NURSING 341 vsim Vernon Watkins Thesis Latest Update

NURSING 341 vsim Vernon Watkins Thesis Latest Update

ONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Pulmonary Embolism (PE) is the blockage of one or more pulmonary arteries by a thrombus, fat or air embolus,
or tumor tissue. These clots do not stop moving until they lodge at a narrowed part of the circulatory system. A
pulmonary embolus consists of material that gain access to the venous system and then to the pulmonary
circulation. The embolus travels with blood flow through smaller blood vessels until it lodges and obstructs
perfusion of the alveoli. The lower lobes of the lungs are most commonly affected and approximately ten
percent of patients die from a massive PE within the first hour. Anticoagulants significantly reduces mortality.
Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing:
Assessment and management of clinical problems. St. Louis, MO: Elsevier.
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
• 12-lead electrocardiogram (ECG)such as T-wave
inversion, ST-segment elevation, orthe development
of an abnormal Q wave (may show changes
PATIENT INFORMATION
Vernon Watkinsis a 69-
year-old male who
ANTICIPATED PHYSICAL
FINDINGS
• Shortness of breath
• Chest pain
• Nausea
indicative of ischemia)
+ • Chest X-ray-may show infiltrates, atelectasis,
elevation of the diaphragm on the affected side, or a
pleural effusion
• Spiral CT-Scan with contrast
• Arterial blood gas analysis-it may show hypoxemia
and hypocapnia (from tachypnea).
• D-dimmer test
• Prothrombin time
• International normalized ratio
Department 4 days ago with
complaints of nausea,
vomiting, and severe
abdominal pain and was
admitted for emergent
surgery for bowel
perforation and underwent a
hemicolectomy.
• Vomiting
• Abdominal pain
• Anxiety
• Fever
• Tachycardia
• Apprehension
• Diaphoresis
• Hemoptysis
• Syncope
ANTICIPATEDNURSING INTERVENTIONS
• Maintain oxygen saturation greater than 92%
• If SpO2 lessthan 92% administer oxygen therapy to relieve hypoxemia and dyspnea and position client in highFowler’s 90 degrees
• Initiate and maintain IV access.
• Administer prescribed medications
• Withhold medicationsthat may cause respiratory depression
• Place 12 lead ECG to monitor cardiac status (dysrhythmias)
• Vital signs every 4 hours
• Monitor for signs of bleeding.
• Assess wound and IV site regularly.
• Chest X-Ray
• Spinal CT-scan with contrast
• Request need for arterial blood gas/stat labs
• Check to aPTT in six hours and then follow nurse driven IV heparin protocol