Ms. Sarah Borg, a 37-year-old recovering from multiple fractures sustained in a car injury, is admitted to a Medical Ward for treatment of a pulmonary embolism. Before admission, she was short of breath after walking up a flight of stairs. Ms. Borg asks the nurse what could have caused this, since she was getting better from the injury and getting plenty of rest.
- Which is the best response by the nurse?
- Which symptom most frequently occurs in the presence of a pulmonary embolism and explain the pathophysiological basis?
- In a patient diagnosed with pulmonary embolism, which functional impairment should the nurse assess for, and what is the underlying cause of this impairment?
- The healthcare provider orders anticoagulant therapy for Ms. Borg. What key nursing considerations should be taken into account when initiating and monitoring anticoagulant treatment in a patient with pulmonary embolism?
a) Nurse’s Explanation to Ms. Borg.
The best response by the nurse.
- “Although you’re resting to recover from your fractures, being immobile can slow your blood circulation. This increases the risk of blood clots forming, especially in the legs. Sometimes, these clots can travel to the lungs and cause a pulmonary embolism, which is what has happened.”
- Rationale: Prolonged immobility, particularly after trauma or surgery, can lead to deep vein thrombosis (DVT), which may embolize the lungs.
b) Most Frequent Symptom and Pathophysiological Basis.
- Most frequent symptom. Sudden onset of shortness of breath (dyspnea).
- Pathophysiological basis.A pulmonary embolism blocks blood flow to part of the lung, leading to a ventilation-perfusion mismatch. Although the area is ventilated, it receives no blood flow, resulting in impaired gas exchange and hypoxemia. The sudden obstruction increases pulmonary vascular resistance, strains the right side of the heart, and causes a rapid onset of dyspnea (Camilleri & Talley, 2004).
c) Functional Impairment and Underlying Cause.
- Functional impairment to assess. Impaired gas exchange and reduced oxygen saturation.
- Underlying cause. A PE leads to occlusion of the pulmonary arteries, decreasing the area available for oxygen exchange. This causes hypoxemia and may result in respiratory distress, fatigue, and increased respiratory effort. Additionally, large emboli may lead to hemodynamic instability and right heart failure (ÜSTÜN & KENNEDY, 2009).
d) Nursing Considerations for Anticoagulant Therapy.
When initiating and monitoring anticoagulant treatment (e.g., heparin, warfarin, or DOACs), nurses must consider (Toth, 2016).
Baseline Assessments
- Review baseline CBC, PT/INR, aPTT, and renal/liver function tests.
- Assess for history of bleeding disorders or fall risk.
Monitoring and Administration
- Monitor aPTT (for heparin) and INR (for warfarin) regularly.
- Watch for signs of bleeding: bruising, hematuria, melena, gum/nose bleeds.
- Educate the patient to report any unusual bleeding or bruising.
Safety Precautions
- Use bleeding precautions: soft toothbrush, electric razors, avoid invasive procedures if possible.
- Double-check dosages and infusion rates to prevent over-anticoagulation.
Patient Education
- Explain the purpose of anticoagulation: preventing new clots.
- Stress the importance of medication adherence.
- Advise about dietary interactions (e.g., vitamin K-rich foods with warfarin).
- Discuss the need for follow-up labs and monitoring.
