CELLEROS, Korina L.

BSN 3-B (RLE-MS 2)

Case Scenario 4: Pulmonary Embolism

Ally Borromeo is a 32-year-old man who presents to the emergency department and later admitted to Medical Ward with shortness of breath
that he states has developed over the past 2 days. He has been feeling a bit dizzy this morning and thought he should see a doctor as he
developed what he describes as very mild chest pain, mostly on inspiration, this morning. He also reports his calves are sore and a little
swollen. From your observations, it is clear Ally is using accessory muscles to breathe in and he reports that he has been using a lot of extra
effort. Ally's only past history involves sporting injuries. He is not taking any regular medication. He travelled to Thailand on an end-of-season
trip with his football team(Azkals), returning the day before the symptoms appeared. As the admitting nurse in the Male Medical Ward, you
conduct a full assessment of Álly.

His vital signs are currently: • BP – 104/74 mmHg • HR – 105 beats/minute • RR – 28 breaths/minute • T – 37.2°C • SpO2 – 91% with no
supplemental oxygen You apply a simple face mask with 10 L O2 as supplemental oxygen in response to the low SpO2 .

As Ally has chest pain and is tachycardic, you perform an electrocardiogram (ECG), which shows normal sinus rhythm and a prominent S wave
in lead I and a Q wave and inverted T wave in lead III (S1Q3T3 pattern).

Blood tests are taken for urea and electrolytes, full blood examination, cardiac enzymes and d-dimer. A chest X-ray has been arranged. In these
initial stages of Ally's presentation to hospital, it is strongly suspected that he has a pulmonary embolism, given his recent history of a long
flight, but he is being investigated for other causes of his chest pain including acute coronary syndrome and respiratory infection.
Nursing Care Plan
Assessment Diagnosis Outcome Criteria Intervention Rationale Evaluation Discharge
Planning
Subjective cues: Ineffective Short term goals: Independent: Short term: M- Client must
Shortness of Breathing Pattern know his
breath that he related to After 3-4 hours of Assess the Respiratory rate MET. After 3 medicines. Know
states has hypoxia and nursing respiratory rate, and rhythm hours of nursing what they look
developed over chestpain as intervention, rhythm, and changes are early intervention, the like, how much he
the past 2 days. evidenced by client will be able depth. Assess for signs of client was able to should take each
shortness of to: any increase in impending maintain effective time, how often
Felling a bit dizzy, breath (dyspnea), the work of respiratory breathing pattern, he should take
very mild chest tachypnea, use of Maintain effective breathing: distress. as evidemced by them, and why he
pain, mostly on accessory breathing pattern, shortness of Tachypnea is a relaxed breathing take each one.
inspiration muscles and as evidemced by breath, and the typical finding of at normal rate Take his
tachycardia relaxed breathing use of accessory pulmonary and depth, and medicines exactly
He reports that at normal rate muscle. embolism (PE). absence of as his provider
his calves are sore and depth, and The rapid, shallow dyspnea and tells him to.
and a little absence of respirations participate in the Carry a list of his
swollen dyspnea. results from treatment medicines in his
hypoxia. The regimen. wallet or purse.
Objective cues: Participate in the development of Include any
He is using treatment hypoventilation Long term: nonprescription
accessory muscles regimen. (slowing of medicines and
to breathe in respiratory rate) MET. After 72
Long term goal: supplements on
without hours of nursing
His past history the list.
improvement in intervention,
involves sporting After 72 hours of Talk to his
the client’s client was able to
injuries nursing provider before
condition demonstrate
intervention, he use any other
indicates absence of
BP- 104/74 mmHg client will be able medicines,
respiratory respiratory
HR- 105 bpm to: Assess the including
failure. distress and
RR- 28 bpm characteristics of nonprescription
maintain
T- 37.2 oc Demonstrate pain, especially in medicines.
Pain is usually adequate
SpO2- 91% with absence of association with sharp or stabbing ventilation and E- Provide a quiet
no supplemental respiratory the respiratory and gets worse oxygenation. environment for
oxygen distress. cycle. with deep the patient to feel
Maintain breathing and calmed and
Low SpO2
adequate coughing. It can relaxed
He has chest pain ventilation and result in shallow
and is tachycardic oxygenation. respirations, T-Blood thinners
further impairing help prevent
Monitor arterial effective gas blood clots. Clots
https://nurseslabs.com/pulmonary-embolism-nursing-care-plans/
https://www.saintlukeskc.org/health-library/discharge-instructions-pulmonary-embolism
https://hhma.org/healthadvisor/ac-pulmonaryembolism-dc/
https://www.drugs.com/cg/pulmonary-embolism-discharge-care.html