Help! priority action for pulmonary embolism

  1. I am very confused about this question.

    Patient is in hospital post-op receiving heparin therapy. The patient suddenly presents with chest pain and SOB and the nurse suspects a pulmonary embolus. What is her first nursing action?

    a. elevate head of bed and administer oxygen


    b. assess pulse, respiratory rate and blood pressure

    other choices, I thought not significant were to give more heparin or call the physician.

    I could not figure this out due to my brain contradicting itself. At first I thought definitely elevate the bed and give them O2 because A-B-C and airway is so important, no oxygen means not breathing. Then I started to think wait, does the oxygen need a doctor's order? The answer does not specify how much O2 to give. As a nurse presented with little information, would giving O2 be contraindicated for this pt.?

    So then I started to think, it must be assess first! Part of nursing process is to ASSESS first, perhaps to see if vital signs confirm the nurse's suspicion then oxygen comes after. You must have a rationale for doing something and assessing would be priority in order to make a decision on what to do next.

    In our book it lists both interventions are indicated but not saying which would be priority in this case.

    Can anyone give me some insight and provide a rationale for your thinking? Thanks in advance!
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    About sassynerd, RN

    Joined: Jan '12; Posts: 49; Likes: 30


  3. by   Prairienurse1989
    You have already "assessed" that the patient is on Heparin, is having SOB, and chest pain. You "suspect" a pulmonary embolism. Now what are your actions?
  4. by   Esme12
    ABC, ABC...if someone can't breathe you aren't going to lie them down right? Now tell me what you think
  5. by   sassynerd
    Absolutely! ABCs are critical and exactly what I initially thought. But somewhere in my brain this nagging doubting thought came to mind and said hold on there, you didn't assess yet. I pretended I was the nurse and just walked in the room. Patient is on heparin therapy but a PE is suspected. I thought I would need a reason to back up my action thus needing to grab the patient's RR, BP, and pulse, first.

    In the past I've chosen the "intervention" first and then I would get it wrong because the rationale is you didn't assess first. Now I'm getting mixed up the other way around. I suppose for critical conditions it's ok to just make the patient better first even if there's no order for oxygen from an MD. You aren't going to wait, the patient will be dead by the time the MD confirms anything. The patient will be dead by the time u get all their vital signs. So give O2 first. An earlier post mentioned that the nurse already assessed by suspecting dyspnea so perhaps that was the "assessment" I was looking for to give me the ok to make the action. I have a lot of trouble with prioritizing and I hope I can get this one day.

    When I get my test back, I'll let you guys know what our professors wanted.

    Quote from Esme12
    ABC, ABC...if someone can't breathe you aren't going to lie them down right? Now tell me what you think
  6. by   Esme12
    The thing to remember is.....make sure that a simple repositioning of the patient or airway isn't what the patient needed. If the patient is allslummped over while you fiddle with the B/P cuff and pulse ox...the longer they are with decreased O2. If you position them properly they just might feel so much better no intervention is needed.

    However I do admit I give the real world process please let us know....
  7. by   MendedHeart
    Priority= action
    Assessing is not technically an action
  8. by   classicdame
    you cannot give additional meds without MD order, so notify another nurse to call MD while you stay with patient and monitor breathing, position and O2
  9. by   sassynerd
    great job to those who got this! yes, the answer was "elevate the bed and administer oxygen."

    I missed this definitely because I mistaken an "action" for an assessment of vitals. Also missed this due to thinking O2 had to be ordered by the MD but I suppose in a crisis situation, it's best to get that patient breathing than to deal with "paperwork/orders" etc.

    thanks to all who contributed!
  10. by   Esme12
    What seem so hard right now does get walk in a patients room because they said they were see them all scrunched in their bed....huffing and puffing for air...they are in distress....your first reation is to pull them up in bed and untangle them form the sheets, IV lines, pillows so they can sit upright and breathe call for help to pull them up......but they still c/o feeling SOB they don't look any better you put on their O2 then get some vitals and call the MD.