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Difficulty: Very hardPhysiological Adaptation

A nurse is caring for a client who was admitted with a massive pulmonary embolism and is receiving a continuous intravenous heparin infusion. The client is now difficult to arouse. Current assessment findings include: blood pressure 82/48 mm Hg, heart rate 134 beats/minute and thready, and respiratory rate 28/minute. The client's skin is cold and diaphoretic. The central venous pressure (CVP) reading is 15 mm Hg (normal: 2 to 8 mm Hg), and urine output was 10 mL over the last hour. Which of the following prescribed interventions should the nurse prioritize?

  1. A
    Administering a rapid 500 mL intravenous bolus of 0.9% sodium chloride
  2. B
    Administering intravenous protamine sulfate to reverse the anticoagulation
  3. Initiating a continuous intravenous infusion of norepinephrineAnswer
  4. D
    Placing the client in the modified Trendelenburg position to increase venous return

Answer

Initiating a continuous intravenous infusion of norepinephrine is the priority intervention to support systemic blood pressure in this client experiencing obstructive shock.
This client is demonstrating definitive signs of obstructive shock due to a massive pulmonary embolism, which causes acute right ventricular failure. The significantly elevated CVP (15 mm Hg) indicates that the right ventricle is already overloaded and failing to pump blood forward through the pulmonary circulation. In this critical situation, administering a vasopressor like norepinephrine is the priority to increase systemic vascular resistance. This intervention maintains the systemic blood pressure necessary to perfuse the right ventricular myocardium and prevent total cardiovascular collapse until definitive therapies (like embolectomy or thrombolytics) can be administered.

Step-by-Step Solution

1
Analyze the client's vital signs and physical assessment findings.
The client exhibits profound hypotension, severe tachycardia, altered mental status, oliguria, and cold, diaphoretic skin.
These findings indicate a critical state of shock with severe systemic tissue hypoperfusion.
2
Interpret the central venous pressure (CVP) reading in the context of the client's massive pulmonary embolism diagnosis.
The CVP is significantly elevated at 15 mm Hg (normal is 2 to 8 mm Hg).
An elevated CVP combined with systemic hypotension in a client with a pulmonary embolism indicates acute right ventricular failure and obstructive shock, rather than hypovolemic shock.
3
Determine the priority hemodynamic intervention based on the specific type of shock identified.
Select an intervention that supports systemic blood pressure without causing further right ventricular fluid overload, such as a vasopressor like norepinephrine.
Vasopressors increase systemic vascular resistance, thereby maintaining the necessary blood pressure to perfuse the right ventricular myocardium and prevent cardiovascular collapse without the detrimental effects of fluid volume loading on a failing right heart.

Key Concept

Management of obstructive shock and right ventricular failure secondary to a massive pulmonary embolism requires vasopressor support rather than fluid resuscitation.
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Physiological Adaptation

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