Pulmonary Embolism, Transient Ischemic Attack & Stroke

Exam 2 - sem 3

Arteries

Thick muscular walls

High pressure

Carry oxygenated blood away from the left side of the heart

Veins

Thin walls

Low pressure

One-way valves

Carry deoxygenated blood to right side of the heart

Ventilation

Movement of air in and out of the alveoli

Inhale oxygen and exhale carbon dioxide

Perfusion

Flow of blood through pulmonary capillaries around the alveoli

V/Q ratio

Ratio of ventilation to perfusion (V/Q)

Indicated how well air reaching the alveoli is matched with blood flow to alveoli

Low ventilation and good perfusion = low V/Q ratio

Good ventilation and bad perfusion = high V/Q ratio

Pulmonary embolism

Obstruction of one or more branches of the pulmonary artery by a particular that originates elsewhere in body

There is ventilation, but decreased perfusion

Pulmonary embolism classifications and clinical manifestations

PE comes from the vein and goes as far as it can before it gets stuck

Dyspnea (decrease gas exchange)

Pleuritic chest pain (chest pain from lung blockage)

Tachypnea

Hypotension (decrease blood flow → decrease CO → decrease BP)

Tachycardia (compensation due to hypotension)

Anxiety/confusion (lack of O2 to brain)

Cough

Hemoptysis (coughing up blood)

Pulmonary embolism causes

Deep vein thrombosis

Tumor

Air

Fat

Amniotic fluid

Venous thromboembolism risk factors

Venous stasis (blood flow stand still):

Prolonged bedrest

Post op/immobility

Pregnancy

Burns

Bacterial endocarditis (bacterial infection of the heart)

Hypercoagulability (more desiring to make clot):

Cancer

Oral contraceptives

Dehydration/hemoconcentration

Vessel wall damage:

Trauma or surgery

IV drug use

Atherosclerosis (where is the plaque?)

V/Q ratio mismatch

Decreased blood flow to alveoli leads to impaired gas exchange

Increased ventilation and decrease perfusion ratio

Results: hypoxemia and local vasoconstriction

Increased pulmonary vascular resistance

Blood cannot move past obstruction

If right ventricle cannot overcome resistance - left ventricle preload and cardiac output decreases

Results: hypoxia and hypotension

Pulmonary hypertension

Continued increase in pulmonary vascular resistance

Result: backflow blood into right ventricle and right-sided heart failure

Pulmonary embolism diagnostic testing

EKG (rule out MI)

Chest x-ray (excess fluid build up)

CT scan (see if there are any clots in the lung)

VQ scan

Pulmonary angiography (look for clots - slow and invasive)

Lower extremity ultrasound (scan for DVT)

D-dimer <0.4 mcg/mL (clotting fact level)

Arterial blood gas (show arterial blood flow)

Thrombolytics

Tissue Plasminogen activator (tPA): alteplase

• dissolve clots that have formed

• hemodynamically compromised (don’t give to someone who was just recently in trauma, active bleed, recent surgery)

*break down any clot

*symptomatic/high risk clot

Anticoagulants

Heparin continuous drip

• prevent clot from increasing and decrease formation of new clots

• warfarin PO (INR 2.0-3.0)

  • take 3-5 days to get therapeutic

  • this is what we want to discharge them on

*heparin this the bridge

*symptomatic/high risk clot

Anticoagulants PO

apixaban, rivaroxaban

• inhibits conversion prothrombin to thrombin

• no lab monitoring

*asymptomatic/low risk clot

Embolectomy

Minimally invasive

• catheter directed thrombolysis- thrombolytic medication directly to clot

• pressured saline or rotating tool used to remove the clot

Invasive

• surgically removed

*symptomatic therapy is contraindicated

Inferior vena cave filter

Filter placed insider inferior vena cava between the DVT and the heart

• Wire thing that sits in the inferior vena cava, it will grab it and stop it from getting into the lung

• Can be removed once you can put back on the anticoagulants

• The filter can move  

*symptomatic therapy is contraindicated

Focused assessment, nursing diagnosis, interventions for PE

Focused assessment:

Respiratory (lungs, airway, ABC)

Vitals

NANDA labels

Ineffective airway clearance

Impaired gas exchange

Ineffective breathing pattern

Decrease cardiac output

Risk for bleeding

Interventions

High fowlers

Comfort them

Place O2 on them

Call rapid response

Bleeding/fall precautions

PE client education

Disease process & lifestyle modifications:

• Diet - Low saturated fat & limit foods high in vitamin K

  • high fats → plaque → surgery → increase risk for clots

  • vitamin K = contradiction for Coumadin

• Adequate fluid intake

• Smoking cessation

Medications

Bleeding precautions

Signs & symptoms of recurrent PE/DVT (have them know and why)

Stroke

Disruption of blood flow to a localized area of the brain

Caused by:

• a blockage of blood vessel

• bleeding in the brain

Neurological deficits vary according to the location and extent of the brain involved

Types of stroke

Ischemic (block) stroke - 87%

• Thrombotic - plaque build up and then clot can’t get through leading to decrease blood flow

• Embolic - clot from the heart that travels as far as it can before it becomes a problem

Hemorrhagic (bleed) stroke - 13%

Ischemic stroke

Thrombotic stroke

• blood clot develops on plaque in a cerebral artery

• blocks blood flow and lead to ischemia → infarct

• symptoms may progress over hours to days

Embolic stroke

• embolus circulates and lodges in cerebral artery

• blocks blood flow immediately and leads to ischemia → infarct

• neurologic defects or loss of consciousness to occur instantly

Treatment goal: restore blood flow to brain tissue ASAP

Hemorrhagic stroke

Occurs secondary to ruptured artery or aneurysm

• sudden severe headache - “thunderclap” headache (worst headache ever)

• neck stiffness and pain

Poor prognosis related to ischemia and increase intracranial pressure

Treatment goal: diagnose early and stop bleeding ASAP

Transient Ischemic Attack (TIA)

Brief interruption of cerebral blood flow causing transient neurologic dysfunction

Blood flow is restored before permanent damage occurs

Symptoms are present but completely resolve within minutes → 24 hours

Similar symptoms to an ischemic stroke - diagnostic testing is used to rule out stroke (don’t wait because it could be a stroke)

Seek immediate medical attention - TIA is a warning sign of an impending stroke

Stroke risk factors

Hypertension

Smoking

Hyperlipidemia

Diabetes

Atherosclerosis

Illicit drug use

Age

Atrial fibrillation

Hypercoagulability

Oral contraceptives

Cerebral aneurysm

What side if effected when a stroke happens?

Right sided stroke effects the left sided motor function

Left sided stroke effects the right sided motor function

Left side stroke symptoms

Responsible for language, math, and reasoning

Right side hemiplegia or hemiparesis (paralysis/weakness)

Right hemianopsia (loss of vision half of the eye)

Language deficits

• expressive aphasia

• receptive aphasia

• Agraphia (inability to write)

Depression

Right side stroke symptoms

Responsible for visual, spatial awareness & proprioception (body awareness)

Left hemiplegia or hemiparesis

Left hemianopsia 

Altered perception of deficits

Loss of depth perception

Poor impulse control

Unilateral neglect syndrome

Stroke complications

Safety:

Weakness and paralysis

Skin integrity:

Frequent repositioning

Elevate paralyzed or weak limbs to minimize edema

Nutrition:

Dysphagia and aspiration

Enteral nutrition and medication administration

NG vs. PEG

• NG = short term

• PEG = long term

Stroke diagnostic testing

Computed tomography (CT) scan:

• initial diagnostic test for stroke

• rapidly determines type of stroke and treatment

• performed on patients with contraindications to MRI

• find out where it is, fast result, and type

Magnetic resonance imaging (MRI):

• identifies edema, ischemia and necrosis of blood vessels

Carotid doppler ultrasound: evaluate if carotid occlusion is a suspected cause of stroke

Echocardiogram: evaluate if stoke if due cardioembolic source

EKG: evaluate if cardiac condition caused clot formation

Laboratory tests: CBC, platelet, electrolytes, BUN, creatine, cholesterol

Acute stoke treatment

Ischemic stroke:

Thrombolyics - tPA

• administer within 4.5 hours of symptom onset

• monitor for intracranila bleeding

• review inclusion and exclusion criteria

Invasive procedures - Thrombectomy

Hemorrhagic storke:

• assess airway, breathing, and circulation

• assess level of consciousness

• monitor BP and increased intracranial pressure

Invasive procedures - titanium clip and coil

Assessment and nursing diagnosis for acute stroke

Neurological assessment and vital signs - BP (baseline assessment)

Glasgow Coma Scale - assess LOC

Administer O2 support

Continuous cardiac monitoring

HOB >30 degrees (decrease intracranial pressure)

NANDA labels

• Ineffective tissue perfusion

• Impaired swallowing → risk for aspiration

• Sensory perceptual alterations → risk for injury

• Impaired physical mobility → risk for fall

• Impaired verbal communication

Anti-platelet

acetylsalicylic acid, clopidogrel

Indications:

• prevention of ischemic stroke or TIA

• primary prevention of acute myocardial infarction

Therapeutic actions: prevents platelets from clumping together by inhibiting factors that lead to clotting

Adverse effects:

• bleeding/bruising

• GI irritation

• tinnitus

Contraindications:

• bleeding disorders

• peptic ulcer disease

• thrombocytopenia

Nursing considerations: platelet level & bleeding risk

Client education:

• value in prevention medications

• monitor for bleeding

Anticoagulants - activated factor Xa inhibitor

apixaban, rivaroxaban

Indications:

• stroke prevention for clients with a-fib

• prevention and treatment of deep vein thrombosis and pulmonary embolism

Therapeutic actions: inactivates factor Xa, decrease thrombin and thrombus development

Adverse effects:

• bleeding/bruising

• hemorrhage/GI bleed

Contraindications: active bleeding

Nursing considerations:

• platelet level

• no antidote available

Client education:

• monitor for bruising and bleeding → bleeding precautions

• avoid use of OTC NSAIDS and aspirin

• no lab monitoring for therapautic level

Anticoagulants - Vitamin K inhibitors

warfarin

Indications:

• prevention of ischemic stroke, DVT, PE

• prevents cardioembolic events in a-fib

• reduce risk for recurrent transient ischemic attacks or MI

Therapeutic actions: decreases blood clotting by reducing the action of Vitamin K

Adverse effects:

• warfarin toxicity (INR goes too high, blood is too thin → give vitamin K)

• bleeding/bruising

• hemorrhage/GI bleed

Contraindications: 

• pregnancy- Category X 

• thrombocytopenia

• active bleeding

• liver disorders (liver clots)

Nursing Considerations:

• protime & INR- (therapeutic level 2-3)

• baseline CBC- PLT & HCT

• antidote - Vitamin K

Client Education:

• avoid foods high in Vitamin K

• therapeutic effect takes 3-5 days

• bleeding precautions

Anticoagulants - Heparin Sodium

Indications: 

Conditions requiring prompt anticoagulation therapy (Intravenous route):

• Evolving ischemic stroke, pulmonary embolism, massive deep vein thrombosis 

Therapeutic Actions: 

• Activates antithrombin, deactivates thrombin (ending clotting) & factor Xa

• Inhibits fibrin formation (never over clots that keep that clot there)

Adverse Effects:

• Bleeding/Bruising

• Hemorrhage/GI bleed 

Contraindications: 

• active bleeding or recent surgeries

• thrombocytopenia

Nursing Considerations:

• monitor aPTT every 4-6 hours until therapeutic then daily 

• labs- aPTT normal 25-35 seconds (therapeutic level 60-80 seconds)

• platelet & hematocrit 

• antidote - protamine sulfate

Client Education:

• monitor for bruising & bleeding → bleeding precautions

• avoid OTC NSAIDS & Aspirin

Thrombolytic Agents - Tissue Plasminogen activator (tPA)

alteplase

Indications:

• acute ishcemic stroke

• pulmonary embolism

• acute myocardial infarction

• restore patency to central IV catheters

Therapeutic Actions: dissolve clots that have already formed

Adverse Effects:

• internal & superficial bleeding

• cerebral hemorrhage

Contraindications:

• history of hemotthagic stroke

• recent surgery or trauma

• active or recent internal bleeding

Nursing Considerations:

• monitor labs- Protime, aPTT, Hgb, HCT

• monitor client for bleeding & bruising-limit blood draws & injections. HOLD PRESSURE!

• antidote -  aminocaproic acid (Amicar)

Client Education:

• observe for bleeding & bruising

• bleeding precautions