due to increased afterload |
| Monitor cardiac rhythm continuously and report significant changes | Hypoxemia and right heart strain can precipitate arrhythmias |
| Administer fluid therapy cautiously as prescribed, monitoring response | Fluid optimization supports cardiac output without overloading the compromised right ventricle |
| Position patient to optimize hemodynamics (semi-Fowler’s or right side-lying) | Proper positioning can reduce venous return and decrease right ventricular preload |
Expected Outcomes:
- Patient will maintain vital signs within normal parameters
- Patient will exhibit no new signs or symptoms of heart failure
- Patient will maintain normal sinus rhythm or controlled cardiac rhythm
- Patient will demonstrate adequate peripheral perfusion (warm extremities, capillary refill < 3 seconds)
7. Deficient Knowledge
Related to: Unfamiliarity with condition, treatment regimen, and self-care requirements
As evidenced by: Questions, statements of concern, misconceptions, incorrect follow-through of instructions
| Nursing Interventions | Rationale |
|---|---|
| Assess current knowledge level regarding pulmonary embolism and anticoagulation therapy | Establishes baseline and identifies specific learning needs |
| Provide education about pulmonary embolism pathophysiology using visual aids and simple language | Multiple teaching methods enhance understanding and retention |
| Teach about anticoagulation therapy including medication purpose, dose, schedule, side effects, and monitoring | Adherence to anticoagulation therapy is critical for preventing recurrent emboli |
| Educate about signs and symptoms that require immediate medical attention | Early recognition of complications allows for prompt intervention |
| Provide written materials in preferred language and assess comprehension through teach-back method | Written reinforcement supports verbal teaching; teach-back confirms understanding |
Expected Outcomes:
- Patient will verbalize basic understanding of pulmonary embolism and its treatment
- Patient will demonstrate proper self-administration of prescribed anticoagulant
- Patient will identify at least three signs and symptoms that require immediate medical attention
- Patient will verbalize understanding of follow-up care requirements
8. Risk for Bleeding
Related to: Anticoagulation therapy, possible tissue trauma, altered clotting mechanisms
Risk factors: High-intensity anticoagulation, advanced age, concurrent medications, comorbidities
| Nursing Interventions | Rationale |
|---|---|
| Monitor coagulation studies (PT/INR, aPTT) as ordered and report results outside therapeutic range | Provides objective assessment of anticoagulation status and risk for bleeding |
| Assess for signs of bleeding (petechiae, ecchymosis, hematuria, hemoptysis, melena, bleeding gums) | Early detection of bleeding allows for prompt intervention |
| Implement bleeding precautions (use soft toothbrush, electric razor, avoid IM injections) | Reduces risk of tissue trauma that could lead to bleeding |
| Educate about medication interactions that increase bleeding risk (NSAIDs, certain antibiotics, herbal supplements) | Many common medications and supplements can potentiate anticoagulant effects |
| Ensure reversal agent availability and protocol according to facility policy | Allows for rapid response in case of severe bleeding |
Expected Outcomes:
- Patient will maintain coagulation studies within therapeutic range
- Patient will exhibit no signs of abnormal bleeding
- Patient will demonstrate understanding of bleeding precautions
- Patient will identify medications and activities that increase bleeding risk
9. Ineffective Peripheral Tissue Perfusion
Related to: Deep vein thrombosis, reduced mobility, decreased cardiac output
As evidenced by: Edema, skin color changes, altered sensation, pain in extremities
| Nursing Interventions | Rationale |
|---|---|
| Assess peripheral pulses, capillary refill, skin color, temperature, and sensation in all extremities | Provides baseline data and allows for monitoring of perfusion changes |
| Measure and document extremity circumference daily if edema is present | Objective measurement allows for tracking of edema improvement or worsening |
| Apply prescribed compression stockings or devices correctly | Compression therapy improves venous return and reduces edema |
| Elevate affected extremities when in bed or sitting | Elevation facilitates venous drainage and reduces edema |
| Encourage active ankle pumping exercises hourly while awake | Muscle contractions promote venous return and reduce stasis |
Expected Outcomes:
- Patient will demonstrate improved peripheral circulation with warm extremities
- Patient will show reduced edema as evidenced by decreased extremity circumference
- Patient will report decreased pain in affected extremities
- Patient will demonstrate proper application of compression devices
10. Disturbed Sleep Pattern
Related to: Dyspnea, pain, anxiety, frequent assessments, unfamiliar environment
As evidenced by: Difficulty falling asleep, frequent awakening, reports of not feeling rested
| Nursing Interventions | Rationale |
|---|---|
| Assess sleep pattern and identify factors disrupting sleep | Identifies specific causes that can be addressed in the care plan |
| Cluster care activities to minimize nighttime disruptions | Allows for longer periods of uninterrupted sleep |
| Create comfortable sleep environment (appropriate room temperature, reduced noise, dimmed lights) | Environmental factors significantly impact sleep quality |
| Encourage relaxation techniques before bedtime (deep breathing, progressive muscle relaxation) | Promotes transition from wakefulness to sleep |
| Administer pain medications before bedtime as prescribed | Pain control helps maintain uninterrupted sleep |
Expected Outcomes:
- Patient will report improved sleep quality
- Patient will demonstrate fewer episodes of nighttime awakening
- Patient will verbalize feeling more rested upon awakening
- Patient will identify and use effective sleep-promoting strategies
11. Risk for Infection
Related to: Invasive procedures (IV lines, catheters), immobility, altered immune function
Risk factors: Prolonged hospitalization, multiple access devices, decreased mobility
| Nursing Interventions | Rationale |
|---|---|
| Monitor vital signs with attention to fever and perform regular site assessments | Early detection of infection allows for prompt intervention |
| Maintain aseptic technique during all invasive procedures and site care | Reduces risk of pathogen introduction |
| Perform hand hygiene before and after patient contact | Hand hygiene is the most effective measure to prevent healthcare-associated infections |
| Rotate peripheral IV sites according to facility protocol | Reduces risk of phlebitis and catheter-related infections |
| Encourage deep breathing, coughing, and position changes to prevent atelectasis and pneumonia | Immobility increases risk of respiratory infections; pulmonary hygiene measures help prevent them |
Expected Outcomes:
- Patient will remain free from signs and symptoms of infection
- Patient will maintain temperature within normal range
- Patient will demonstrate normal white blood cell count
- Patient’s IV sites will remain free from signs of inflammation or infection
12. Fear
Related to: Life-threatening condition, uncertain prognosis, lack of control
As evidenced by: Verbalization of fear, increased tension, focus on worst outcomes, protective behaviors
| Nursing Interventions | Rationale |
|---|---|
| Assess specific fears and concerns using open-ended questions | Identifies the specific nature of fears to address them effectively |
| Provide accurate information about condition, treatment plan, and prognosis | Knowledge reduces fear of the unknown and corrects misconceptions |
| Encourage expression of feelings and acknowledge the legitimacy of fears | Validation of feelings helps patient process emotions constructively |
| Teach specific coping strategies (thought reframing, distraction techniques) | Provides practical tools for managing fear when it arises |
| Offer presence and support, involving chaplain or support services as appropriate | Human connection provides reassurance and reduces feelings of isolation |
Expected Outcomes:
- Patient will express fears and concerns openly
- Patient will demonstrate reduced physical signs of fear (decreased muscle tension, improved vital signs)
- Patient will use learned coping strategies when experiencing fear
- Patient will report feeling more in control of emotional responses
Patient Health Education
Medication Management
- Take anticoagulant medication exactly as prescribed, at the same time each day
- Do not skip doses or take extra doses to “catch up”
- Understand the importance of regular blood tests if on warfarin
- Recognize potential side effects and when to seek medical attention
- Avoid taking over-the-counter medications without consulting healthcare provider
- Wear medical alert identification indicating anticoagulant use
Activity & Lifestyle
- Gradually increase activity as tolerated and as recommended by healthcare team
- Avoid prolonged sitting or standing; take breaks during long trips
- Perform leg exercises when sitting for extended periods
- Wear compression stockings as prescribed
- Maintain adequate hydration
- Maintain a consistent vitamin K intake if on warfarin
Warning Signs
- Recognize and immediately report:
- Increased shortness of breath
- Chest pain
- Coughing up blood
- Severe headache or dizziness
- Unusual bleeding (nose, gums, dark urine, black stools)
- Signs of new clot (leg pain, swelling, warmth, redness)
Bleeding Precautions
- Use soft-bristled toothbrush
- Use electric razor instead of blade razors
- Avoid activities with high risk of injury or falls
- Apply pressure to cuts for extended time until bleeding stops
- Avoid using sharp tools without proper protection
- Be cautious when using scissors, knives, or other sharp objects
Follow-up Care
- Keep all scheduled follow-up appointments
- Complete all ordered laboratory tests on schedule
- Bring a complete medication list to all appointments
- Report any new medications prescribed by other healthcare providers
- Discuss plans for pregnancy with healthcare provider if applicable
- Discuss any planned surgeries or dental procedures with healthcare provider
Special Considerations
Pulmonary embolism nursing care requires a focus on preventing recurrence while balancing bleeding risk. Patients should understand that recovery is a gradual process, and symptoms may improve slowly over time. Encourage patients to maintain a journal of symptoms and medication effects to share with healthcare providers during follow-up visits.
Emphasize the importance of lifestyle modifications that reduce risk, including smoking cessation, weight management if applicable, and regular physical activity as tolerated. Many patients benefit from joining support groups where they can connect with others who have experienced similar conditions.