# A nurse is caring for a 70-year-old postoperative patient with a history of COPD who underwent knee replacement surgery 2 days ago and suddenly develops acute onset of dyspnea, chest pain, anxiety, with vital signs: BP 90/60 mmHg, HR 120 bpm, RR 28/min, O2 sat 88% on room air. Which nursing action should be the nurse's FIRST priority?

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## 문제

A nurse is caring for a 70-year-old postoperative patient with a history of COPD who underwent knee replacement surgery 2 days ago and suddenly develops acute onset of dyspnea, chest pain, anxiety, with vital signs: BP 90/60 mmHg, HR 120 bpm, RR 28/min, O2 sat 88% on room air. Which nursing action should be the nurse's FIRST priority?

## 보기

1. Administer prescribed anticoagulant medication immediately
2. Position the patient in high Fowler's position and administer oxygen **✔ 정답**
3. Prepare the patient for immediate CT pulmonary angiogram
4. Notify the physician and obtain arterial blood gas analysis for diagnostic evaluation

**정답: 2**

## 해설

The priority is to address immediate hypoxemia by positioning in high Fowler's and administering oxygen to support oxygenation. Other actions like anticoagulants or diagnostic tests are important but secondary to stabilizing the patient's breathing.

## 심화 해설

Clinical Reasoning and Priority Setting

This scenario describes a classic presentation of an acute pulmonary embolism (PE). The patient has multiple risk factors: advanced age (70 years), a history of COPD, and recent major orthopedic surgery (knee replacement 2 days ago). Joint arthroplasty is a well-documented high-risk procedure for venous thromboembolism (VTE), with the postoperative period representing a critical window for thrombus formation and migration [1,4]. The sudden onset of dyspnea, chest pain, and anxiety, combined with hypotension (BP 90/60 mmHg), tachycardia (HR 120 bpm), tachypnea (RR 28/min), and significant hypoxemia (O2 sat 88% on room air) signals a life-threatening cardiopulmonary event.

When applying the nursing process and Maslow's hierarchy of needs, airway, breathing, and circulation (ABCs) always take precedence. The patient’s oxygen saturation is critically low, indicating severe impairment in gas exchange. The best evidence for perioperative nursing management of hypoxemia emphasizes that the immediate priority is to optimize oxygenation and ventilation to prevent further decompensation [2]. Positioning the patient in high Fowler's position reduces the work of breathing by maximizing chest expansion and lung capacity, while supplemental oxygen directly addresses the hypoxemia. These are independent nursing interventions that can be initiated without delay and are foundational to stabilizing the patient before diagnostic or advanced therapeutic steps are taken.

While administering anticoagulants, preparing for a CT pulmonary angiogram, and notifying the physician are all necessary components of care for a suspected PE, they are not the *first* priority action by the nurse at the bedside. The nurse must first manage the immediate threat to oxygenation. A patient with an oxygen saturation of 88% is in respiratory distress and at risk for rapid deterioration, including cardiac arrest. Initiating oxygen therapy and proper positioning directly supports the patient's physiological stability, creating a safer window for subsequent diagnostic procedures like a CT scan or laboratory tests such as an arterial blood gas analysis [2]. This approach aligns with the evidence that nursing interventions for perioperative complications must be timed correctly, focusing on the most acute physiological derangement first [4].

References (research sources)

- [2]Best Evidence Summary of Nursing Management for Perioperative Patients with Hypoxemia.Research articleLi G, Xiang J, Li J, Peng S, Cui X, Liu S. (2026) · DOI: 10.2147/jmdh.s598436

- [4]Dynamic Evolution Characteristics and Nursing Intervention Windows of Perioperative Deep Vein Thrombosis in Patients with Lower Extremity Traumatic Fractures: A Prospective Cohort Study.Research articleHu X, Wang Y, Li Y, Cao H, He M, Li Y. (2026) · DOI: 10.2147/tcrm.s598379

## 임상 시나리오

Clinical Practice Guide: Immediate Response to Suspected Acute Pulmonary Embolism

This guide outlines the immediate nursing priorities for a postoperative patient presenting with sudden dyspnea, chest pain, and hemodynamic instability suggestive of an acute pulmonary embolism.

1. Immediate Nursing Actions (First 5 Minutes)

- **Positioning:** Place the patient in high Fowler's position (head of bed at 90 degrees) to maximize chest expansion and reduce the work of breathing.

- **Oxygen Therapy:** Administer high-flow oxygen via a non-rebreather mask at 10-15 L/min to target SpO2 above 92%. Titrate based on continuous pulse oximetry.

- **Rapid Assessment:** Simultaneously assess airway patency, breathing effort, and circulatory status (ABCs). Monitor vital signs every 5-15 minutes.

- **Stay with Patient:** Do not leave the patient unattended. Provide reassurance to reduce anxiety and oxygen consumption.

2. Escalation and Diagnostic Preparation

- **Notify Provider:** Once immediate ABCs are addressed, urgently notify the physician or rapid response team, providing a concise SBAR report including vital signs, oxygen saturation, and mental status.

- **Prepare for Diagnostics:** Anticipate orders for a STAT CT pulmonary angiogram, arterial blood gas analysis, and baseline coagulation studies. Ensure intravenous access is patent.

- **Hemodynamic Support:** If hypotension persists (MAP less than 65 mmHg), prepare for cautious fluid resuscitation as ordered, avoiding volume overload that could worsen right ventricular strain.

3. Anticoagulation and Ongoing Monitoring

- **Anticoagulation:** Administer prescribed anticoagulants (e.g., unfractionated heparin bolus and infusion) promptly after diagnostic confirmation, unless contraindicated. Do not delay oxygenation for medication administration.

- **Monitoring:** Continuously monitor cardiac rhythm for signs of right ventricular strain. Assess for signs of bleeding, especially if thrombolytic therapy is later considered.

- **Documentation:** Document the time of symptom onset, interventions performed, and the patient's response in the electronic health record.

## 핵심 개념

- **Pulmonary Embolism (PE)** — A blockage in one of the pulmonary arteries in the lungs, commonly caused by blood clots that travel from the legs or other parts of the body, leading to impaired gas exchange and hemodynamic instability.
- **High Fowler's Position** — A sitting position where the head of the bed is elevated to 90 degrees, which maximizes chest expansion, reduces the work of breathing, and improves lung capacity in patients with respiratory distress.
- **ABC Priority Framework** — A nursing prioritization model based on Airway, Breathing, and Circulation, guiding immediate interventions to address the most life-threatening physiological needs first.
- **Hypoxemia** — An abnormally low concentration of oxygen in the arterial blood, indicated by low oxygen saturation levels, requiring prompt oxygen therapy to prevent tissue hypoxia.
- **Venous Thromboembolism (VTE)** — A condition encompassing deep vein thrombosis and pulmonary embolism, with major orthopedic surgeries like knee replacement being a significant risk factor due to venous stasis and endothelial injury.

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