# A nurse is caring for a patient with suspected pulmonary embolism who has been receiving anticoagulation therapy for 48 hours. The patient suddenly develops severe dyspnea, chest pain, and hypotension. Which nursing intervention should be the priority?

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## 문제

A nurse is caring for a patient with suspected pulmonary embolism who has been receiving anticoagulation therapy for 48 hours. The patient suddenly develops severe dyspnea, chest pain, and hypotension. Which nursing intervention should be the priority?

## 보기

1. Increase the oxygen flow rate to 15 L/min via non-rebreather mask
2. Administer the prescribed PRN morphine for chest pain relief
3. Prepare for emergency thrombolytic therapy administration **✔ 정답**
4. Position the patient in high Fowler's position to improve breathing

**정답: 3**

## 해설

Preparing for thrombolytic therapy is the priority as acute deterioration with hypotension indicates massive PE requiring immediate clot dissolution. Other interventions address symptoms but do not treat the underlying cause.

## 심화 해설

Clinical Priority Setting for Massive Pulmonary Embolism

The scenario describes a patient with a known pulmonary embolism (PE) who, despite 48 hours of anticoagulation, acutely decompensates with severe dyspnea, chest pain, and hypotension. This clinical picture represents a transition to a high-risk or massive pulmonary embolism, defined by hemodynamic instability. In this context, the priority nursing intervention shifts from supportive care to preparing for definitive, life-saving reperfusion therapy.

While increasing oxygen, administering morphine, and repositioning are all appropriate nursing actions for a patient with PE, they are supportive measures that do not address the underlying, immediately life-threatening pathophysiology. The sudden onset of hypotension indicates right ventricular failure and obstructive shock due to a large clot burden in the pulmonary arteries. The physiological focus, as highlighted in the evolution of PE management, must be on rapidly reducing this obstruction to restore right ventricular function, pulmonary artery pressures, and cardiac output [1]. Administering morphine, a vasodilator, could further drop the patient's preload and blood pressure, potentially worsening the shock state. Therefore, the nurse's immediate priority is to anticipate and prepare for the administration of systemic thrombolytic therapy, which is the first-line definitive treatment for massive PE with shock. This involves gathering necessary equipment, ensuring IV access, drawing labs, and coordinating with the rapid response team or provider to deliver the fibrinolytic agent without delay.

The critical nature of this intervention is underscored by evidence showing that thrombolysis is a key strategy in managing cardiac arrest and peri-arrest states caused by PE. A systematic review and meta-analysis has evaluated the role of intra-arrest thrombolysis, demonstrating its potential benefit in cases where PE is the suspected etiology of hemodynamic collapse [4]. Although this patient has not yet arrested, the presence of shock places them on a trajectory toward cardiac arrest, making rapid preparation for thrombolysis the highest-priority action to prevent further deterioration. The historical perspective on PE management confirms a decades-long reliance on systemic thrombolysis as the foundational therapy for reversing this physiology before the advent of more advanced catheter-based interventions [1]. In a massive PE, the nurse's role is to facilitate the swift delivery of this clot-dissolving medication to reduce pulmonary vascular resistance and salvage cardiac function.References (research sources)

- [1]Evolution of advanced revascularization strategies for high-risk pulmonary embolism: a physiology-guided single-center experience.Research articleGreenspon LW, Whealon S, Bonn J, Caroline M, Gnall E. (2026) · DOI: 10.3389/fcvm.2026.1864812

- [4]Intra-arrest systemic thrombolytic therapy during cardiopulmonary resuscitation: a systematic review and meta-analysis of randomized controlled trials.Meta-analysis/systematic reviewDehghani S, Ohshimo S, Giustini D, Böttiger BW, Nikolaou N, Couper K, Scquizzato T, Grunau B. (2026) · DOI: 10.1016/j.resplu.2026.101291

## 임상 시나리오

Massive PE Decompensation ProtocolRecognizing Hemodynamic Collapse on Anticoagulation
A patient on anticoagulation who develops new hypotension, severe dyspnea, and chest pain is manifesting obstructive shock from a massive PE. The physiological priority is rapid clot reduction to restore right ventricular function and cardiac output.

The nurse's immediate action is to prepare for systemic thrombolysis. Gather emergency equipment, ensure IV access, and anticipate administering a fibrinolytic agent as the definitive therapy for hemodynamic instability.

CautionDo not administer morphine or other vasodilators in massive PE with shock; they can reduce preload and cause cardiovascular collapse. Supportive measures like oxygen and positioning are secondary to definitive reperfusion.

## 핵심 개념

- **Massive Pulmonary Embolism** — PE with sustained hypotension (SBP 15 min) or requiring inotropic support, indicating obstructive shock.
- **Thrombolytic Therapy** — Administration of fibrinolytic agents to dissolve pathologic clots, the first-line definitive treatment for massive PE with shock.
- **Obstructive Shock** — A state of shock caused by physical obstruction of the great vessels or heart, leading to reduced cardiac output.

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