Page 157 - Critical Care Nursing Demystified

142 CRITICAL CARE NURSING DeMYSTIFIED

Signs of shock can occur if the PE is massive. These include
• Hypotension

• Cyanosis
• Change in the level of responsiveness
• Cold, clammy skin
• Decreased urinary output
• Hemoptysis

• Elevated CVP or RA and PA pressures (right-sided heart pressures)
• Low PCWP pressure (left-sided pressure)

Prognosis
The best thing to do is prevent PE, but once it occurs the mortality rate is high,
especially if a large portion of the pulmonary circulation is blocked.

Interpreting Test Results
Because PE mimics other conditions, many studies are done to rule out those
conditions. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

Worsening hypoxemia and hypercapnea with respiratory acidosis.
Chest x-ray to rule out pulmonary edema or tumor.
ECG to rule out MI.
Spiral CT of the lungs.
Positive D-dimer assay, which shows presence of blood clots.
Pulmonary angiogram where dye is injected into the heart is the definitive
test, but it has a high mortality rate.

Nursing Diagnoses for PE Expected Outcomes
Tissue perfusion, ineffective (pul- The patient will have stable VS
monary) RT damming of blood The patient will have normal RA, PAP, and
from the right side of the heart PCWP pressures
Ineffective tissue oxygenation The patient will have normal pH, pO and
2
pCO levels on room air
2
Interventions

Ongoing assessment of VS and SaO to see if therapy returns the VS to
2
baseline and oxygen levels rise.