Nursing Management of PE

3 most common initial assessment findings

Sudden onset of

• PLEURITIC chest pain (worse with deep breaths)

• Dyspnea (SOB)

• Tachypnea

What may be seen if the PVR is elevated?

Early signs of Right Ventricular failure → JVD

What can be the result of a massive PE with reduced preload to the left side of the heart?

Decreased CO and HYPOtension

What can occur with decreased cerebral perfusion?

Confusion, change in mental status, anxiety, “impending doom”

Why does the pulse oximetry reading decrease?

Dead-space ventilation → V/Q mismatch → blood not properly oxygenated by the lungs

What does an increase in lactic acid levels indicate?

Anaerobic metabolism (later on)

Signs of Shock

TACHYcardia

HYPOtension

Decreased urine output (<0.5mL/kg/hr)

Confusion/anxiety

Decreased MAP (WNL 70-100)

How should you position the patient?

Elevate the HOB to allow the diaphragm to drop

When are thrombolytics used?

Hemodynamic compromise

What is given to help maintain systolic BP of at least 80?

Norepinephrine or vasopressin

Bleeding precautions

Minimize venipunctures

Watch for blood in urine, stool, and sputum

Watch for bruising

Electric razor

soft toothbrush

No flossing

avoid activities that have a risk of bleeding (football)

Dietary Considerations

Heart-healthy diet

Limit foods high in vitamin K

Foods high in vitamin K

green leafy vegetables are the top source of Vitamin K, including kale, spinach, collard greens, turnip greens, and cabbage, plus cruciferous veggies like broccoli and Brussels sprouts, with soybeans (natto, edamame), asparagus, avocado, and liver

S/S of DVT

Unilateral LE edema and pain with redness and warmth