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Nursing Guide to Pulmonary Embolism: Nursing Diagnosis, Interventions, & Care Plans

Updated On 8 Minute Read

Pulmonary Embolism Etiology and Epidemiology

A pulmonary embolism (PE) is a disruption of blood flow to one or more branches of the pulmonary artery. Often, the disruption of blood flow is from a blood clot originating from elsewhere in the body (DynaMed, 2018). Thromboembolism from deep vein thrombosis (DVT) is the main cause of PE. Some other causes of pulmonary embolism can include:

  • Septic emboli
  • Venous air emboli
  • Tumor emboli
  • Fat emboli
  • Air emboli
  • Foreign body

Risk factors that predispose an individual to develop a pulmonary embolism include (Tapson, 2021a):

  • Conditions that impair venous return:
    • Bedrest
    • Inability to ambulate
  • Conditions that cause endothelial injury
  • Hormonal modulation:
    • Exogenous progestins and estrogens such as those in contraceptives and hormone replacement (Tapson, 2021b)
    • Exogenous testosterone
  • Heart failure
  • Indwelling venous catheters
  • Atrial fibrillation/flutter
  • Trauma
  • Nephrotic syndrome
  • Surgery
  • Pregnancy and the postpartum period
  • Sickle cell disease
  • Smoking
  • Hypercoagulability disorders:
    • Cancers
    • Primary clotting disorders
    • Covid-19
  • Errors during insertion or removal of central venous catheters
  • Obesity
  • Liposuction
  • Long bone fractures
  • Orthopedic procedures

When a thrombus or embolus enters the venous system, it travels through the right side of the heart and into the pulmonary artery, blocking one or more of its branches (Tapson, 2021a).

Factors that influence the consequence(s) of emboli include:

  • Size and number of the emboli
  • Underlying lung condition
  • Right ventricle function
  • Body’s ability to dissolve clots

Very small emboli may have minimal to no effect on the lungs and resolve quickly. Larger emboli typically have symptoms which include:

  • Tachypnea
  • Hypoxemia
  • Low cardiac output
  • Atelectasis
  • Increased pulmonary vascular resistance
  • Hypotension
  • Death if the right ventricle fails

Pulmonary embolism can occur without symptoms, but this is not usually the case. Symptoms associated with PE include:

  • Acute dyspnea
  • Pleuritic chest pain (pulmonary infarction)
  • Cough
  • Hemoptysis (pulmonary infarction)
  • Altered mental status (often the first symptom in older adults)
  • Tachycardia
  • Tachypnea
  • Hypotension
  • S2 heart sound (uncommon)
  • Crackles or wheezing
  • Jugular vein distension
  • Low-grade fever
  • Signs of right-sided heart failure:
    • Easily fatigued
    • Exertional dyspnea
    • Peripheral edema
  • Symptoms of deep vein thrombosis in extremity:
    • Pain
    • Swelling
    • Erythema
  • Symptoms of hypocapnia:
    • Abnormal heartbeat
    • Muscle cramps
    • Seizures
    • Syncope

As many as 900,000 individuals are affected by thromboembolism in the U.S. each year (Centers for Disease Control and Prevention [CDC], 2020). It is estimated that 60,000 to 100,000 Americans die of PE caused by a DVT annually. Approximately 10% TO 30% of those who are affected die within the first month. Sudden death is the first symptom for about 25% of individuals who have PE (CDC, 2020).

Diagnosing a Pulmonary Embolism

Diagnosis of PE should be suspected in anyone who exhibits dyspnea, tachypnea, or pleuritic chest pain (DynaMed, 2018). The majority of individuals with PE will have symptoms.

Approximately 81% will present with dyspnea; 70% of those will have tachycardia and 50% will also have hypoxia (Martinez Licha et al., 2020).

The initial examination includes a pulse oximetry reading followed by a chest x-ray. Other testing for individuals with a suspected high risk of PE include:

  • Computed tomography pulmonary angiography (considered the gold standard)
  • Computed tomography (CT) with contrast enhancement
  • Bedside transthoracic echocardiography (TTE)
  • Transesophageal echocardiography (TEE), which can detect right ventricle function and intracardiac thrombi
  • Duplex venous ultrasonography of lower extremities to detect DVT
  • Serum D-dimer test (levels elevate with a PE)
  • Arterial blood gas
  • Ventilation-perfusion scan (V/Q scan) to detect symptoms of pulmonary hypertension
  • Magnetic resonance imaging (MRI) (usually performed on pregnant women)
  • Electrocardiogram (ECG) to show tachycardia and nonspecific ST-wave abnormalities

Pulmonary Embolism Management

If individuals with PE are hypoxic, oxygen should be the first-line treatment (Tapson, 2021a). Intravenous normal saline can be administered for hypotension, using caution not to increase the work of the right ventricle. If hypotension persists, IV vasopressors such as norepinephrine, epinephrine, and dobutamine can be administered. Antiarrhythmic medications may be administered if the individual has unstable cardiac arrhythmias.

Treatment for Pulmonary Embolism Risk Levels 

Low-risk or asymptomatic patients

Patients should receive anticoagulation therapy such as weight- based unfractionated heparin IV that is titrated for a therapeutic prothrombin time (PTT). The PTT level should be monitored every 6 hours and adjusted to reach a therapeutic level. For individuals with heparin-induced thrombocytopenia (HIT), IV argatroban infusion may be effective.

High-risk patients 

Patients require anticoagulation along with additional measures such as catheter- directed thrombolysis.

Intermediate-risk patients

Patients may only require anticoagulation therapy but may require more extensive treatment depending upon their clinical picture. The following should be evaluated when deciding on other treatments (Tapson, 2021a):

  • Signs and symptoms present
  • The severity of right ventricular dysfunction
  • Troponin level
  • Amount of oxygen and vasopressors required
  • Clot burden and location

Individuals should be admitted for at least 24 to 48 hours. Outpatient management is considered for only those who have no symptoms and minimal clot burdens. An intensive care admission is necessary for individuals with the following:

  • Massive clot burden
  • Compromised right ventricle
  • Substantial hypoxemia
  • Low blood pressure
  • Clinical deterioration

Individuals receiving IV heparin should be monitored closely for adverse effects, including:

  • Bleeding
  • Thrombocytopenia
  • Urticaria
  • Anaphylaxis (rare)

Maintenance doses of anticoagulation therapy should be given when the IV heparin is no longer needed. The maintenance dose can help prevent further clotting or extension of a pre-existing clot. Medications for anticoagulation maintenance include (DynaMed, 2018):

  • Warfarin (Coumadin®)
  • Apixaban (Eliquis®)
  • Rivaroxaban (Xarelto®)
  • Edoxaban (Lixiana®)
  • Dabigatran (Pradaxa®)
  • Subcutaneous low molecular weight heparin

Surgical intervention may be needed when an extensive DVT is the cause of a PE and carries a risk of it traveling throughout the body. This involves placement of a transvenous inserted intraluminal filter into the inferior vena cava, also known as an IVC filter. The IVC filter will keep clots from migrating into the pulmonary system.

An embolectomy may be required for a massive PE. The embolectomy is done either by open surgical procedure or a catheter embolectomy. This procedure is recommended for individuals with right ventricular dysfunction.

Pulmonary Embolism Nursing Care Plan

Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for pulmonary embolism are listed below.

Assessment

Assess signs and symptoms such as:

  • Vital signs
  • Dyspnea, severity, and the onset
  • Chest pain associated with breathing
  • Contraindications to thrombolytic therapy
  • Legs for signs of DVT:
    • Swelling
    • Duskiness
    • Warmth
  • Pain or tenderness with pressure
  • Respiratory rate
  • Tachycardia
  • Arrhythmias
  • Chest resonance or dullness
  • Abnormal heart sounds such as a split in the second heart sound
  • Coagulation studies:
    • Platelet count
    • Prothrombin time
    • D-dimer
  • Signs of hypoxia:
    • Confusion
    • Headache
    • Diaphoresis
    • Restlessness
    • Tachycardia
    • Tachypnea
    • Pallor
  • Signs of pulmonary infarction:
    • Fever
    • Cough
    • Bronchial breathing
    • Hemoptysis
    • Pleuritic pain
  • Pleural friction rub
  • Anxiety level

Nursing Diagnosis/Risk For

  • Ineffective breathing pattern related to an increased alveolar dead space as evidenced by (Phelps, 2021):
    • Abnormal arterial blood gasses (ABGs)
    • Oxygen desaturation
    • Dyspnea
  • Use of accessory muscles
  • Restlessness
  • Impaired gas exchange related to decreased lung perfusion as evidenced by (Phelps, 2021):
    • Decreased PaO2, increased PaCO2
    • Desaturation of oxygen
    • Dyspnea
    • Tachypnea
    • Restlessness, irritability
    • Confusion
  • Acute pain: pleuritic, related to possible lung infarction as evidenced by (Phelps, 2021):
    • Pain with inspiration
    • Chest pain not related to inspiration

Pulmonary Embolism Interventions

  • Monitor vital signs
  • Monitor pulse oximetry for hypoxia
  • Administer oxygen as ordered
  • Monitor the response to IV fluids and vasopressors
  • Monitor lab results (ABGs, D-dimer, PTT, platelet count)
  • Prepare the individual for assisted ventilation if ordered
  • Monitor the effectiveness of oxygen therapy
  • Monitor for signs of shock:
    • Decreasing blood pressure
    • Tachycardia
    • Cool, clammy skin
  • Administer analgesic medications as ordered and monitor their effectiveness
  • Maintain bed rest
  • Monitor their urinary output
  • Provide antiembolism stockings
  • Keep the head of the bed slightly elevated unless the individual is in shock
  • Monitor for signs of hypoxia:
    • Restlessness
    • Anxiety
    • Agitation
    • Cyanotic nail beds
    • Circumoral pallor or cyanosis
    • Increased respiratory rate
  • Explain all treatments and medications to the individual
  • Administer anticoagulation therapy as ordered
  • Monitor for signs of bleeding from anticoagulation therapy
  • Perform guaiac test on stool when ordered
  • Stop anticoagulation infusion if signs of bleeding are detected and notify the provider immediately
  • Monitor for changes in the level of consciousness
  • Encourage coughing and deep breathing exercises and incentive spirometry use

Expected Outcomes

  • Maintains effective breathing pattern
  • Maintains adequate gas exchange
  • Arterial blood gas within normal range
  • No change in the level of consciousness
  • Pain is controlled

Individual/Caregiver Education

  • Condition, treatment options, and expected outcomes
  • Notify healthcare provider or seek immediate medical care for:
    • Increased shortness of breath
    • Increased chest pain
    • Fever
    • Decreased blood pressure
    • Syncope
    • Rapid heart rate
    • Rapid respiratory rate
  • Follow up blood testing for anticoagulant therapy

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Additional Information

Content Release Date 

6/11/2024

Content Expiration

12/31/2027

Course Contributor

The content for this course was created by Kathleen Koopmann, RN, BSN, PCCN. Kathleen earned her Associate Degree in nursing in 1987 at Mid-Michigan Community College and her Bachelor of Science in nursing in 2018 from Western Governor’s University. She has training from the North Carolina Statewide Program for Infection Control and Epidemiology through NCDHHS and the University of North Carolina. Kathleen has worked in long-term care, outpatient care, acute care, and nursing education. She has hospital experience in Med-Surg, OR/PACU, Critical Care, Telemetry, and outpatient experience in Occupational Health. Kathleen has experience as a clinical instructor for the LPN program at Susquehanna County Career and Technical Center in Pennsylvania. Most recently, she worked in long-term care as a Staff Development Coordinator and Infection Control Practitioner.

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Kathleen Koopmann, RN, BSN, PCCN

Kathleen earned her Associate Degree in nursing in 1987 at Mid-Michigan Community College and her Bachelor of Science in nursing in 2018 from Western Governor’s University. She has training from the North Carolina Statewide Program for Infection Control and Epidemiology through NCDHHS and the University of North Carolina. Kathleen has worked in long-term care, outpatient care, acute care, and nursing education. She has hospital experience in Med-Surg, OR/PACU, Critical Care, Telemetry, and outpatient experience in Occupational Health. Kathleen has experience as a clinical instructor for the LPN program at Susquehanna County Career and Technical Center in Pennsylvania. Most recently, she worked in long-term care as a Staff Development Coordinator and Infection Control Practitioner.