Pulmonary Embolism

obstruction of pulmonary vasculature by embolus

pulmonary embolism

embolus object can be…

solid, liquid, or gas

what is the most common cause of a pulmonary embolism?

dvt

what happens when there is impaired blood flow?

pulmonary tissue hypoxia

besides solid, liquid, or gas, what other types of objects can there be?

fat
air
septic (secondary to bacterial invasion of a thrombus)

risk factors for pulmonary embolism:

D__, I____, R___ S____
P___, O____, O__ C____, E___ U___
C____ D____, T___ U___
C____ V____ C____
H____ F____, C_____ A-___, S___ C____
L____ B____ F____, C____, T____, S_____

DVT, immobility, recent surgery
pregnancy, obesity, oral contraceptives, estrogen use
clotting disorders, tobacco use
central venous catheters
heart failure, chronic a-fib, sickle cell
long bone fracture, cancer, trauma, septicemia

Respiratory findings:
P____
P___ F____ R____
D____
T____
C____
H____
C____

pleurisy
pleural friction rub
dyspnea
tachypnea
cough
hemoptysis
crackles

Cardiac Findings:
C___ P___
T____
H____
M____ in S__ and S__
S____

chest pain
tachycardia
hypotension
murmur in s3 and s4
syncope

Other findings:
A___
D___
P___ E___
L___-G___ F___
O___ S____ D____
P____
D____ N____ V___
C_____

anxiety
diaphoresis
pleural effusion
low-grade fever
oxygen saturation decreased
petechiae
distended neck veins
cyanosis

What are the labs?

ABG
D-Dimer

what does an elevated D-Dimer suggest?

clot

what is a normal d-dimer value?

less than 0.4 mcg/mL

what are early signs of pulmonary embolism on an ABG?

hypoxemia and respiratory alkalosis

this diagnostic test can detect DVT source

doppler ultrasound

these diagnostics can rule out other causes and assess strain

Chest X-ray
ECG
echocardiogram

if contrast is contraindicated this test can be done to show circulation of air and blood and can detect PE

V/Q (ventilation perfusion scan)

this test shows lung tissue

MDCTA (multidetector computed tomography angiography)

a medical imaging procedure that uses computed tomography to visualize the pulmonary arteries, the blood vessels in the lungs and is the gold standard

CT pulmonary angiography

normal pH range

7.35-7.45

normal PaCO2 range

35-45

normal PaO2 range

75-100

normal HCO3 range

22-26

why is respiratory alkalosis an early sign?

increased RR causing too much CO2 blown off

what develops due to Respiratory alkalosis?

hypoxemia

what does PE look like on a V/Q?

lungs ventilated but blood flow is blocked

what are late signs on ABG for PE?

respiratory acidosis

fatigue causing decreased ventilation causing CO2 retention

respiratory acidosis

What are the medications for PE?

anticoagulants (heparin, enoxaparin, warfarin)

IV anticoagulant that has a rapid onset that prevents clot growth

heparin

what should you monitor when on heparin? what is the goal?

aPTT 
1.5-2.5 x control

what is the antidote for heparin?

protamine sulfate

SQ anticoagulant that is a low-molecular weight heparin that is more predictable and less monitoring is needed

enoxaparin

this medication can cause systemic hypotension, pulmonary hypertension, liver and kidney tissue damage, and anaphylactic reaction.

protamine sulfate

contraindications for anticoagulants:
A___ B___
P___ U___ D___
S___ H___
R___ T___

active bleeding
peptic ulcer disease
stroke history
recent trauma

oral, long-term anticoagulant that inhibits vitamin k-dependant clotting factors

warfarin

what should you monitor when on warfarin?

PT and INR

what is the INR goal?

2-3

what is the antidote for warfarin?

vitamin K (FFP/PCC if severe)

what is the normal aPTT value?

30-40 seconds

bleeding can manifest as:
B___
B___ G__
A___ P___
E____
C__-G___ E___
B___/T____ S____

bruising
bleeding gums
abdominal pain
epistaxis
coffee-ground emesis
black/tarry stools

what should you avoid when on anticoagulants?

NSAIDs, ASA, salicylates

what kind of razor and toothbrush should be used on anticoagulants

electric razor
soft toothbrush

 dark green leafy vegetables (lettuce, cooked spinach), cabbage, broccoli, Brussels sprouts, mayo, canola and soybean oil

foods high in Vitamin K

How can the nurse maintain a pts airway and oxygenation?

high fowlers
administer o2 as prescribed

what should the nurse monitor in PE pts?

respiratory and cardiac status
ABGs and labs (clotting studies, electrolytes)

how can the nurse support a pt with PE?

emotional support
reduce anxiety

surgical/catheter removal of an embolus in the pulmonary artery (used in severe/life-threatening PE)

embolectomy

removal of a thrombus from a deep vein (DVT treatment → prevents future PE)

thrombectomy

device placed in vena cava to trap emboli and prevent PE (option if anticoagulation not possible)

IVC filter

What are PE complications?

pulmonary htn
right-sided heart failure
shock 
death

complication if untreated or massive embolus

death

complication caused by impaired oxygenation & cardiac output

shock

complication caused when the right ventricle cant pump against high pressure

right sided heart failure (cor pulmonale)

complication cuased by increased pressure from blocked pulmonary circulation

pulmonary htn

What lifestyle changes can pts with PE make?

quit smoking
maintain healthy weight
stay hydrated

What mobility changes can pts with PE make?

regular physical activity
avoid prolonged immobility
use compression stockings (if prescribed)

What medication changes can pts with PE make?

adhere to anticoagulant regimen
keep regular lab checks