References: Pulmonary Embolism Nursing Care and Management:

References: Pulmonary Embolism Nursing Care and Management: Study Guide (nurseslabs.com) https://nurseslabs.com/pulmonary-embolism/ Pulmonary Embolism Nursing Diagnosis (nursestudy.net) https://nursestudy.net/pulmonary-embolism-nursing-diagnosis/ CASE STUDY: PULMONARY EMBOLISM It is Thursday morning (Time 0845), and you are working in a busy Emergency Department. History of Present Illness: You are caring for Giles, a 70-year-old male. He arrived at the emergency department with his spouse, Mary Lou. He complains of shortness of breath which started yesterday and has gotten worse today as well as lethargy. He also reports sudden chest discomfort which started one-hour prior. He is afebrile and appears apprehensive. Social History: (from Giles) Giles is a retired electrician for GE. He has an active lifestyle and often “fixes” things around the house for pleasure. His wife describes him as a handyman. He eats mostly meat and potatoes and drinks alcohol on occasion. He previously smoked cigarettes but quit 20 years ago. His BMI is 32. He is compliant with yearly exams but sometimes “forgets” to take his blood pressure medications. He does not have a home blood pressure monitor. He denies any recent injures or fractures. Medical History: CHF, obesity, hypertension. Subjective History: Giles was born on a farm and grew up working the land with his 10 brothers and sisters. He has always worked hard his entire life. He retired last year and has continued his hobby of fixing old appliances and gardening. He has only been hospitalized once when newly diagnosed with CHF. Since then he has not had any exacerbations or issues. He lives in 1-story house with his wife. His 5 children live clo Medication Dose Last dose taken Coreg (carvedilol) 3.125 mg BID 0800 Lasix (furosemide) 20 mg BID Not yet taken today GENERAL APPERANCE: Giles looks apprehensive. He is sitting up in bed and is clean and well groomed. His spouse is at bedside. He complains of shortness of breath and chest discomfort. VITAL SIGNS: Temp: 36.8°C (98.24°F) BP:120/80 mmHg MAP 93 HR: 118 bpm RR: 30 SpO2: 90% on RA NEURO: Alert and oriented to person/place/time/situation. GCS 15. PERRLA. Anxious CARDIAC: Mucous membranes are pink. Capillary refill <3 seconds. Apical HR tachycardic. Peripheral pulses palpable and weak x4 at +1. No edema. No murmur RESP: Lung sounds clear in RUL, LUL, RML and basilar crackles in RLL and LLL. No stridor. Respirations are symmetrical and labored GI: Abdomen obese. Soft, non-tender. NABS x4. Last BM was today. Negative for nausea and vomiting. GU: Voids painlessly and without hesitation. Clear, yellow urine. UA normal. MUSCOLOSKELETAL: Moves all extremities with no overt deficits. Ambulates unassisted but is slow paced. Equal grip strength bilaterally. INTEGUMENTARY: Skin is warm, dry, and intact. No bruises or wounds noted. PSYCHOSOCIAL: Broad affect, apprehensive. Wife at bedside for support. Case Study Continued Pulmonary Embolism Giles is being transferred to ICU for thrombolytic therapy with the use of recombinant tissue plasminogen activator (TPA). Baseline lab values have been collected prior to starting the administration of TPA including INR, partial thromboplastin time (PTT), hematocrit, and platelet counts. You prepare to call report to the ICU nurse, Gabriel RN. You review Giles' most recent labs and presenting symptoms. Giles' oxygenation is unstable on 15L with a non-rebreather mask. The doctor is preparing to intubate with an endotracheal tube. His blood pressure is now unstable at 85/40 mmHg (58 MAP). He has an 18g in the right forearm. He is anxious and alert. His wife is being escorted to the ICU waiting area. Nurse's Notes Thrombolytic therapy is used in patients with an acute PE who have hypotension and do not have a contraindication or potential bleeding risk. Before thrombolytic therapy is started, INR, PTT, Hematocrit, and platelet counts are obtained to have a baseline measurement and to identify acute abnormal levels once therapy is started. A mean arterial pressure below 60 mmHg confirms poor tissue perfusion and is life threatening. Vasopressors will most likely be started. 1) What nursing interventions will Gabriel implement and why? Nursing Interventions Clinical Significance/Impact Observe PIV catheter site Assess BP and HR every 1-2 hours. Respiratory assessment Q2 hours Assess pain Monitor telemetry Administer oxygen as needed Monitor vital signs Assist patient with ADL's (nutrition, elimination, hydration, personal hygiene). Discharge Instructions You are preparing Giles for discharge home. He received TPA therapy and was in ICU for 10 days. He was extubated and has been tolerating room air. His vital signs are back to baseline. He is eating well and ambulates independently. He is going home with his wife and they have set up home health and laboratory appointments to monitor his INR levels. He is scheduled to see his PCP in 5 days. New Prescriptions Given: Medication Dose Last dose taken Coreg (carvedilol) 3.125 mg BID 0800 Lasix (furosemide) 20 mg BID 0900 Coumadin (warfarin) 5 mg daily 1700 yesterday 2) What instructions will be included for him at discharge? SCIENCE HEALTH SCIENCE NURSING NUR 123

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