Chapter 29 Pulmonary Embolism
A patient has deep vein thrombosis. The nurse is teaching the patient's caregiver about measures for preventing pulmonary embolism. Which statement made by the caregiver indicates effective learning? Select all that apply. One, some, or all responses may be correct. "Help the patient to cross the legs." "Gently massage the patient's leg muscles." "Change the patient's position every 2 hours." "Avoid placing a pillow under the patient's knee." "Elevate the affected limb above the heart level."
"Change the patient's position every 2 hours." "Avoid placing a pillow under the patient's knee." "Elevate the affected limb above the heart level." Rationale Changing the patient's position every 2 hours may reduce the pressure in specific areas and promote blood circulation. Placing a pillow under the knees can cause pressure under the popliteal space. Elevation of the affected limb 20 degrees or more above the level of the heart improves the venous return. Crossing legs should be avoided to prevent pressure on the blood vessels in the affected limbs, which may result in clot formation. The caregiver should refrain from massaging the leg muscles to prevent dislodging of the clot and causing pulmonary embolism. p. 587
Which patient is at high risk for developing a pulmonary embolism (PE)? 67-year-old man who works on a farm 45-year-old man admitted for a heart attack 23-year-old woman with a bleeding disorder 25-year-old woman who frequently flies internationally
25-year-old woman who frequently flies internationally Rationale People who engage in prolonged and frequent air travel are at high risk for PE. A 67- year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs, where a venous clot could later become a PE. PE is a clotting disorder, not a bleeding disorder. p. 588
Which risk factor increases a patient's risk for a venous thromboembolism that may progress to a pulmonary embolism? Select all that apply. One, some, or all responses may be correct. Nonsmoker 72 years of age Presence of a central venous catheter Admission weight of 290 lb (131.8 kg) Ability to ambulate with assistance of one person
72 years of age Presence of a central venous catheter Admission weight of 290 lb (131.8 kg) Several factors place a patient at an increased risk for developing a pulmonary embolism from a thromboembolism. Risk factors that should be assessed include prolonged immobility, central venous catheter, surgery, obesity, advanced age, history of thromboembolism, smoking history, pregnancy, estrogen therapy, heart failure, stroke, and cancer. p. 587
With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)? A 50 year old with type 2 diabetes mellitus and cellulitis of the leg A 36 year old who had open reduction and internal fixation of the tibia A 25 year old receiving IV antibiotics through a peripheral line A 72 year old with dehydration and hypokalemia taking oral potassium supplements
A 36 year old who had open reduction and internal fixation of the tibia To reduce the risk for developing PE, the nurse provides immediate interventions for the client who had an open reduction and internal fixation of the tibia. Lower limb surgery and perioperative immobility are high risks for deep vein thrombosis (DVT) formation and PE. Peripheral infusion of antibiotics in a younger client is not a significant risk for PE. Although dehydration is a mild risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery.
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium
ANS: A Alteplase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows that this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice
ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin
ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. Platelet count: 82,000/L (82 × 109/L) c. Red blood cell count: 4.8/mm3 (4.8 × 1012/L) d. White blood cell count: 8700/mm3 (8.7 × 109/L)
ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.
A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush
ANS: B Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The other option is to lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs
ANS: B This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes Reports feeling frightened "Can't catch my breath" Labs: pH: 7.32 PaCO2: 28 mm Hg PaO2: 78 mm Hg SaO2: 88% Physical assessment: Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.
ANS: B This client has signs and symptoms of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse would facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-age client with an exacerbation of asthma d. Older client who is 1 day post-hip replacement surgery e. Young obese client with a fractured femur f. Middle-age adult with a history of deep vein thrombosis
ANS: B, D, E, f Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.
ANS: C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.
A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."
ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Acute respiratory distress syndrome can occur, but this is not as likely soon after the client starts on oxygen plus there is no indication of how much oxygen the client is on. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.
ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.
Which drug would the nurse expect to be prescribed for a patient experiencing massive pulmonary embolism who has shock symptoms? Alteplase Enoxaparin Rivaroxaban Fondaparinux
Alteplase Rationale Fibrinolytic agents, such as alteplase, are used in the treatment of pulmonary embolism, specifically when the patient has shock and hemodynamic collapse. Enoxaparin is a low-molecular-weight heparin and is prescribed for a submassive pulmonary embolism. Rivaroxaban is an anticoagulant that prevents deep vein thrombosis and pulmonary embolism, and it is prescribed when the patient is at low risk for pulmonary embolism. Fondaparinux is a synthetic pentasaccharide factor Xa inhibitor, which is used unless the pulmonary embolism is massive or occurs with hemodynamic instability. p. 590
Which drug is an antidote to fibrinolytic therapy? Alteplase Vitamin K 1 Protamine sulfate Aminocaproic acid
Aminocaproic acid Rationale Aminocaproic acid is the antidote for fibrinolytic therapy. Fibrinolytic therapy is used to break up an existing clot, but these agents may cause excessive bleeding; it may be necessary to block the activity of fibrinolytic agents by using its antidote to prevent further excessive bleeding. Alteplase is a fibrinolytic drug that increases the risk for bleeding. Vitamin K is an antidote for warfarin, an oral anticoagulant used for the long-term prevention of venous thrombi. Protamine sulfate is used to block the activity of heparin. p. 591
A patient receiving IV alteplase after developing a pulmonary embolism develops bloody stools and bleeding gums. Which product would the nurse expect to administer as an antidote? Phytonadione Protamine sulfate Aminocaproic acid Packed red blood cells
Aminocaproic acid Rationale The antidote for excessive bleeding for patients receiving alteplase is aminocaproic acid. Packed red blood cells may be given if blood loss is excessive to treat anemia, but they are not used as an antidote. Phytonadione is the antidote for warfarin. Protamine sulfate is the antidote for heparin. p. 591
A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having a difficult time "catching her breath" and having a reddish-purple, nonitchy rash on her chest. After assessing the client, what is the nurse's best action or response to prevent harm? Ask the client about possible drug allergies Apply oxygen and call the rapid response team Determine when she last received an opioid dose Check the oxygen saturation and encourage her to cough
Answer: B Rationale: This client is at high risk for developing a pulmonary embolism from a venous thromboembolism (has cancer and recently underwent extensive abdominal surgery). She has two major symptoms of PE, sudden onset shortness of breath and petechiae on her chest. These are significant enough to call the rapid response team because and without assessing oxygen saturation or most recent opioid dose (she has no symptoms of respiratory depression) because time is of the essence in starting appropriate therapy to prevent permanent lung damage or death. Applying oxygen can help improve her gas exchange and should be done immediately. Rash caused by a drug allergy are usually red, raised, itchy, and do not look like petechiae.
Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)? Anticoagulants Antihypertensives Antidysrhythmics Antibiotics
Anticoagulants A PE is collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Anticoagulants are the first-line therapy drugs for this problem, even if the actual particulate matter is not a clot. Anything lodged in the blood vessels will cause clot formation around it. Anticoagulants help prevent new clots from forming in the area and extension of existing clots.Depending on other problems cause by a PE, antibiotics, or antidysrhythmics may also be used but not always. Clients with PE are hypotensive, not hypertensive.
When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94%. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachy-cardia. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain.
Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachy-cardia. The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention.The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.
Which finding is consistent with a pulmonary embolism (PE)? Select all that apply. One, some, or all responses may be correct. Crackles Diaphoresis Bradycardia Low-grade fever Severe headache
Crackles Diaphoresis Low-grade fever Rationale A PE is a collection of particulate matter that enters venous circulation and lodges in the pulmonary vessels. Crackles, diaphoresis, and low-grade fever are some of the signs of PE. Crackles are heard because the embolism blocks pulmonary vessels and fluid accumulates. Diaphoresis occurs because of the pooling of fluid. Tachycardiaoccurs during a PE; the patient experiences an elevated heart rate as the heart works harder to circulate blood throughout the body. A severe headache is not a sign of PE. p. 588
Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client's condition is worsening? Increasing temperature Abdominal cramping Hand tremors Distended neck veins in the high-Fowler position
Distended neck veins in the high-Fowler position Distension of neck veins in the upright (high-Fowler) position occurs with right-sided heart failure, which is a complication of PE. None of the other changes in assessment findings are directly associated with worsening PE.
Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction? Hemoptysis and shortness of breath Fever and tracheal deviation Audible wheezing on inhalation and exhalation Paradoxical chest movements
Hemoptysis and shortness of breath Symptoms of a PE with infarction include profound shortness of breath and bloody sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues. Paradoxical chest movements are associated with a flail chest, not PE. Tracheal deviation is associated with a pneumothorax. Audible wheezing on inhalation and exhalation is a partial obstruction of the tracheobronchial tree.
In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)? Administering sodium bicarbonate Having the client breathe rapidly and deeply into a paper bag Assessing for the presence of adventitious lung sounds Increasing the oxygen flow rate
Increasing the oxygen flow rate These ABG values indicate respiratory acidosis (low pH and high PaCO2) and severe hypoxemia (low PaO2) from greatly reduced gas exchange.This client needs more oxygen now.by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). Breathing more rapidly and deeply into a paper bag would decrease oxygen levels and increase CO2 further, making hypoxemia and acidosis worse. The bicarbonate level is normal and requires no intervention. Adventitious sounds are expected and identifying them is not the first priority
Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probably presence of a PE? (Select all that apply.) Inspiratory chest pain Dizziness and syncope Pink, frothy sputum Worsening dyspnea for 3 days Tachycardia Productive cough
Inspiratory chest pain Dizziness and syncope Tachycardia Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE.Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over 2 weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.
Which drug increases cardiac output by improving myocardial contractility? Alteplase Milrinone Nitroprusside Phytonadione
Milrinone Rationale Milrinone is a positive inotropic drug that increases the contractility of the cardiac musculature, thereby increasing cardiac output. Alteplase is a fibrinolytic drug that prevents the formation of clots in blood vessels. Nitroprusside is a vasodilator that is used for lowering blood pressure. Phytonadione is an antidote for warfarin and is administered in cases of warfarin overdose. p. 591
Which precautionary measure would the nurse plan to take while a patient is on heparin sodium therapy? Select all that apply. One, some, or all responses may be correct. Monitor the platelet count. Have the antidote, vitamin K, readily available. Monitor the partial thromboplastin time (PTT). Monitor the international normalized ratio (INR). Have the antidote, protamine sulfate, readily available.
Monitor the platelet count. Monitor the partial thromboplastin time (PTT). Have the antidote, protamine sulfate, readily available. Rationale Monitoring the platelet count daily helps detect any heparin-induced thrombocytopenia because a decrease in platelet count is a common adverse effect caused by the use of heparin sodium. Regular monitoring of PTT is necessary because it helps detect side effects and prevent complications. Protamine sulfate is used as an antidote in emergency situations caused by heparin overdose because it reverses the anticoagulation effect by binding to heparin. While using warfarin, patients may experience adverse effects of the drug; vitamin K is used as an antidote because of its coagulating effect. Regular monitoring of INR is recommended when a patient is on warfarin therapy. pp. 590-591
Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion? Assessing gums daily for indications of bleeding Monitoring the platelet count daily Assessing breath sounds Comparing pedal pulses bilaterally
Monitoring the platelet count daily Daily platelet counts are a safety priority in assessing for heparin-induced thrombocytopenia (HIT), a potential side effect of heparin.Assessing breath sounds each shift is an important action, as is examining for indications of bleeding. However, identifying HIT early is a greater priority so that appropriate interventions can be initiated. Assessing bilateral pedal pulses is important if the source of the embolism is a venous thromboembolism (VTE) in the legs; however, this is not an important general action for a client with PE.
A patient has developed a pulmonary embolism. Which laboratory test would the nurse anticipate being prescribed before beginning heparin therapy? Kidney function tests Arterial blood gases (ABGs) Partial thromboplastin time (PTT) International normalized ratio (INR)
Partial thromboplastin time (PTT) Rationale: A baseline PTT should be obtained before the administration of heparin. The other actions are also important to take for the patient with a pulmonary embolism but do not have to be done before heparin administration. Kidney function tests are not indicated for this patient. p. 590
??? The nurse is assessing a patient with possible pulmonary embolism (PE). For which symptom would the nurse assess? Select all that apply. One, some, or all responses may be correct. Productive cough Bloody sputum Inspiratory chest pain Dizziness and fainting Shortness of breath (SOB) worsening over the last 2 weeks
Productive cough ?? Bloody sputum Inspiratory chest pain Dizziness and fainting Rationale PE may cause a dry or productive cough with bloody sputum (hemoptysis). Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE. p. 588
A patient is receiving IV heparin therapy for a pulmonary embolism. Which antidote would the nurse confirm is available? Vitamin K Protamine sulfate Aminocaproic acid Antihemophilic factor
Protamine sulfate Rationale Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for warfarin. Antihemophilic factor and aminocaproic acid are both antidotes for fibrinolytic therapy that attempts to break up established clots. p. 591
In addition to the pulmonary health care provider, which other member of the interprofessional team will the nurse expect to collaborate with most frequently when providing care to a client with a pulmonary embolism (PE)? Registered dietitian nutritionist Respiratory therapist Occupational therapist (OT) Pharmacist
Respiratory therapist The client with a PE has ongoing respiratory problems that change gas exchange almost hourly and require adjustments in respiratory support. The respiratory therapist will be collaborating with the nurse and client at least daily. Other team members listed have roles than change with the client's condition and collaboration is more intermittent.
What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)? Partial bronchial airway obstruction Thickened alveolar membranes and poor gas exchange Increased oxygen need resulting from a septic clot PE Shunting of deoxygenated blood to the left side of the heart
Shunting of deoxygenated blood to the left side of the heart A PE lodges in the blood vessels decreasing perfusion to a lung area, which wastes ventilation. When this blood that has not been oxygenated is returned to the left side of the heart, it dilutes the oxygen concentration of the arterial blood entering systemic circulation.PE does not block bronchial airways or thicken alveolar membranes. A septic clot is not the same as general sepsis, which when widespread, does increase tissue metabolism and the need for more oxygen.
A patient who has a pulmonary embolism is very anxious. In which situation would the nurse expect the health care provider to prescribe sedation for the patient? When the patient reports pain When the patient cannot sleep When the patient is mechanically ventilated When the patient does not lie still for diagnostic testing
When the patient is mechanically ventilated Rationale A health care provider may prescribe sedation to a patient with pulmonary embolism who is mechanically ventilated. Even if the patient reports pain, is unable to sleep, or will not cooperate for diagnostic testing, sedation may result in hypoventilation, so it is contraindicated for this patient. p. 592
