Medical Surgical Pulmonary embolism #2

Question

The nurse is preparing a room for a client coming to her floor from the ER with the diagnosis of pulmonary embolism. Which actions by the nurse are indicated? Select all that apply.

Answers

  1. Raise the head of the bed 45 degrees.
    • Rationale:

      This answer is not correct because the client diagnosed with pulmonary embolism should be placed in high-Fowler’s position, which is 90 degrees. This position of 45 degrees is semi-Fowler’s position.

  2. Have incentive spirometry available.
    • Rationale:

      This answer is correct because a pulmonary embolism causes the lungs to contract and lose volume. Coughing and deep breathing helps inflate the lungs. The incentive spirometer is a great tool to assist in lung rehabilitation. The incentive spirometer requires a prescription.

  3. Place intubation equipment at the bedside.
    • Rationale:

      This answer is correct because for clients who are at risk of severe hypoxemia, intubation supplies should always be at the bedside. If the PE causes right ventricular failure, arterial hypoxemia ensues. Airway and breathing are always priorities.

  4. Place an IV pump in the room.
    • Rationale:

      This answer is correct because a pulmonary embolism will be treated with intravenous anticoagulation. By having the IV pump in the room, the nurse is anticipating the need to start anticoagulation therapy. If the client experiences a massive thromboembolism, the use of thrombolytic therapy will also be administered intravenously.

  5. Station a bedside commode.
    • Rationale:

      This answer is not correct because there is no indication that the client is immobile. The client with a pulmonary embolism will maintain bedrest, but will be encouraged to get up to use the bathroom if they are able.

Overview

A pulmonary embolism is a blockage of one of the pulmonary arteries from a deep vein thrombosis that has separated. Interventions include placing the client in the high Fowler’s position, oxygen use, encouraging use of incentive spirometry as prescribed, IV anticoagulation, and intubation/mechanical ventilation if necessary.

Explanation

Learning Outcomes

When a deep vein thrombosis has broken off, it travels to the right side of the heart and becomes lodged inside a pulmonary artery. The clot blocks the normal flow of blood causing hypoxemia. The client will be placed on oxygen and placed in the high-Fowler’s position to improve breathing. Anticoagulants will be administered intravenously to stop the clot from growing larger and to prevent new clots. Thrombolytics are used to dissolve a massive clot and they can be administered intravenously. Lung rehabilitation will be encouraged through the use of deep breathing and coughing and an incentive spirometer is a special tool that can assist with this exercise. For clients with PE, it is imperative to have intubation equipment readily available due to the potential for severe hypoxemia.

Test Taking Tip

Three things that should come to mind when “pulmonary embolism” is mentioned is airway, breathing, and circulation, the ABCs of triage. Thinking about how a pulmonary embolism affects these “ABCs” will help the student answer the question.

Video Rationale