N443 Pulmonary Embolism

Pulmonary Embolism

Blockage of one or more pulmonary arteries by:

- thrombus (blood clot)

- fat

- air embolism

- tumor tissue

Originates from venous system --> obstructs blood vessel & impairs infusion of alveoli --> ischemia/ necrosis

Primary Origin: deep vein thrombosis of the:

- femoral or iliac vein

right side of heart (blood pooling d/t A Fib)

pelvic veins (surgery or child birth)

Types of Emboli

Fat- fracture of the long bone

Air- improper IV administration

Bacterial vegetation on heart valves that break off

Amniotic fluid- breaks free when pregnant

Cancer- break off from site

Risk factors for pulmonary embolism

-immobility

- surgery within three months (esp pelvic or LE)

- hx of embolism

- cancer

- obesity

- oral contraceptives

- hormone therapy

- smoking

- prolonged travel

- pregnancy

- clotting disorders

Symptoms of pulmonary embolism

Small: little to no symptoms (can grow larger)

Large:

- dyspnea

- hypoxemia

- tachypnea & tachycardia

- cough

- chest pain (worse w inspiration)

- hemoptysis (blood in sputum)

- crackles and wheezing

- fever

- syncope (lack of O2)

- HYPERtension

Massive:

- HYPOtension

- mental status change

- impending doom

- cardiopulmonary arrest

Complications of pulmonary embolism

Pulmonary infarction

Pulmonary effusions

Saddle embolism

Pulmonary infarction

Occlusion of large vessel --> insufficient collateral blood flow --> necrosis --> infection

- higher risk if pre-existing lung disease

Infection detected by

- high WBCs

- left shift neutrophils (high)

- high lactate

- severe fever

Pulmonary Effusion

Fluid in pleural space due to lack of breaths --> manifestations of R side heart failure

- More strain due to back up of blood on R side

Intervention: incentive spirometer

Saddle embolism

Large thrombus lodged in arterial bifurcation --> hemodynamic collapse & death

- cardiac arrest

- cardiogenic shock

- respiratory failure

- increased length of hospitalization

Solutions:

- heparin prevents more --> not effective

- TPA breaks clots --> not enough

- NEED surgery

Diagnosing a PE

- ABE: not specific, helpful for 2nd acid base imbalance (pH, paO2, CO2).

- CXR: can show obstruction, not specific

- ECR strain or new ischemia 2nd to PE

- Troponin: heart strain

- BNP heart strain

- D-diner fibrin fragments (not specific- rules out if neg)

Definitive Dx

- CT scan: shows where, how big, etc

V/Q (ventilation, perfusion) scan for people who cannot have contrast (kidney disease, allergy, obesity)

Management of PE

Goals:

- support cardio/ pulmonary function

- ensure blood flow

- prevent further growth of extension of emboli (via heparin, TPA)

- prevent future occurrences (heparin, mobility, etc)

Assessments: ABGs, vitals, trending VS

Interventions: TEDs, mobility, spirometer, blood thinner administration

Medications:

- immediate anticoagulation via low molecular weight heparin (lovenox) or regular heparin

- may require TPA or alteplase

----> bridge w warfarin later

----> or use apixaban (DOAC-Xa agonist or direct thrombin inhibitor

Surgical:

- embolectomy

IVC filter: mesh to prevent embolism in lungs (builds up but easier to manage).

Monitoring PE

- Monitor Anti-Xa to get therapeutic range (0.3-0.7)

- Monitor for signs of bleeding & HIT= low platelets & microemboli

--> give Vitamin K & stop drug use

-Change to DOACs (apixaban)

--> do not require monitoring, but not reversal agents

-Change to warfarin

--> requires monitoring, has reversal agent

The nurse is reviewing the medical record of a client with pulmonary embolism. What priority does the nurse set after reviewing the blood gas result?

pH 7.46, PaCO2 30 mmHg, HCO3 26, PaO2 62

a. have client breathe rapidly & deeply

b. apply oxygen

c. administer sodium bicarbonate

d. collaborate with provider to increase pH

b. apply oxygen

A client has been admitted with a diagnosis of pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the care plan?

a. teach the client to avoid using dental floss

b. monitor the platelet count daily

c. ensure adequate staffing for unit

d. notify radiology of impending scan

b. monitor the platelet count --> if low, stop heparin

The nurse is developing a plan of care for client with pulmonary embolism. Which client problem does the nurse establish as the priority?

a. Inadequate nutrition related to food-drug interactions with anticoagulant therapy

b. Risk for infection related to leukocytosis

c. Hypoxemia related to ventilation-perfusion mismatch

d. insufficient knowledge related to cause of PE

c. Hypoxemia related to ventilation-perfusion mismatch

The nurse is developing a plan of care for a client with postoperative complication of pulmonary embolism. The nurse determines the patient has adequate perfusion by which data? Select all.

a. Pulse oximetry of 95%

b. Patient's subjective desire to go home

c. arterial blood gas pH of 7.28 (therapeutic 7.35-7.45)

d. absence of pallor or cyanosis

e. mental status of patient's baseline

a. pulse ox of 95%

d. absence of pallor or cyanosis

e. mental status of patient's baseline