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NSG 478 > Pulmonary embolism > Flashcards

Pulmonary embolism Flashcards

1
Q

Overview of PE

A
  • Obstruction of the pulmonary artery or one of its branches by a thrombus that originate in the venous system or right side of the heart
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2
Q

Other things that can cause a PE other than a blood clot

A
  • Air Embolism
  • Fat
  • Amniotic fluid
  • Septic emboli (from an infection)
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3
Q

Incidence of VTE

Probably dont need to know

A
  • 1-2 per 1000 population per year
  • Chronically underdiagnosed
  • 10-20% med surg patients
  • 30% of people with VTE will develop post thrombotic complications (Stroke/PE)
  • Complications occur post discharge due to short hospital stays
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4
Q

Why are VTE underdiagnosed

A
  • Silent and asymptomatic, often diagnosis of exclusion with subtle s+s
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5
Q

VTE patho

A
  • Thrombus obstructs PA or its branches
  • With it obstructed, alveolar become dead space with little to no blood flow
  • Impaired or no gas exchange
  • bronchoconstriction
  • Increase in pulmonary vascular resistance
  • V/Q mismatch
  • Decreased CO
  • Decreased BP
  • Shock/Death
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6
Q

V/Q

A
  • V= Ventilation
  • Q= Quality of perfusion
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7
Q

Virchow triad

A
  • Endothelial damage
  • Venous stasis
  • Altered coagulation

Processes that lead to clot formation

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8
Q

Virchow’s triad: Endothelial dmg

A
  • Central venous cath
  • Dialysis access
  • Local vein dmg
  • Pacing wires
  • Surgery
  • Trauma
    (Introduction of something foreign to the vein)
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9
Q

Virchow’s triad: Venous stasis

A
  • Age 65+
  • Bed rest or immobilization
  • HF
  • Varicose veins
  • Obesity
  • Spinal cord injury
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10
Q

Virchow’s triad: Altered coagulation

A
  • Chemo in cancer
  • Polycythemia (Blood too thicc)
  • Pregnancy
  • Protein deficiency
  • Septicemia
  • Oral contraceptives
  • Smoking
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11
Q

What protein deficiencies cause altered coagulation

A

Protein C and S

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12
Q

S+S PE

A

Often there is few S+S, or it can mimic a cardiopulmonary disorder (PNA, HF)
* Dyspnea
* CP, pleuritic pain
* Substernal angina
* Hypoxia with decreased PaCO2
* Anxiety and apprehension
* Fever (Low from inflammation)
* Tachycardia
* Cough hemoptysis
* Diaphoresis
* Tachypnea
* Syncope (No O2 to brain)

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13
Q

Pleuritic pain

A

Worse upon inspiration

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14
Q

Normal PaCO2

A

35-45 mmHg

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15
Q

Normal PaO2

A

80-100 mmHg

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16
Q

S+S PE: Obstruction of Pulmonary artery

A
  • Dyspnea
  • Sudden substernal pain
  • Rapid and weak pulse
  • Shock
  • Syncope
  • Sudden death
17
Q

What should be done first for a pt with risk for a PE complains of CP and SOB

  1. Take the patient’s vital signs
  2. Position the patient for optimal ventilation
  3. Call the physician
  4. Connect the patient to a cardiac monitor
  5. Apply oxygen
A
  1. Position the patient for optimal ventilation
18
Q

How soon can death occur with PE

A

Within 1 Hour of symptom onset

19
Q

Main concern with Heparin

A

Bleeding

20
Q

What are used to rule out other causes of S+S of PE

A
  • CXR, ECG, ABG
21
Q

What is primary test to diagnose PE

A

CT is number one
* Pulmonary angiography, provides direct visualization with contrast (More invasive like cardiac cath)

Both these use nephrotoxic contrast/ allergy

22
Q

V/Q scan or V/Q SPECT

A
  • Vent and perfusion, single emission computed tomography
  • Nuclear medicine
  • Uses radioisotopes IV and inhaled
  • Used in renal failure or contrast allergy
  • Caution in preg due to risk of radiation, needs smaller does
23
Q

D dimer

A

Non specific test that says there is a clot, just not where

24
Q

Test done for Heparin

A

Ptt/Pt
drawn every 6 hours till therapeutic

Anti Xa done for low molecular weight heparin

25
Q

Test done for warfarin/ coumadin

A

PT/INR

26
Q

Antidote for coumadin

A

Vitamin K

27
Q

Anticoagulation therapy

A
  • IV heparin during the acute period
  • Low-molecular weight heparin used after
  • Warfarin (Coumadin) used at home (3-6 mo)
28
Q

LMWH examples

A
  • fondaparinux (arixtra)
  • enoxaparin sodium (lovenox)
  • Unfractionated heparin in renal impairment
29
Q

Collaborative care of PE mgmt

A
  • O2 admin
  • IV access
  • Treat hypotension (Vasopressors)
  • Pulse Ox, ABG, VS
  • ECG
  • Labs (Electrolytes,CBC, colagulation)
  • Foley cath
  • Fibrinolytics (TPA) or heparin
  • IV morphine or sedatives
  • Limited activity in the acute phase (BR, semi-fowlers), especially if anticoagulated can cause a stroke
  • Gradual early ambulation post acute phase
30
Q

Thrombolytic (Fibrinolytic) Therapy

A
  • TPA
  • Used to treat massive PE that affects significant area of blood flow to the lungs and causes hemodynamic instability
  • Tissue plasminogen activator, (TPA), dissolves the clot
  • Bleeding is a huge side effect
31
Q

Contraindications for TPA

A
  • CVA in the past 2 mo
  • Active bleeding
  • Surgery within 10 days
  • Recent labor and delivery
  • Trauma
  • Severe hypertension (Not actually they just treat the hypertension)
32
Q

Alternative treatment for PE involves use of subcutaneous low molecular weight heparin (LMWH) (enoxaparin). In patients receiving low molecular weight heparin, which of the following lab values is monitored?
1. Prothrombin time (PT)
2. Platelet count
3. Activated partial thromboplastin time (APTT)
4. International normalized ratio (INR)

A
  1. Platelet count, LMWH plt count is a huge concern
33
Q

IVC filter

A
  • Vena cava filter that is used in some pt who are at risk for future emboli
  • Vena cava filter is placed percutaneously in the inferior vena cava, acting to block clots traveling up from distal extremities before they reach the lungs
  • Used in old people who shouldn’t be on anticoagulants
34
Q

Surgical mgmt of PE

A

Suction embolectomy, surgical removal of emboli

35
Q

Nursing mgmt of VTE

A
  • Identify High risk pts (Everyone is high risk in the hospital)
  • Preventive measures
  • Active and passive ROM to avoid venous stasis
  • Early ambulation
  • No leg crossing
  • Anti embolic stockings
  • Remove unnecessary IV’s, central lines
36
Q

Prevention of VTE

A
  • Early ambulation
  • SCD
  • Prophylactic anticoagulants (Lovenox), heparin before surgery because of short half life
37
Q

Nursing mgmt of acute VTE/PE

A
  • Assess extremities for warmth redness, inflammation, pain
  • Pain meds
  • Semi-fowler’s position, T+P
  • Monitor pulse ox for hypoxemia
  • Continuous O2 when warranted
  • Deep breathing and incentive spirometer
38
Q

Patient teaching: Anticoagulants/ Lab work

A
  • Side effects are bleeding and bruising
  • Avoid razors
  • Soft bristle toothbrush
  • No ASA while on coumadin
  • Report dark tarry stools
  • Carry a card stating anticoagulant therapy
39
Q

Patient teaching: Strategies to prevent DVT and PE

A
  • Compression stockings
  • Avoid periods of long sitting or standing (Travel)
  • Push fluids
  • Know S+S recurrence

NSG 478 (23 decks)

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