Blood flow is obstructed in the lungs caused by thrombus (blood clot), air, or fat emboli that become stuck in an artery, causing impaired gas exchange. Patients may be predisposed to clot formation, have pooling of blood, or damage to vessel walls, or take certain medications that increase the risk of thrombus formation.
Thrombus are commonly found in vessels in lower extremities. When a thrombus loosens and travels in the peripheral circulation, it is called an embolus. The embolus travels through the right side of the heart and is sent to the lungs where it lodges in one of the arteries. Depending on the size of the artery that the embolus lodges in, a section of lung will have no blood supply and alveolar function will suffer. As blood supply to an area of the lung diminishes, alveoli collapse,causing atelectasis.
Nursing Diagnosis for Pulmonary Embolism Client
• Impaired gas exchange
• Ineffective tissue perfusion
Nursing Intervention for Pulmonary Embolism Client
• Monitor arterial blood gas for changes and decrease in oxygenation.
• Monitor pulse oximetry for oxygen saturation.
• Place patient in high Fowler’s position.
• Monitor cardiovascular status for heart rate, rhythm, heart sounds, and pulse deficit.
• Have the patient perform turning, coughing, and deep-breathing exercises to enhance air movement.
• Monitor respiration for rate, effort, use of accessory muscles, skin color, and lung sounds.
Explain to the patient:
• To avoid sitting and standing for too long to decrease chance of clot
• Not to cross legs to avoid constriction of vessels in the lower extremities,decreasing the chances of clot formation.
• That pulmonary embolism is an adverse effect from using hormonal contraceptives and a different form of birth control needs to be used in the future
• How to identify side effects from using anticoagulants, such as bleeding or bruising.
Medical-Surgical Nursing (Demystified)
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Ditulis oleh: Shahzad Khan - 27 February 2012