Suspected Condition: Pulmonary Embolism

QUESTION

The nurse is providing care to a patient with a stage 4 sacral ulcer. The patient is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, "I am having trouble breathing." RR is 32. 02 saturation 84 on RA. Patient is placed on 5L via simple face mask. 02 sat is now 85%. Which of the following conditions does the nurse suspect the patient is experiencing? Complete the diagram below by dragging from the choices below to specify what condition the client is most likely experiencing, two anticipated interventions/provider orders, and two parameters the nurse should monitor. Anticipated Parameters to Monitor 1 Interventions/Provider Orders 1 Anticipated Parameters to Monitor 2 Interventions/Provider Orders 2 Anticipated Potential Condition Parameters to Monitor Interventions/provider Orders Pulmonary Urine output embolism Intravenous heparin infusion Acute respiratory Wound drainage distress syndrome characteristics Wound care consult Pneumonia Vital signs with secondary to oxygen saturation atelectasis Arterial blood gas Flash pulmonary aPT edema Chest X-ray Work of breathing Intravenous furosemide infusion

ANSWER

Suspected Condition: Pulmonary Embolism

When a patient with a stage 4 sacral ulcer presents symptoms of a systemic infection, such as trouble breathing, increased respiratory rate (RR) of 32, and oxygen saturation of 84% on room air (RA), it raises concerns about a potential pulmonary embolism. The patient’s condition may be deteriorating, leading to decreased oxygen saturation even with oxygen supplementation.

Anticipated Parameters to Monitor

1. Oxygen Saturation: Continuous monitoring of oxygen saturation levels to ensure improvement with interventions.
2. Respiratory Rate: Frequent monitoring of respiratory rate to assess for any further increase or respiratory distress.

Interventions/Provider Orders

1. Intravenous Heparin Infusion: Initiation of an intravenous heparin infusion to prevent clot propagation and reduce the risk of further pulmonary embolism.
2. Arterial Blood Gas (ABG) Analysis: Order an ABG to assess the patient’s acid-base balance, oxygen, and carbon dioxide levels, providing valuable information about the adequacy of oxygenation and ventilation.

Anticipated Parameters to Monitor

1. Urine Output: Regular monitoring of urine output to ensure adequate kidney perfusion and function.
2. Vital Signs with Oxygen Saturation: Continuous monitoring of vital signs, particularly blood pressure and heart rate, alongside oxygen saturation to assess the overall hemodynamic stability.

Interventions/Provider Orders

1. Intravenous Furosemide Infusion: Administer intravenous furosemide to address fluid overload, reduce pulmonary congestion, and improve oxygenation.
2. Chest X-ray: Order a chest X-ray to assess lung fields for any signs of congestion, consolidation, or pulmonary edema.

In conclusion, the patient’s presentation of trouble breathing, decreased oxygen saturation, and a systemic infection while receiving intravenous antibiotics warrants immediate consideration of a pulmonary embolism. By closely monitoring oxygen saturation, respiratory rate, urine output, and vital signs, and implementing interventions such as heparin infusion, ABG analysis, furosemide infusion, and chest X-ray, the nurse can ensure timely intervention and improve the patient’s respiratory status and overall condition.