Critical care case study - Pulmonary embolism: Nursing

Nurse, Joe works in the emergency department and is caring for Rachel, a 64 year old who was diagnosed with a pulmonary embolism or pe nurse.

Joe goes through the steps of the clinical judgment measurement model to make clinical decisions about Rachel's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action and evaluating outcomes.

First, nurse, Joe recognizes important cues including Rachel's vital signs which are temperature 99.7 °F or 37.6 °C. Heart rate 110 BPM, respirations, 26 breaths per minute, BP, 94/62 millimeters of mercury and oxygen saturation, 86% on 6 L per minute, nasal cannula upon assessment.

Nurse, Joe, Notes, Rachel is apprehensive short of breath, coughing and has crackles in her bilateral lower lobes. She reports a sharp pain in her chest that worsens with inspiration that she rates as four on a 10 point numeric scale.

Next nurse Joe analyzes these cues. He reviews the electronic health record or EHR and Notes, Rachel has a history of Factor Five, Leiden, a genetic disorder that increases the risk of blood clots and that she returned home from a long overnight flight last night.

He also reviews her ECG which shows sinus tachycardia and her CT that confirms a pe in her left lung nurse. Joe knows a pe can occur when a clot or plug of material travels to the lungs and lodges in the small pulmonary vessels obstructing blood flow.

He realizes Rachel's history of Factor Five Leiden and prolonged immobility during her flight places her at risk for venous thromboembolism or VT E VT E is when a deep vein thrombosis or DVT, which is a blood clot that develops in a vein in an extremity travels to the lungs causing a pe as the pe obstructs blood flow, it creates a ventilation perfusion or VQ mismatch where in the affected area of the lung, there's enough oxygen but not enough blood to pick it up.

This results in ventilatory dead space, inadequate gas exchange and hypoxemia triggering tachypnea. Initial compensation occurs as blood is shunted from poorly perfused areas of the lungs to areas where there is normal perfusion.

A process called compensatory shunting. The obstruction also initiates the release of inflammatory mediators which constricts the pulmonary blood vessels further decreasing blood flow throughout the lungs.

This decreases production of surfactant leading to atelectasis. A condition where all or part of a lung collapses.

Inflammatory mediators also caused bronchoconstriction of the small airways which together with atelectasis worsen hypoxemia even more.

On top of that increasing pulmonary vascular resistance increases right ventricular afterload which can eventually lead to right ventricular failure.

Meanwhile, peripheral chemo receptors respond to hypoxemia by sending signals to the brain to increase ventilation. Leading to hyper ventilation.

This leads to hypocapnia and respiratory alkalosis as carbon dioxide is blown off. Nurse.

Joe recognizes that Rachel needs prompt management of her pe. Now using the information he's gathered nurse, Joe chooses a priority hypothesis of impaired gas exchange.

Then he generates solutions to address Rachel's impaired gas exchange including pharmacologic and nonpharmacologic interventions.

And he establishes the expected outcome that after intervening Rachel's oxygen saturation will improve to 92% or greater within 15 minutes.

Then nurse Joe takes action to implement these solutions. Nurse Joe notes orders to initiate and titrate oxygen using a high flow nasal cannula to maintain Rachel's oxygen saturation at 92% or above and to administer a direct oral anticoagulant or doac in analgesic and IV fluids.

After gathering the necessary supplies, nurse Joe reenter Rachel's room. Hi, Rachel.

I just spoke with the emergency provider who put in some orders to help your breathing. Ok?

I can't catch my breath. I'm going to start high flow oxygen which will give you more oxygen and help your breathing.

I'm also going to administer some blood thinners that will prevent further clotting. While on these medications, we'll monitor lab tests to check how quickly your blood clots and you'll be monitored for signs of bleeding.

I'll also be administering a pain medication to help with your chest pain and start you on some IV fluids. Ok.

Nurse Joe replaces Rachel's nasal cannula with a high flow oxygen, nasal cannula and increases the rate to 8 L per minute.

Then he administers the medications following safe medication administration principles. Nurse Joe positions Rachel slightly on her right side to facilitate perfusion on the unaffected lung and ensures Rachel is attached to the vital signs, Monitor to continuously monitor her heart rate and rhythm BP and oxygen saturation.

Then he gives Rachel the call light and monitors her closely. 15 minutes later, nurse Joe evaluates the outcomes of his actions.

He notes Rachel's vital signs which are temperature 99.6 °F or 37.5 °C, heart rate, 100 BPM respirations, 20 breaths per minute BP, 98/66 millimeters of mercury and oxygen saturation.

94% on 8 L per minute, high flow nasal cannula. She also rates her chest pain as a two on a 10 point numeric scale and she's able to speak in short sentences.

All right. As a quick recap nurse, Joe recognized and analyzed cues related to Rachel's impaired gas exchange and prioritized hypotheses and generated solutions to address this problem.

Nurse Joe then implemented pharmacologic and non pharmacologic measures to manage Rachel's pe and evaluated the outcomes compared with the expected outcomes.

Since Rachel's oxygen saturation improved within 15 minutes nurse, Joe determined the plan of care was successful.