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NUR 265 EXAM 2 - exam 2
Nur Med Surg (Galen College of Nursing)
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EXAM 2 NUR 265
● Pulmonary embolism: clot that travels to the lungs
○ Risk factors
■ Prolonged immobility
■ Central venous catheter surgery
■ Obesity
■ Advancing age
■ Conditions that increase blood clotting (DIC)
■ Distort of thromboembolism
■ Smoking
■ Pregnancy
■ Hormonal birth control (estrogen therapy)
■ Heart failure
■ Stroke
■ Cancer
■ Trauma
■ Afib
○ S/s:
■ Dyspnea - SUDDEN ONSET
■ Pleuritic chest pain (sharp, stabbing type pain on inspiration)
■ Crackles
■ Wheezes
■ Apprehension
■ Anxiety
● Give O2
■ Restlessness
■ Impending doom
■ Cough (productive or dry)
■ Tachypnea
■ Pleural friction rub
■ S3 or s4 heart sound
■ Diaphoresis
■ Low grade fever
■ Petechiae (fat embolism , does not impede blood flow, causes actual
damage to the blood vessels) over chest and a axillae
■ If really big you can see EKG changes
■ hemoptysis - bloody sputum
■ Decreased Sao2
■ Sudden dyspnea and chest pain= immediately notify rapid response team
○ Labs:
■ Hyperventilation (caused from pain and hypoxia) = respiratory alkalosis
(low paco2 <35, high PH >7.45) = blood shunting from right side to left
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side without picking up O2 from the = respiratory acidosis (high paco2
>45, low PH <7.35)= build up of lactic acid = metabolic acidosis (low
HCO3 <22, low PH <7.35)
■ D-dimer rises (positive)
○ Dx:
■Pulmonary angiography = gold standard
● Only if stable
● Inject dye, use imaging
■ CT
■ Chest X-ray
■ Doppler ultrasound
○ Nursing intervention:
■ Call rapid
■ O2 - use pulse ox
● Nasal cannula
● Mask
● Mechanical ventilation
■ Tele
■ IV access
■ Monitor VS. lung sounds and cardiac/ respiratory status Q1-2hrs
● Assess for and document increasing dyspnea, dysrhythmias, JVD,
pedal or sacral edema, crackles, cyanosis
■ CTPA, pulmonary angiography
■ Bleeding precautions
● Monitor and record amount of bleeding
● Asses Q2 hours
■ Measure abdominal girth Q8 Hours
■ Monitor labs daily
● Monitor CBC to watch for blood loss
○ Blood loss= RBC, plasma
○ Monitor platelet count = decreased platelet count = HIIT
■ Drug therapy
■ Make sure antidote is on the floor
● Anticoagulants - keep clots from getting bigger
○ Unfractionated heparin
■ Check PTT (normal 20-30) before administering
(range between 1.5-2.5 times the control)
(therapeutic 46-70) (>75 = complication)
■ 5-10 days (for 24 hours)
■ Protamine sulfate = antidote
○ Then transferred to oral warfarin
■ Monitor INR (2.0-3.0)
■ Vitamin K = antidote
Downloaded by B Staton ()
NUR 265 EXAM 2 - exam 2
Nur Med Surg (Galen College of Nursing)
StuDocu is not sponsored or endorsed by any college or university
Downloaded by B Staton ()
, lOMoARcPSD|8945469
EXAM 2 NUR 265
● Pulmonary embolism: clot that travels to the lungs
○ Risk factors
■ Prolonged immobility
■ Central venous catheter surgery
■ Obesity
■ Advancing age
■ Conditions that increase blood clotting (DIC)
■ Distort of thromboembolism
■ Smoking
■ Pregnancy
■ Hormonal birth control (estrogen therapy)
■ Heart failure
■ Stroke
■ Cancer
■ Trauma
■ Afib
○ S/s:
■ Dyspnea - SUDDEN ONSET
■ Pleuritic chest pain (sharp, stabbing type pain on inspiration)
■ Crackles
■ Wheezes
■ Apprehension
■ Anxiety
● Give O2
■ Restlessness
■ Impending doom
■ Cough (productive or dry)
■ Tachypnea
■ Pleural friction rub
■ S3 or s4 heart sound
■ Diaphoresis
■ Low grade fever
■ Petechiae (fat embolism , does not impede blood flow, causes actual
damage to the blood vessels) over chest and a axillae
■ If really big you can see EKG changes
■ hemoptysis - bloody sputum
■ Decreased Sao2
■ Sudden dyspnea and chest pain= immediately notify rapid response team
○ Labs:
■ Hyperventilation (caused from pain and hypoxia) = respiratory alkalosis
(low paco2 <35, high PH >7.45) = blood shunting from right side to left
Downloaded by B Staton ()
, lOMoARcPSD|8945469
side without picking up O2 from the = respiratory acidosis (high paco2
>45, low PH <7.35)= build up of lactic acid = metabolic acidosis (low
HCO3 <22, low PH <7.35)
■ D-dimer rises (positive)
○ Dx:
■Pulmonary angiography = gold standard
● Only if stable
● Inject dye, use imaging
■ CT
■ Chest X-ray
■ Doppler ultrasound
○ Nursing intervention:
■ Call rapid
■ O2 - use pulse ox
● Nasal cannula
● Mask
● Mechanical ventilation
■ Tele
■ IV access
■ Monitor VS. lung sounds and cardiac/ respiratory status Q1-2hrs
● Assess for and document increasing dyspnea, dysrhythmias, JVD,
pedal or sacral edema, crackles, cyanosis
■ CTPA, pulmonary angiography
■ Bleeding precautions
● Monitor and record amount of bleeding
● Asses Q2 hours
■ Measure abdominal girth Q8 Hours
■ Monitor labs daily
● Monitor CBC to watch for blood loss
○ Blood loss= RBC, plasma
○ Monitor platelet count = decreased platelet count = HIIT
■ Drug therapy
■ Make sure antidote is on the floor
● Anticoagulants - keep clots from getting bigger
○ Unfractionated heparin
■ Check PTT (normal 20-30) before administering
(range between 1.5-2.5 times the control)
(therapeutic 46-70) (>75 = complication)
■ 5-10 days (for 24 hours)
■ Protamine sulfate = antidote
○ Then transferred to oral warfarin
■ Monitor INR (2.0-3.0)
■ Vitamin K = antidote
Downloaded by B Staton ()
