- Acute Pain Related to Blockage of blood flow and Lack of oxygen in cells as evidenced by Clutching chest and reports pain in the chest area
- Ineffective Breathing Pattern related to blood clot obstruction in the blood supply to the lungs and Ineffective gas exchange in the lungs as evidenced by Rapid breathing (tachypnoea) and Accessory muscle use
- Impaired Gas Exchange related to Alveolar-capillary membrane changes and Ventilation-perfusion imbalance as evidenced by Abnormal ABGs and Diaphoresis
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Expressions of pain, such as crying Unpleasant feeling (such as a prick, burn, or ache) Objective Data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviors | Acute Pain Related to Blockage of blood flow and Lack of oxygen in cells as evidenced by Clutching chest and reports pain in the chest area | Patient will rate the pain scale lower than the initial rate at a level that is acceptable to them or 0/10. Patient will manifest vital signs within normal limits. Patient will verbalize regaining appetite and sleep. | 1. Provide accurate information about the condition. An educated explanation of the nature of the pain, present condition, and the treatment regimen can enhance pain control. 2. Administer medications as indicated. Pain medication and anticoagulants are indicated for patients with PE to help improve the symptoms of the condition. Do not administer aspirin or NSAIDs that could further thin the blood. 3. Provide supplemental oxygen. Pain in PE is associated with decreased oxygenation in the blocked areas in the lungs. Providing supplemental oxygen can help reduce hypoxia and pain. 4. Provide non-pharmacological pain relief. Non-pharmacologic techniques for pain relief include relaxation, imagery, positioning, and distraction and can also work to decrease the work of breathing causing pain. | Patient rated the pain scale lower than the initial rate at a level that is acceptable to them or 0/10. Patient manifested vital signs within normal limits. Patient verbalized regaining appetite and sleep. |
| Subjective Data: Difficulty breathing; shortness of breath or dyspnea Anxiety in relation to breathing Objective Data: -Dyspnoea -Abnormal respiratory rate; tachypnea or bradypnea -Poor oxygen saturation -Abnormal ABG results -Shallow breathing -Pursed-lip breathing -Accessory muscle use when breathing | Ineffective Breathing Pattern related to blood clot obstruction in the blood supply to the lungs and Ineffective gas exchange in the lungs as evidenced by Rapid breathing (tachypnea) and Accessory muscle use | Patient will maintain an effective breathing pattern with normal respiratory rate, depth, and oxygen saturation. Patient will have ABG results within normal limits. Patient will incorporate breathing techniques to improve breathing pattern. Patient demonstrates the ability to complete ADLs without dyspnea. | 1. Administer oxygen as ordered. Supplemental oxygen is recommended for individuals with oxygen saturation levels under 90%. 2. Consider mechanical ventilation for unstable patients. In severe cases of PE, the patient who deteriorates to respiratory distress may require mechanical ventilation. 3. Position the patient in an upright position. To encourage oxygenation, raise the head of the bed and maintain the patient in a semi- or high-Fowler’s position as tolerated. 4. Work with an RT. Respiratory therapists titrate oxygen and ventilation settings, administer breathing treatments, obtain and assess ABGs, and assist the patient in promoting oxygenation. | Patient maintained an effective breathing pattern with normal respiratory rate, depth, and oxygen saturation. Patient has ABG results within normal limits. Patient incorporated breathing techniques to improve breathing pattern. Patient demonstrated the ability to complete ADLs without dyspnoea. |
Subjective Data: Dyspnoea Diaphoresis (excessive sweating) Objective Data: -Altered respiratory patterns -Restlessness -Lethargy -Cyanosis -Confusion -rritability -Abnormal arterial blood gas values or blood pH -Decreased oxygen saturation | Impaired Gas Exchange related to Alveolar-capillary membrane changes and Ventilation-perfusion imbalance as evidenced by Abnormal ABGs and Diaphoresis | Patient will have an oxygen saturation of greater than 90%. Patient will manifest vital signs within normal limits. Patient will present signs and symptoms of improved ventilation. Patient will demonstrate arterial blood gas (ABG) levels within normal limits. Patient will have imaging scans with normal lung findings. | 1. Administer medications as indicated. Immediate anticoagulation is required for patients suffering from PE. Anticoagulants prevent clots from enlarging or new clots from forming but can’t dissolve existing clots. Thrombolytics are “clot busters” that can be given in severe cases. 2. Assist with V/Q scan. A ventilation-perfusion scan (V/Q scan) evaluates air movement in the bronchi and bronchioles as well as the perfusion of blood within the lungs. 3. Administer supplemental oxygen. Supplemental oxygen will help promote adequate oxygenation and relieve dyspnea. 4. Prepare for surgical intervention as indicated. Embolectomy may be indicated for patients with massive PE who are hemodynamically unstable. Vena cava filters can also be placed to prevent clots from traveling to the lungs. | Patient has an oxygen saturation of greater than 90%. Patient manifested vital signs within normal limits. Patient presented signs and symptoms of improved ventilation. Patient demonstrated arterial blood gas (ABG) levels within normal limits. Patient has imaging scans with normal lung findings. |