Pulmonary Embolism Nursing Care Plan Template

Key Takeaways

Impaired gas exchange is the primary NANDA nursing diagnosis for pulmonary embolism, requiring oxygen therapy and ventilation monitoring

Wells Criteria assesses clinical PE probability before imaging; CTPA (CT pulmonary angiography) is the diagnostic gold standard

NIC interventions include oxygen therapy, anticoagulation monitoring, positioning for circulation, and SpO2 target maintenance above 95%

Pabau’s digital forms streamline nursing care plan documentation and integrate anticoagulation tracking into clinic workflows

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What is a Pulmonary Embolism Nursing Care Plan?

A pulmonary embolism nursing care plan template is a clinical document that systematically organizes assessment findings, evidence-based nursing diagnoses, targeted interventions, and measurable patient outcomes for individuals diagnosed with PE. Pulmonary embolism occurs when a blood clot (thrombus) lodges in pulmonary arteries, disrupting blood flow to lung tissue and compromising oxygenation. This life-threatening condition demands rapid nursing assessment and coordinated intervention aligned with physician-ordered anticoagulation therapy and hemodynamic support.

The nursing care plan serves as both a legal documentation framework and a clinical communication tool. Under nursing standards from the American Nurses Association (ANA), practitioners must document the nursing process-assessment, diagnosis, planning, implementation, and evaluation-for each patient encounter. For PE cases, this means capturing baseline oxygen saturation, respiratory rate, heart rate, anxiety level, and pain before therapy begins.

From a regulatory perspective, Joint Commission standards require VTE (venous thromboembolism) prevention and detection measures in all acute care settings. A structured nursing care plan demonstrates compliance with these standards and provides traceable evidence of clinical reasoning and patient-centered care planning.

How to Use the Pulmonary Embolism Nursing Care Plan Template

Using a pulmonary embolism nursing care plan template in your clinic workflow involves five operational steps:

1. Complete the Assessment Section: Document patient history, vital signs (respiratory rate, SpO2, blood pressure, heart rate), risk factors for PE (recent surgery, immobility, malignancy, anticoagulation status), and presenting symptoms (dyspnea, chest pain, syncope). Use the Wells Criteria scoring system to calculate clinical probability-a score above 4 indicates intermediate-to-high risk and warrants immediate imaging referral.
2. Select Applicable NANDA Diagnoses: Choose nursing diagnoses that match your assessment findings. Impaired gas exchange related to PE is nearly universal. Additional diagnoses typically include acute pain, anxiety, decreased cardiac output, and ineffective breathing pattern. Document the related factors (e.g., “related to ventilation-perfusion mismatch”) and signs/symptoms (e.g., “as evidenced by SpO2 <95%, tachypnea”).
3. Establish NOC Outcomes and Measurement Criteria: For each diagnosis, define expected outcomes using Nursing Outcomes Classification (NOC). Example: “Patient will maintain SpO2 ≥95% on prescribed oxygen therapy within 2 hours of admission” and “Patient will verbalize understanding of anticoagulation precautions by discharge.” Specify how you will measure success-pulse oximetry readings, patient teach-back, vital sign trends.
4. Implement NIC Interventions with Rationales: List Nursing Interventions Classification (NIC) actions tied to each outcome. For impaired gas exchange: administer prescribed oxygen, position upright or semi-Fowler, monitor arterial blood gases, encourage deep breathing and coughing, and assess lung sounds every 2-4 hours. Include rationales (e.g., “oxygen therapy increases hemoglobin saturation and reduces hypoxemia”). Document anticoagulation monitoring intervals per protocol-typically INR checks for warfarin or anti-Xa levels for LMWH.
5. Track Monitoring Parameters and Adjust Care: Use the template to record SpO2, respiratory rate, pain scores, bleeding precautions compliance (soft toothbrush, no sharp instruments), and signs of complications (hemoptysis, chest pain worsening, syncope). Compare daily findings against baseline to assess progress toward outcomes. If SpO2 remains <90% or respiratory distress increases, escalate to physician for oxygen adjustment or ICU consideration.

Integrating automated clinical documentation tools into your care plan workflow reduces time spent on manual charting and ensures consistent adherence to evidence-based protocols across shifts and team members.

Who is the Pulmonary Embolism Nursing Care Plan Helpful For?

This template is essential for nursing staff and clinical teams in multiple settings:

• Hospital acute care and ICU nurses managing newly diagnosed or massive PE requiring mechanical ventilation and vasopressor support. PE in ICU carries higher mortality risk and demands minute-by-minute parameter monitoring.
• Emergency department nurses
• Med-surg floor nurses
• Nursing students and faculty
• Clinical educators
• Occupational health and flight nurses

Benefits of Using a Pulmonary Embolism Nursing Care Plan Template

A structured care plan template accelerates clinical decision-making and ensures comprehensive patient safety. It eliminates guesswork by providing a standardized framework aligned with NANDA, NIC, and NOC taxonomies recognized across healthcare systems. When nursing staff follow the same template, handoffs between shifts become safer-incoming nurses instantly understand the patient’s baseline, current goals, and intervention responses.

Legally, documentation using a care plan template creates a defensible clinical record. If anticoagulation complications arise or patient deterioration occurs, the template demonstrates that nursing performed systematic assessment, identified appropriate diagnoses, and implemented evidence-based interventions according to standards. This is especially critical in PE cases, where mortality risk is substantial and clinical judgment under pressure is inevitable.

From a team coordination perspective, a shared template reduces communication breakdown. Physicians, respiratory therapists, and clinical pharmacists can quickly review the care plan and understand the nursing assessment and current intervention effectiveness. This accelerates collaborative decisions around oxygen weaning, anticoagulation escalation, or ICU transfer.

Nursing Diagnoses and Assessment for Pulmonary Embolism

The assessment phase of a pulmonary embolism nursing care plan establishes the clinical foundation. Begin by measuring baseline vital signs: respiratory rate (normal 12-20 breaths/min, PE typically causes tachypnea >20), SpO2 (normal >95% on room air), heart rate (often elevated due to hypoxemia and anxiety), and blood pressure. Obtain a focused history: recent surgery, prolonged immobility, malignancy, previous VTE, hormone use, and current symptoms onset and duration.

Apply evidence-based clinical probability assessment. The Wells Criteria score includes risk factors (immobility, surgery, malignancy, heart rate >100, clinical signs of DVT) and symptom severity. A score >4 indicates high probability and warrants immediate CTPA or V/Q scan. Scores 2-4 are intermediate probability and may include D-dimer testing (negative D-dimer rules out PE in low-probability cases).

From assessment findings, the primary NANDA diagnosis is Impaired Gas Exchange related to ventilation-perfusion mismatch caused by pulmonary artery occlusion, as evidenced by decreased SpO2, tachypnea, and dyspnea. Secondary diagnoses commonly include Acute Pain related to pleurisy or anxiety, Anxiety related to perceived life threat, and Decreased Cardiac Output related to right ventricular strain from elevated pulmonary vascular resistance.

Nursing Interventions and Evidence-Based Rationales

Nursing interventions for impaired gas exchange prioritize oxygen delivery and respiratory support. Administer supplemental oxygen via prescribed method (nasal cannula, non-rebreather, or mechanical ventilation) to target SpO2 >95%; rationale is that hypoxemia worsens tissue perfusion and increases mortality risk. Monitor arterial blood gases or pulse oximetry at least every 4 hours until stable, then per hospital protocol; this detects worsening oxygenation or ventilation requiring escalation to ICU or intubation.

Position the patient upright or semi-Fowler (30-45 degrees) to maximize diaphragmatic excursion and reduce work of breathing. Encourage deep breathing and coughing every 2 hours; this mobilizes secretions and recruits atelectatic alveoli, improving gas exchange. Suction airway as needed if cough is ineffective.

For anticoagulation monitoring, check international normalized ratio (INR) if warfarin is ordered (target range typically 2-3 for PE); monitor activated partial thromboplastin time (aPTT) if heparin or low-molecular-weight heparin (LMWH) is prescribed. Document bleeding precautions: use soft toothbrush, avoid intramuscular injections, monitor for hematuria or hemoptysis, and educate the patient to avoid NSAIDs and sharp instruments. Rationale: anticoagulation prevents thrombus propagation but increases bleeding risk.

Assess pain using a standardized scale and administer analgesia per order; rationale is that pain increases anxiety and oxygen consumption, worsening hypoxemia. Teach relaxation techniques and provide reassurance to reduce anxiety-driven tachypnea.

Patient Education and Discharge Planning

Before discharge, educate the patient on anticoagulation adherence, bleeding precautions, and when to seek emergency care. Provide written materials listing signs of recurrent PE (sudden dyspnea, chest pain, syncope) and DVT (calf swelling, warmth, pain) that warrant immediate hospital return. Discuss activity restrictions-gradual return to normal activity as tolerated, avoiding prolonged immobility. Arrange follow-up anticoagulation clinic appointments and physician check-ups within 1-2 weeks.

Coordinate with the pharmacy to ensure the patient understands medication timing, dietary interactions (warfarin and vitamin K-rich foods), and any follow-up lab monitoring needed. If the patient is discharged on enoxaparin or another LMWH, teach subcutaneous injection technique or arrange home health nursing visits. Document all education in the care plan and use clinic management systems to schedule automated recall reminders for follow-up appointments and lab orders.

Monitoring and Expected Outcomes for Pulmonary Embolism Nursing Care

Expected outcomes for a patient with pulmonary embolism include: (1) SpO2 maintained ≥95% on prescribed oxygen therapy within 2 hours; (2) respiratory rate 12-20 breaths/min and dyspnea decreased to mild or absent within 24 hours; (3) pain controlled to ≤4/10 on a pain scale; (4) patient demonstrates understanding of anticoagulation precautions and signs of bleeding by discharge; (5) no signs of bleeding complications (hematuria, hemoptysis, major bruising) during hospitalization; and (6) patient ambulates safely and independently or with minimal assistance by discharge.

Monitor progress daily by comparing current vital signs and SpO2 against baseline and against outcome targets. If outcomes are not met within the expected timeframe, reassess the diagnosis, consider additional interventions (e.g., ICU transfer, intubation, thrombolytic therapy for massive PE), or involve the interdisciplinary team in care plan revision.

Ready to streamline nursing care plan documentation across your team? Book a demo to see how Pabau’s digital forms and clinical tracking reduce charting time and ensure consistent, evidence-based care for complex conditions like pulmonary embolism.

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