About
A blood clot that has traveled and lodged itself into an area of the lung, resulting in decreased oxygenation to that area of the lung.
Assess
Assess for sudden pain in chest, pulse oximetry, sudden difficulty with breathing, anxiety. Assess for recent blood clots ( DVT's), pregnancy, previous immobilization, recent surgery. ABG's, d-dimer, spiral CT.
Complications
Respiratory or cardiac arrest- start CPR.
Hypoxemia
Embolectomy- surgery to remove clot
Hemorrhage- monitor Ptt, Pt, and INR; monitor for bruising, petechiae, and bleeding
Diagnosis
- Impaired gas exchange related to interruption of pulmonary blood flow
- Pain related to tissue ischemia and lack of oxygen
- Fear related to pain, inability to breathe, and possible death
Goals
- The client will maintain adequate oxygenation.
- The client will be able to state three ways to prevent injury while on anticoagulants.
- The client will verbalize signs and symptoms to report to repost to nursing.
Interventions
- Monitor vitals, pulse oximetry, and pain level.
- Auscultate for increase in crackles, dysrhythmias, and other adventitious sounds at least hourly during initiation of anticoagulant therapy.
- Monitor for s/s of active bleeding ( bleeding gums, ecchymosis, petechiae, purpura).
- Administer oxygen as prescribed.
- Administer fibrinolytics and/ or anticoagulants as ordered.
- Teach client s/s to monitor for increased bleeding.
- Teach client safety precautions while on anticoagulant therapy.
- Notify physician, immediately, if any change in patient status indicating worsening.
- Monitor for signs/ symptoms of complications.
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