Purba Java

<p><b>Pulmonary embolism (PE) </b>is a life-threatening condition in which a blood clot blocks one or more arteries in the lungs. It is considered a medical emergency requiring rapid diagnosis, aggressive treatment, and close nursing monitoring. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE0FUSjpHiDAR4z8qDjrX8oZ_joqx2oyUTv_q5RA7fRQmQ8Gp4WvQw7p8LmWeXyeGHkmvSm-qKp0zW9eCGBZnuqRrMEBJ2qErmanhKo9gbzXaONK0MJP1JP6U_bOZ0lnIiPtBtg6kDraMCdsnlQcYXdTkq2qkjVoD-flnT_0KW6T5tqWB2CvJz0_gfzmHO/s1536/Nursing%20Care%20Plan%20for%20Pulmonary%20Embolism.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img alt="Nursing Care Plan for Pulmonary Embolism" border="0" data-original-height="1024" data-original-width="1536" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjE0FUSjpHiDAR4z8qDjrX8oZ_joqx2oyUTv_q5RA7fRQmQ8Gp4WvQw7p8LmWeXyeGHkmvSm-qKp0zW9eCGBZnuqRrMEBJ2qErmanhKo9gbzXaONK0MJP1JP6U_bOZ0lnIiPtBtg6kDraMCdsnlQcYXdTkq2qkjVoD-flnT_0KW6T5tqWB2CvJz0_gfzmHO/w400-h266/Nursing%20Care%20Plan%20for%20Pulmonary%20Embolism.png" width="400" /></a></div><br /><p><br /></p><h2>What Is Pulmonary Embolism?</h2>
<p>Pulmonary embolism occurs when a thrombus—usually originating from a deep vein in the leg—travels to the pulmonary artery, obstructing blood flow and impairing oxygen exchange.</p>

<h3>Common Causes</h3>
<ul>
    <li>Deep vein thrombosis (DVT)</li>
    <li>Prolonged immobility or long flights</li>
    <li>Recent surgery (especially orthopedic surgery)</li>
    <li>Trauma or fractures</li>
    <li>Pregnancy or postpartum period</li>
    <li>Smoking</li>
    <li>Hormonal contraceptives</li>
</ul>

<h3>Signs and Symptoms</h3>
<ul>
    <li>Sudden shortness of breath</li>
    <li>Chest pain (usually sharp and pleuritic)</li>
    <li>Tachypnea and tachycardia</li>
    <li>Cough, possibly with hemoptysis</li>
    <li>Low oxygen saturation (SpO₂)</li>
    <li><a href="https://purba-java-indo.blogspot.com/2015/09/definition-of-anxiety-according-to.html">Anxiety</a> or feeling of impending doom</li>
</ul>

<h2><br /></h2><h2>Nursing Assessment for Pulmonary Embolism</h2>
<p>Comprehensive assessment is essential for early detection and preventing complications.</p>

<h3>Subjective Data</h3>
<ul>
    <li>“I can’t breathe” or sudden shortness of breath</li>
    <li>Chest pain that worsens with inspiration</li>
    <li><a href="https://purba-java-indo.blogspot.com/2016/03/symptoms-and-causes-of-panic-attacks.html">Anxiety</a> or restlessness</li>
</ul>

<h3>Objective Data</h3>
<ul>
    <li>RR > 20 breaths/min</li>
    <li>HR > 100 beats/min</li>
    <li>SpO₂ < 92% on room air</li>
    <li>Cyanosis</li>
    <li>Cough with or without blood</li>
    <li>Abnormal ABG (e.g., respiratory alkalosis)</li>
    <li>ECG: sinus tachycardia</li>
</ul>

<h2><br /></h2><h2>Nursing Care Plan (NANDA–NIC–NOC)</h2>

<h3><strong>NANDA #1: Impaired Gas Exchange</strong></h3>

<h4>NOC Outcomes</h4>
<ul>
    <li><strong>Respiratory Status: Gas Exchange</strong></li>
    <li>SpO₂ ≥ 95% with supplemental oxygen</li>
    <li>Improved breath sounds</li>
    <li>Normal ABG levels</li>
</ul>

<h4>NIC Interventions</h4>
<ul>
    <li><strong>Monitor respiratory status</strong> every 1–2 hours (RR, depth, lung sounds).</li>
    <li><strong>Monitor SpO₂ continuously</strong> and provide oxygen as ordered.</li>
    <li><strong>Place patient in a semi-Fowler or high Fowler position</strong> to maximize lung expansion.</li>
    <li><strong>Administer anticoagulants</strong> (heparin, enoxaparin, warfarin) as prescribed.</li>
    <li><strong>Prepare for thrombolytic therapy</strong> (e.g., alteplase) if ordered.</li>
    <li><strong>Monitor ABG</strong> for changes in oxygenation and acid-base balance.</li>
    <li><strong>Assess for signs of bleeding</strong> due to anticoagulant therapy.</li>
</ul>

<hr />

<h3><strong>NANDA #2: Decreased Cardiac Output</strong></h3>

<h4>NOC Outcomes</h4>
<ul>
    <li>Stable blood pressure within normal limits</li>
    <li>HR 60–100 beats/min</li>
    <li>Warm extremities and normal skin color</li>
</ul>

<h4>NIC <a href="https://purba-java-indo.blogspot.com/2024/01/nursing-interventions-for-acute-pain.html">Interventions</a></h4>
<ul>
    <li>Monitor vital signs every 1 hour or as indicated.</li>
    <li>Assess for signs of decreased perfusion (cool skin, delayed capillary refill).</li>
    <li>Maintain IV access for emergency medications.</li>
    <li>Administer vasopressors if ordered in cases of shock.</li>
    <li>Monitor ECG continuously for dysrhythmias.</li>
</ul>

<hr />

<h3><strong>NANDA #3: Anxiety</strong></h3>

<h4>NOC Outcomes</h4>
<ul>
    <li>Patient verbalizes reduced anxiety</li>
    <li>Demonstrates relaxed breathing</li>
    <li>Stable vital signs</li>
</ul>

<h4>NIC Interventions</h4>
<ul>
    <li>Provide reassurance and stay with the patient during acute distress.</li>
    <li>Teach slow, deep breathing techniques.</li>
    <li>Explain all procedures to reduce fear.</li>
    <li>Provide a calm environment.</li>
</ul>

<hr />

<h2>Example of a Complete Nursing Care Plan Table</h2>

<table>
    <thead>
        <tr>
            <th>Nursing Diagnosis (NANDA)</th>
            <th>Goals/Outcomes (NOC)</th>
            <th>Interventions (NIC)</th>
            <th>Rationale</th>
        </tr>
    </thead>
    <tbody>
        <tr>
            <td>Impaired Gas Exchange related to pulmonary circulation disruption.</td>
            <td>
                <ul>
                    <li>SpO₂ ≥ 95%</li>
                    <li>Normal respiratory rate</li>
                    <li>Clear lung sounds</li>
                </ul>
            </td>
            <td>
                <ul>
                    <li>Monitor respiratory status</li>
                    <li>Administer oxygen therapy</li>
                    <li>Place in semi-Fowler position</li>
                    <li>Administer anticoagulants</li>
                </ul>
            </td>
            <td>
                <ul>
                    <li>To detect early deterioration</li>
                    <li>Improves oxygenation</li>
                    <li>Promotes lung expansion</li>
                    <li>Prevents further clot formation</li>
                </ul>
            </td>
        </tr>
    </tbody>
</table>

<h2>Patient Education</h2>
<p>Teaching is a crucial part of nursing care to prevent recurrence.</p>

<ul>
    <li>Encourage early ambulation after surgery.</li>
    <li>Teach proper use of compression stockings.</li>
    <li>Educate about anticoagulant therapy and bleeding risks.</li>
    <li>Advise smoking cessation.</li>
    <li>Promote hydration to prevent blood thickening.</li>
</ul>

<h2>Complications of Pulmonary Embolism</h2>
<ul>
    <li>Pulmonary hypertension</li>
    <li>Right-sided heart failure</li>
    <li>Recurrent PE</li>
    <li>Cardiac arrest (severe cases)</li>
</ul>

<h2>Conclusion</h2>
<p>Pulmonary embolism is a critical and potentially fatal condition requiring rapid assessment, early intervention, and continuous monitoring. This <a href="https://purba-java-indo.blogspot.com/2017/01/nursing-care-plan-hypertension.html">Nursing Care Plan </a>(NCP) provides a structured approach using NANDA, NIC, and NOC to guide nursing students and healthcare professionals in managing patients effectively. Implementing evidence-based interventions can significantly improve patient outcomes and prevent complications.</p>

<h2>References</h2>
<ul>
    <li>American Heart Association. (2024). <em>Pulmonary Embolism Guidelines.</em></li>
    <li>Lewis, S. L., et al. (2023). <em>Medical-Surgical Nursing.</em> Elsevier.</li>
    <li>Ignatavicius, D. (2023). <em>Patient-Centered Collaborative Care.</em></li>
    <li>National Institutes of Health (NIH). Pulmonary Embolism Overview.</li>
    <li>NANDA International. (2024). <em>NANDA-I Nursing Diagnoses: Definitions & Classification.</em></li>
</ul>

Nursing Care Plan for Pulmonary Embolism (NCP for PE)

Pulmonary embolism (PE) is a life-threatening condition in which a blood clot blocks one or more arteries in the lungs. It is considered a m...