CHAPTER 2 Respiratory System^129
TREATMENT
Treatment is aimed at meeting the body’s oxygen needs, preventing the clot from
enlarging or moving, and preventing other clots from forming.
- Supplemental oxygen therapy.
- Administer thrombolytics to enhance breakdown of existing clot:
- urokinase, alteplase
- Administer anticoagulants to prevent further clot formation:
- heparin, warfarin
- Administer analgesic for pain control and to decrease myocardial oxygen
demand:- morphine
- Surgical insertion of a vena cava filter in select patients to catch clots that
travel from lower extremities up through inferior vena cava toward lung. - Bed rest to prevent thrombus from breaking free from lower extremities.
- Surgical removal of the embolus may be necessary in some cases.
NURSING DIAGNOSES
- Impaired gas exchange
- Ineffective tissue perfusion
- Anxiety
NURSING INTERVENTION
- Monitor cardiovascular status for heart rate, rhythm, heart sounds, and pulse
deficit. - Monitor arterial blood gas for changes and decrease in oxygenation.
- Monitor pulse oximetry for oxygen saturation.
- Place patient in high Fowler’s position.
- Have the patient perform turning, coughing, and deep-breathing exercises to
enhance air movement. - Monitor respiration for rate, effort, use of accessory muscles, skin color, and
lung sounds.