- Decreased Cardiac Output related to thrombus traveling to heart/lungs and Blood flow obstruction as evidenced by Sudden shortness of breathing and Syncope
- Deficient Knowledge related to Unfamiliarity with diagnosis or prevention and
Poor knowledge of risk factors as evidenced by Verbalization of questions about diagnosis and Recurrent DVT - Impaired Gas Exchange Related to Ventilation perfusion imbalance and Development of pulmonary embolism as evidenced by Dyspnoea worsened by exertion and Sudden chest pain
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalizes chest discomfort and shortness of breath Objective Data: -Sudden chest pain -Decreased oxygen saturation -Sudden shortness of breathing -Tachypnoea -Alteration in the level of consciousness -Dizziness or light-headedness -Restlessness -Prolonged capillary refill time | Decreased Cardiac Output related to thrombus traveling to heart/lungs and Blood flow obstruction as evidenced by Sudden shortness of breathing and Syncope | Patient will show adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient will be able to return to baseline activity level. Patient will display adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient will be able to verbalize future self-care activities to improve cardiac health. | 1. Begin immediate anticoagulation. If PE is suspected, immediate anticoagulation with IV unfractionated heparin, low molecular weight heparin, or fondaparinux is administered. 2. Consider thrombolytics. If the patient is hemodynamically unstable, thrombolytic therapy may be considered to dissolve the clot and restart blood flow to the heart. 3. Prepare for surgical interventions. Surgical or catheter embolectomy is advised if the patient cannot receive or is not responding to medications. Surgical removal of the clot is necessary if the patient is hemodynamically unstable or experiencing severe right ventricular dysfunction or cardiac necrosis. 4. Treat shock. The patient can quickly decompensate and become hypotensive. Interventions may include careful fluid administration so as not to cause right ventricular overload and vasopressors to restore perfusion. | Patient shown adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient returned to baseline activity level. Patient displayed adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient verbalized future self-care activities to improve cardiac health. |
| Subjective Data: -Verbalizes poor understanding -Seeks additional information Objective: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment | Deficient Knowledge related to Unfamiliarity with diagnosis or prevention and Poor knowledge of risk factors as evidenced by Verbalization of questions about diagnosis and Recurrent DVT | Patient will verbalize an understanding of diagnosis and treatment. Patient will verbalize the importance of medications and follow-up lab tests. Patient will identify their risk factors and three ways to prevent recurrent DVT. | 1. Explain the signs of pulmonary embolism. Instruct on the signs of pulmonary embolism such as sudden chest pain, tachycardia, sudden shortness of breath, tachypnea, and restlessness. Explain why this is a medical emergency and to seek immediate medical attention. 2. Discuss individual risk factors. Help the patient recognize their risk factors for developing DVT and discuss ways they can decrease their risk. Smoking is a huge, preventable risk factor for DVT. Immobility can also lead to the development of DVT so patients can be encouraged to ambulate frequently or adhere to compression devices if unable. 3. Provide education about medications. Review medications to continue at discharge thoroughly. Ask the patient to verbalize each medication and to explain the proper dose, frequency, and reason for each one to evaluate effective teaching. 4. Teach ways to prevent a recurrence. Instruct on easy ways patients can decrease their risk of recurrent DVT. Do not sit with legs or ankles crossed as this can hinder circulation. Higher altitudes such as when flying can increase the risk of DVT as well as sitting on long car rides. Stand and walk frequently on long flights and stop for rest breaks to stretch the legs on car rides. | Patient verbalized an understanding of diagnosis and treatment. Patient verbalized the importance of medications and follow-up lab tests. Patient identified their risk factors and three ways to prevent recurrent DVT. |
| Subjective Data: Verbalizes difficulty in breathing Objective Data: -Dyspnoea worsened by exertion -Sudden chest pain -Cough with bloody mucus -Tachypnoea -Dizziness -Change in skin colour -Tachycardia -Palpitations | Impaired Gas Exchange Related to Ventilation perfusion imbalance and Development of pulmonary embolism as evidenced by Dyspnoea worsened by exertion and Sudden chest pain | Patient will demonstrate oxygen saturation and breathing patterns within normal limits. Patient will report relief of chest pain, difficulty breathing, and light-headedness. | 1. Obtain a V/Q scan. A ventilation/perfusion scan measures how air moves into and out of the lungs and the circulation of blood in the lungs. A V/Q scan can diagnose a PE if the patient is exhibiting symptoms. 2. Apply oxygen. Supplemental oxygen should be applied to keep oxygen saturation >90%. 3. Implement nonpharmacologic interventions. Apply compression stockings to prevent further thromboembolisms. Activity is recommended as tolerated, and early ambulation is encouraged over bed rest. 4. Prepare for respiratory support. Severe hypoxemia or respiratory failure may require intubation and mechanical ventilation. | Patient demonstrated oxygen saturation and breathing patterns within normal limits. Patient reported got relieved from chest pain, difficulty breathing, and light-headedness. |