Assessment

HISTORY. Many patients with PE report a history of DVT, surgery, or some other condition that results in vascular injury or increased blood coagulability. Patients may describe a sudden onset of dyspnea and chest pain for no apparent reason. Some patients report severe symptoms, such as severe pain, wheezing, diaphoresis, and a sense of impending doom. The severity of the symptoms partly depends on the size, number, and location of the emboli.

PHYSICAL EXAMINATION. Patients often appear short of breath, diaphoretic, weak, fearful, and anxious. They may be febrile, or their skin may be cold and clammy. Those in critical condition may develop severe chest pain, syncope, and chest splinting and may cough up bloody sputum. Not all patients become hypoxemic because the increased respiratory rate increases their minute volume and thereby maintains gas exchange. However, some patients have signs of hypoxemia, such as confusion, agitation, and central cyanosis.

When you auscultate the patient's chest, you may note decreased breath sounds, wheezing, crackles, or a transient pleural friction rub. You may also note tachycardia, a third heart sound, or a loud pulmonic component of the second heart sound. You may note a warm, tender area in the leg. Ongoing monitoring during an acute episode of PE is essential for patient recovery. Monitor the patient's vital signs, including temperature, pulse, blood pressure, and respiratory rate, every hour or as needed. Observe the patient continuously for signs of right ventricular failure as evidenced by neck vein distension, rales, peripheral edema, enlarged liver, dyspnea, increased weight, and increased heart rate. Monitor the patient for signs of shock, such as severe hypotension, mottling, cyanosis, cold extremities, and weak or absent peripheral pulses.

PSYCHOSOCIAL. Depending on the severity of symptoms, patients and their families usually display some degree of anxiety. Because PE is life-threatening, their fears are justified and appropriate. Assess the patient's and family's ability to cope.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Arterial blood

Pao2: 80-100 mm Hg;

Pao2: <80 mm Hg In a

Poor gas exchange and shunting

gases

Paco2: 35-45 mm Hg;

majority of patients;

leads to hypoxemia; hypocap-

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