Pulmonary Embolism

Question 1

Pulmonary Embolism (PE)

Answer 1

• Obstruction of the pulmonary artery or one of its branches by a thrombus that originates somewhere in the venous system or in the right side of the heart
• Inflammatory process obstructs area, results in diminished or absent blood flow
• Bronchioles constrict, further increasing pulmonary vascular resistance, pulmonary arterial pressure, and right ventricular workload
• Ventilation – perfusion imbalance, right ventricular failure

Question 2

PE Risk Factors
IS-STEPH-CTS

Answer 2

• Immobility, venous stasis
• Smoking
• Surgery
• Trauma
• Estrogen therapy
• Pregnancy
• Hypercoagulability
• Cancer ( lung, prostate)
• Trousseau’s syndrome
• Stroke

Question 3

PE Pathophysiology

Answer 3

• Most common acute pulmonary disease among hospitalized patients
• A collection of particulate (solids, liquids, air)
• Blood clot is most frequent
• Obstruct pulmonary blood flow
• Reduced oxygenation of the whole body
• Pulmonary tissue hypoxia
• Potential death (may occur in as little as 1 hr)
• Embolus obstructs the pulmonary artery
• The embolus creates “dead space”. DeO2 blood is shunted back to arterial circulation.
• Platelets behind embolus cause vasoconstriction. • RHF can result.
• Most common cause is due to deep vein thrombosis (DVT)

Question 4

PE Clinical Manifestations
DCAF-THC-SCHD

Answer 4

• Dyspnea – sudden onset (use of accessory muscles/sternal retraction)
• Chest pain (sudden onset, especially inspiration, pleural, may mimic MI or angina)
• Apprehension, restless, Anxiety,
• Feeling of impending doom
• Tachycardia
• Hemoptysis
• Cough (Dry unless pulmonary infarction)
• Massive-Distended neck veins, syncope, cyanosis, hypotension

Question 5

Assess for signs of PE
CDDFPPTTSS

Answer 5

• Crackles due to atelectasis
• Decreased arterial oxygen sat (Sao2)
• Diaphoresis
• Fever, low-grade
• Pleural friction rub
• Petechial over chest and axillae
• Tachypnea
• Tachycardia
• S3 or S4 heart sound
• Shock and death (d/t decreased CO)

Question 6

PE Diagnostic Workup & Findings
PACE- C-VED

Answer 6

• Pulse oximetry
• Arterial blood gas (ABG)
• Chest x-ray
• ECG
• CT pulmonary angiogram
• V/Q scan
• Echocardiogram
• D-Dimer assay

Question 7

PE Health Promotion and Prevention

Answer 7

• Prevent venous stasis
• Passive ROM
• Early ambulation
• Anti-embolism or pneumatic compression stockings
• Avoid tight clothing
• Prevent pressure on popliteal space (no crossing legs)
• ↑ LE to improve venous return
• No leg massage
• Avoid Valsalva maneuver
• Smoking cessation

Question 8

Medical Management of PE

Answer 8

• Emergency – stabilize cardiopulmonary system
• Treatment includes a variety of measures to improve respiratory and vascular status, anticoagulation therapy, thrombolytic therapy and surgical intervention
  — Provide O2; may need to be intubated for mechanical ventilator support
  — IV line established for fluids and possible vasopressor
  — ABG and pulse oximetry
  — Blood draw for electrolytes, CBC, coagulation studies
  — Small sedative to relieve anxiety

Question 9

PE Anticoagulation Therapy

Answer 9

• Suspected PE- immediate anticoagulation therapy for up to 10 days. Heparin or Lovenox for the hemodynamically stable patient
• Thrombolytic therapy is used for the hemodynamically unstable patient. Recombinant tissue plasminogen activator – Activase
• Long term treatment options includes Warfarin and Lovenox until INR is within therapeutic range.
• New oral anticoagulants (NOAC) – rivaroxaban (Xarelto), apixaban (Eliquis) are more expensive but don’t require regular monitoring

Question 10

PE Surgical and Nursing Management

Answer 10

• Massive PE – a surgical embolectomy may be performed but it is rare.
• Inferior Vena Cava (IVC) filter may be placed for patient with recurrent DVT/PE or contraindication to anticoagulation therapy.
• Prevent Thrombus formation – Encourage early ambulation, SCD’s, remove central lines,
• Assess for potential PE – Health history, family history and medications, pain or discomfort in lower extremities
• Monitor Thrombolytic Therapy – Assess vital signs, labs, only essential arterial & venous punctures

Question 11

Nursing Management post PE

Answer 11

• Manage pain
• Manage Oxygen Therapy
• Relieve Anxiety
• Monitor for complications
• Provide post op care
• Provide education