Question

Pulmonary Embolism Emergency Situations

Scenario

S.K., a 51-year-old roofer, was admitted to the hospital 3 days ago after falling 15 feet from a roof. He sustained bilateral fractured wrists and an open fracture of the left tibia and fibula. He was taken to surgery for open reduction and internal fixation (ORIF) of all of his fractures. He is recovering in your orthopedic unit. You have instructions to begin getting him out of bed and into the chair today. When you enter the room to get S.K. into the chair, you notice that he is agitated and dyspneic. He says to you, "My chest hurts really badly. I can't breathe." You auscultate S.K.'s breath sounds and find they are diminished in the left lower lobe. S.K. is diaphoretic and tachypneic and has circumoral cyanosis. His apical pulse is irregular and 110 beats/min.

1. Identify five possible reasons for S.K.'s symptoms.

2. What is your primary nursing goal at this time?

3. List in order of priority three actions you should take next.

4. Using ISHAPE, what information will you provide to the physician?

Physician orders are as follows:

STAT arterial blood gases (ABGs), chest x-ray (CXR) examination,

ECG, and a helical (spiral) CT of the lungs.

Chart View:

Arterial Blood Gases (ABGs)

pH 7.49

Paco2 30.6 mm Hg

Pao2 52 mm Hg

HCO3 24.2 mmol/L

Sao2 83%

A-a oxygen gradient 32 mm Hg

5. Interpret S.K.'s ABG results and give the rationale for your interpretation.

6. Based on the ABGs and your assessment findings, what complication do you think S.K. is

Experiencing?

7. Why is S.K. at risk for developing this complication?

Case progression: See orders

8. The resident writes the following orders for S.K. Review each order. Mark with an A

if the order is appropriate; mark with an I if the order is inappropriate. Correct all inappropriate

orders, and provide rationales for your decisions.

______ 1. Albuterol (Proventil) metered-dose inhaler (MDI), two puffs q6h

______ 2. Heparin 20,000 units IV now, then 20,000 units in 1000 mL/D5W to run at 1000

units/hr.

______ 3. PT/INR and PTT q4h; call house officer with results

______ 4. 3 L oxygen by nasal cannula

______ 5. Patient-controlled analgesia (PCA) pump with morphine sulfate: loading dose

______ 6. Streptokinase 250,000 IU IV over 30 minutes, then 100,000 IU/hr. for 24 hours

______ 7. Prednisolone (Solu-Cortef) 1 g IV push now

______ 8. Warfarin (Coumadin) 7.5 mg PO daily ´ 2 days

______ 9. CBC daily

9. S.K. asks why he is being put on heparin. Your best response is:

a. "It will stop any blood clots from going to your lungs."

b. "The heparin will dissolve any other blood clots you have."

c. "Heparin will prevent any new blood clots from developing."

d. "The heparin will thin your blood so you will be able to breathe better."

Case progression

All the orders are corrected. S.K.'s helical CT scan confirms the diagnosis of pulmonary embolism (PE) in the left lower lobe and heparin therapy is initiated. Two hours later, repeat ABGs show the values shown in the chart.

10. What do these ABGs indicate?

11. The physician orders furosemide (Lasix) 20 mg IV push now. What is the expected outcome?

associated with administering furosemide to S.K.?

12. Because S.K. is being treated with heparin therapy, he has the potential for bleeding. What

interventions will be part of his plan of care to reduce this risk. Select all that apply.

a. Assess vital signs every 4 hours.

b. Use a central line to obtain blood specimens.

c. Apply direct pressure to any venipuncture site for 5 minutes

d. Do not administer any IM medications unless absolutely necessary.

e. At least once a shift, check stool, urine, sputum, and vomitus for occult blood.

13. List four independent nursing interventions that would be implemented for S.K. and the

rationale for each.

14. What instructions would you give to the Patient care tech who is assisting with S.K.'s care? Select all that apply.

a. Use an electric razor when shaving S.K.

b. Immediately report any signs of bleeding.

c. Inflate the BP cuff only as high as needed to obtain a reading.

d. Position S.K. with the head of the bed elevated, on his left side

e. Use a sponge-toothed applicator when helping S.K. with oral care.

f. Be careful when repositioning S.K.; make sure you have adequate help.

Laboratory Test Values

Prothrombin time (PT) 12.1 sec

Partial thromboplastin time (PTT) 60 sec

INR 1.4

15. Coagulation times are rechecked after S.K. has been on heparin therapy for 4 hours. What

changes, if any, do you anticipate, based on your interpretation of these values?

Case progression

S.K. is watched closely for the next several days for the onset of pulmonary edema. Anticoagulant therapy, oxygen, pulse oximetry, daily CXR studies and ABG analysis, and pain management are continued.

16. On postoperative day 8, S.K. suddenly becomes very angry and throws the physical therapist

out of his room. He yells, "I'm sick and tired of having everyone tell me what to do." How are

you going to deal with this situation? List  3 things

Answer 1

1. Five possible reasons

1. The patient may have a small / hair line rib fracture or fractures that may be missed at the time of investigations for the surgery. After surgery over and when the patient gets moved the small fractured rib / ribs may hurt the lungs and leads to lack of oxygen supply. This causes circumoral cyanosis, diaphorectic, tachypenic, agitation, dyspenic and breathing difficulties.

2. Lack of oxygen supply may be limited due to some infections caused in the lungs during the time begins with the fall from the roof .

3. Anxiety and panic attacks may also a possible reason to get diaphoretic, tachyphenic and also agitated and dyspenic condition.

4. Very high or very low temperature and severe pain in the chest area which got from the fall may leads to these type of breathing difficulties.

5. If patient has a history of asthma, cardiac diseases and copd related disorders, these type of symptoms may be happen.

2. Primary Nursing Goal: First Lie down the patient safely on the bed and take necessary steps to make breathing easier to the patient, provide him with oxygen and then call the doctor.

3. Three priority options:

1. Recording and observing respirations and inform the doctor.

2. Observing the patients colour to evaluate the condition of circumoral cyanosis, heart rate c/o tachypenic.

3. Observing the patient's position, ensure the better safety position to be applied to breathe easy and not to damage any area of the lungs.

4. Imformations provide to the Physician:

1. Arterial blood gases (ABGs) whichincludes the follows :

pH: 7.49

PaCo2: 30.6 mm Hg

PaO2: 52 mm Hg

HCo3: 24.2 mm Hg

SaO2: 83%

A-a oygen gradient - 32 mm Hg.

After then

2. Chest X-ray (CXR) examination.

3. ECG examination.

4. Spiral (Helical) CT of Lungs.