Pulmonary Embolism

Pulmonary Embolism

• Refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (thrombi) that originates somewhere in the venous system or in the right side of the heart. 

• Gas exchange is impaired in the lung mass supplied by the obstructed vessel. Massive Pulmonary Embolism is a life threatening emergency, death commonly occurs within 1 hour after the onset of symptoms.

•  It is common disorder associated with trauma, surgery (orthopedic, major abdominal, pelvic, gynecologic), pregnancy, HF, age more than 50 years, hypercoagulable states, and prolonged immobility. It also may occur in apparently healthy people. 

• Most thrombi originate in the deep veins of the legs. 
  

Clinical Manifestation

• Symptoms based on the size of the thrombus and the area of the pulmonary artery occlusion. 

• Dyspnea is the most common symptoms. Tachypnea is the more frequent sign 

• Chest pain is common, usually sudden in onset and pleuritic in nature; it can be substernal and may mimic angina pectoris, or a myocardial infarction 

• Anxiety, fever, tachycardia, apprehensions, cough, diaphoresis, hemoptysis, syncope, shock and sudden death may occur 

• Clinical picture may mimic that of bronchopneumonia or heart failure 

• In apical instances, Pulmonary Embolism causes for signs and symptoms, whereas in other instances if mimics various other cardiopulmonary disorders 

Assessment

• Because the symptoms of Pulmonary Embolism can vary from few to severe, a diagnostic workup is performed to rule out other diseases 

• The initial diagnostic workup may include chest x-ray, ECG, ABG analysis and ventilation- perfusion occurs 

• Pulmonary angiography is considered the best method to diagnose Pulmonary Embolism however, it may not be feasible, cost effective, or easily performed, especially with critically ill patients 

• Spiral CT scan of the lung, D-dimer assay (blood test for evidence of blood clots), and pulmonary arteriogram may be warranted.

Prevention

• Ambulation or leg exercises in patients on bed rest 

• Application of sequential compression devices 

• Anticoagulant therapy for patients whose hemostasis is adequate and who are undergoing major elective abdominal or thoracic surgery. 

Medical Management

• Immediate objective is to stabilize the cardiopulmonary system 

• Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis 

• IV infusion lines are inserted to establish routes for medications or fluids that will be needed 

•  A perfusion scan, hemodynamic measurements, and ABG determinations are performed. Spiral (helical) CT or pulmonary angiography may be performed 

• Hypotension is treated by a slow infusion of dobutamine (Dobutrex), which has a dilating effect on the pulmonary vessels and bronchi, or Dopamine (Intropin) 

• The ECG is monitored continuously for dysrhythmias and right ventricular failure, which may occur suddenly 

• Digitalis glycosides, IV diuretics, and antiarrhythmic agents are administered when appropriate 

• Blood is drawn for serum electrolytes, complete blood cell count, and hematocrit 

• If clinical assessment and ABG analysis indicate the need, the patient is intubated and placed on a mechanical ventilation

• If the patient has suffered massive embolism and is hypotensive, an indwelling foley catheter is inserted to monitor urine output 

• Small doses of IV morphine or sedatives are administered to relieve patient anxiety, to alleviate chest discomfort, to improve tolerance of the endotracheal tube, and to ease adaption to the mechanical ventilator

Anticoagulant Therapy

• (Heparin, warfarin sodium [Coumadin]) has traditionally been the primary method for managing acute DVT and Pulmonary Embolism (numerous specific options for treatment are available) 

• Patients must continue to take some form of anticoagulation for at least 3 to 6 months after the embolic event 

• Major side effects are bleeding anywhere in the body and anaphylactic reaction resulting in shock or death. Other side includes fever, abnormal liver function, and allergic skin reaction 

Thrombolytic Therapy

• May include urokinase, streptokinase, and alteplase. It is reserved for PE affecting a significant area and causing hemodynamic instability 

• Bleeding is significant side effect, nonessential invasive procedures are avoided

Nursing Management: Minimizing the Risk of Pulmonary Embolism

• The nurse must have a high degree of suspicion for PE in all patients, but particularly in those with conditions predisposing to a slowing venous return 

Nursing Management: Preventing Thrombus Formation

• Encourage early ambulation and active passive leg exercises 

• Instruct the patient to move legs in a “pumping” exercise 

• Advice patient to avoid prolonged sitting, immobility and constrictive clothing 

• Do not permit dangling of legs and feet in a dependent position

• Instruct patients to place feet on floor or chair and to avoid crossing legs 

• Do not leave IV catheters in veins for prolonged periods 

Nursing Management: Monitoring Anticoagulant and Thrombolytic Therapy

• Advise bed rest, monitor vital signs every 2 hours and limit invasive procedures 

• Measure International Normalized Ratio (INR) or activated thromboplastin time (PTT) every 3 to 4 hours after thrombolytic infusion is started to confirm activation of fibrinolytic systems 

• Perform only essential ABG studies on upper extremities, with manual compression of puncture site for at least 30 minutes 

Nursing Management: Minimizing Chest Pain

• Place in semi- fowler’s position; turn and reposition frequently 

• Administer analgesics as prescribed for severe pain

Nursing Management: Managing Oxygen Therapy

• Assess the patient frequently for signs of hypoxemia and monitor the pulse oximetry values 

• Assist patient with deep breathing and incentive spirometry 

• Nebulizer therapy or percussion and postural drainage may be necessary for management of secretions 

Nursing Management: Alleviating Anxiety

• Encourage patient to express feelings and concerns 

• Answer questions concisely and accurately 

• Explain therapy, and describe how to recognize untoward effects early 

Nursing Management: Monitor for Complications

• Be alert for the potential complications of cardiogenic shock or right ventricular failure subsequent to the effect of PE on the cardiovascular system

Nursing Management: Teaching Patient Self-Care

• Before and discharge and at follow up clinic or home visits, teach patient how to prevent recurrence and which signs and symptoms should alert patient to seek medical attention 

• Teach patient to look for bruising and bleeding when taking anticoagulants and to avoid bumping into objects. Advise patient to use a toothbrush with soft bristles to prevent gingival bleeding 

• Instruct patient not to take aspirin (an anticoagulant) or antihistamine drugs while taking Warfarin Sodium (Coumadin) 

• Advise patient to check with physician before taking any medication including OTC drugs 

• Advise patient to continue wearing antiembolism stockings as long as directed  

• instruct patient to avoid laxatives, which affect Vitamin K absorption (Vitamin K promotes coagulation)

• Teach patient to avoid sitting with legs crossed or for prolonged periods 

• Recommend that patient change position regularly when traveling, walk occasionally and active exercises of legs and ankles 

• Advise patient to drink plenty of liquids 

• teach patient to report dark, tarry stools immediately 

• Recommend that patient wear identification band stating that he or she is taking anticoagulation