Pulmonary Embolism: Causes, Risks, and Virchow's Triad
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Questions and Answers

A patient post-liposuction presents with sudden onset dyspnea and chest pain. Which type of pulmonary embolus is the MOST likely cause?

  • Thrombus
  • Amniotic Fluid
  • Fat (correct)
  • Tumor

A patient with a long-bone fracture is at risk for developing a pulmonary embolism. Which of the following mechanisms is MOST likely responsible for the PE in this scenario?

  • A thrombus forming due to vessel wall damage from the fracture.
  • Air entering the pulmonary circulation during surgery.
  • Amniotic fluid entering the pulmonary vasculature.
  • Fat globules released from the bone marrow entering the bloodstream. (correct)

A patient undergoing central venous catheter (CVC) insertion suddenly develops respiratory distress and cyanosis. What is the MOST probable cause related to the CVC procedure?

  • Thrombus formation at the catheter tip.
  • Air embolism due to negative intrathoracic pressure. (correct)
  • Tumor fragmentation during catheter insertion.
  • Amniotic fluid entering the circulation.

A postpartum patient suddenly deteriorates, exhibiting dyspnea, hypotension and tachycardia. Which type of pulmonary embolism should the nurse suspect FIRST?

<p>Amniotic fluid embolus (C)</p> Signup and view all the answers

A nurse assessing a client with a suspected pulmonary embolism understands that Virchow's triad is a major predisposing factor for deep vein thrombosis (DVT), a common cause of PE. Which of the following BEST describes the components of Virchow's triad?

<p>Venous stasis, vessel wall damage, and hypercoagulability. (C)</p> Signup and view all the answers

What is the primary physiological benefit of prone positioning for patients with ARDS?

<p>Reduced ventilator-induced lung injury (VILI). (C)</p> Signup and view all the answers

Within what timeframe of ARDS diagnosis should prone positioning ideally be implemented to achieve optimal results?

<p>Within 72 hours. (A)</p> Signup and view all the answers

Which of the following is a contraindication for placing a patient in the prone position?

<p>Spine instability. (B)</p> Signup and view all the answers

Which nursing intervention is crucial to prevent complications associated with prone positioning?

<p>Eye and facial skin care. (D)</p> Signup and view all the answers

What immediate action should be taken if a patient shows a change in baseline oxygenation parameters after being placed in the prone position?

<p>Obtain a new ABG determination. (A)</p> Signup and view all the answers

What is the primary mechanism by which a pulmonary embolism (PE) leads to decreased oxygenation in the body?

<p>Reduced cardiac output due to right ventricular failure, leading to inadequate tissue perfusion. (B)</p> Signup and view all the answers

Why might a post-pyloric feeding tube be considered for a patient in the prone position?

<p>To prevent aspiration. (B)</p> Signup and view all the answers

A patient with a pulmonary embolism (PE) is experiencing pulmonary hypertension. What physiological response is most directly contributing to this condition?

<p>Backflow of blood into the right ventricle due to increased PVR. (A)</p> Signup and view all the answers

In the event of hemodynamic compromise or cardiac arrest during prone positioning, what is the initial step in managing the patient?

<p>Rapidly return the patient to the supine position. (A)</p> Signup and view all the answers

Which of the following best describes how a massive pulmonary embolism (PE) can lead to rapid death?

<p>Sudden obstruction of more than 50% of blood flow to the lungs, causing acute right ventricular failure. (D)</p> Signup and view all the answers

What is the recommended duration for a patient with ARDS to remain in the prone position each day for optimal outcomes?

<p>Up to 20 hours. (A)</p> Signup and view all the answers

How does a saddle pulmonary embolism (PE) typically lead to sudden death?

<p>By obstructing the bifurcation of the pulmonary artery, severely restricting blood flow to both lungs. (D)</p> Signup and view all the answers

A post-operative patient who has undergone long-bone surgery suddenly exhibits intense dyspnea and tachypnea. What type of pulmonary embolism (PE) should be highly suspected?

<p>Acute PE (D)</p> Signup and view all the answers

What is the underlying physiological cause of jugular venous distention (JVD) in a patient experiencing acute right ventricular failure due to a massive pulmonary embolism (PE)?

<p>Backflow of blood into the right atrium and superior vena cava due to the failing right ventricle. (A)</p> Signup and view all the answers

A patient is diagnosed with a submassive pulmonary embolism (PE). What criterion defines this classification?

<p>Right heart dysfunction on echocardiogram without hemodynamic instability. (C)</p> Signup and view all the answers

In addition to dyspnea and tachypnea, what other symptom is commonly associated with an acute pulmonary embolism (PE) due to the release of inflammatory mediators?

<p>Pleuritic chest pain (D)</p> Signup and view all the answers

Which of the following best describes the primary mechanism by which APRV (Airway Pressure Release Ventilation) improves gas exchange?

<p>Timed reductions in airway pressure facilitate CO2 removal, while high pressure supports oxygenation. (B)</p> Signup and view all the answers

A patient with mild ARDS is being considered for HFNC therapy. What is the MOST important physiological effect of HFNC that could improve their condition?

<p>Washout of nasopharyngeal dead space and increased nasopharyngeal airway pressure. (C)</p> Signup and view all the answers

What is a significant limitation associated with HFNC use in patients with ARDS?

<p>A significant percentage of patients may still require intubation and mechanical ventilation. (D)</p> Signup and view all the answers

ECMO is being considered for a patient with severe ARDS. What is the fundamental principle behind ECMO's support of gas exchange?

<p>Circulating blood through an artificial lung outside the body for oxygenation and CO2 removal. (A)</p> Signup and view all the answers

What is the primary risk associated with ECMO?

<p>It's a highly invasive therapy with inherent risks and complications. (A)</p> Signup and view all the answers

A patient with ARDS exhibits increased work of breathing, refractory hypoxemia, and rising oxygen demand. Which nursing diagnosis is MOST appropriate?

<p>Impaired gas exchange related to disrupted pulmonary function (C)</p> Signup and view all the answers

In the context of ARDS management, what is the primary rationale for placing a patient in the prone position?

<p>To increase recruitment of collapsed posterior alveolar units and improve V/Q matching. (B)</p> Signup and view all the answers

A patient with ARDS is on mechanical ventilation with PEEP. A sudden decrease in blood pressure is noted. Which physiological mechanism is MOST likely responsible?

<p>Decreased venous return related to increased intrathoracic pressure (C)</p> Signup and view all the answers

A patient with severe ARDS is not responding to conventional ventilation strategies. Which intervention should be considered NEXT?

<p>Placing the patient in a prone position. (C)</p> Signup and view all the answers

How does proning improve oxygenation in ARDS patients, according to the principles described?

<p>By directing blood flow to the better-aerated anterior portion of the lungs, improving V/Q mismatch. (C)</p> Signup and view all the answers

A patient with ARDS is being mechanically ventilated. Initial ABGs show respiratory alkalosis. What is the MOST likely underlying cause for this?

<p>Hyperventilation as a compensatory mechanism for hypoxemia (D)</p> Signup and view all the answers

A patient with ARDS has a decreasing SpO2 despite an increasing FiO2. What physiological process is primarily responsible for this?

<p>V/Q mismatch and intrapulmonary shunting (D)</p> Signup and view all the answers

When assessing a patient with ARDS, which of the following findings would indicate neurological compromise due to refractory hypoxemia and potential increase in PaCO2?

<p>Decreased level of consciousness (B)</p> Signup and view all the answers

A patient with ARDS is mechanically ventilated and chemically paralyzed. What is the MOST important nursing intervention related to neurologic assessment for this patient?

<p>Perform frequent checks of level of consciousness and pupillary response (D)</p> Signup and view all the answers

Which of the following nursing interventions is crucial when administering heparin or enoxaparin?

<p>Monitoring for signs and symptoms of bleeding. (A)</p> Signup and view all the answers

A patient with ARDS is on continuous sedation. Which tool is BEST to use for regular assessment of the patient's sedation level?

<p>Richmond Agitation-Sedation Scale (RASS) (D)</p> Signup and view all the answers

A patient with refractory ARDS is prescribed glucocorticoids. What is the MOST important consideration regarding the administration of these medications?

<p>Tapering the dose when discontinuing the medication. (B)</p> Signup and view all the answers

The pulse of a patient with ARDS increases. Which of the following mechanisms is MOST likely responsible for this change?

<p>Decreased oxygenation (C)</p> Signup and view all the answers

A critically ill patient without a history of diabetes develops insulin resistance. What should be a primary nursing intervention?

<p>Monitoring blood glucose levels as ordered. (A)</p> Signup and view all the answers

Why is fentanyl preferred over morphine in patients with ARDS who require sedation?

<p>Fentanyl decreases the response to carbon dioxide, which promotes ventilator synchrony. (A)</p> Signup and view all the answers

A patient receiving continuous IV fentanyl develops chest wall rigidity. What immediate intervention should the nurse prepare for?

<p>Preparing for intubation and mechanical ventilation if not already. (A)</p> Signup and view all the answers

A patient is receiving methylprednisolone for refractory ARDS. Which assessment finding requires immediate action?

<p>New onset of crackles in the lungs (B)</p> Signup and view all the answers

A patient on a continuous insulin infusion is also receiving intermittent doses of opioid for pain. What monitoring parameter is MOST critical for this patient?

<p>Frequent blood glucose checks and assessment for hypoglycemia (D)</p> Signup and view all the answers

A patient receiving midazolam for sedation suddenly becomes agitated and attempts to remove their endotracheal tube. What is the MOST appropriate initial nursing intervention?

<p>Assessing the patient's level of sedation and potential causes of agitation. (A)</p> Signup and view all the answers

Flashcards

Higher-than-baseline CPAP

A mode of ventilation with timed reductions in airway pressure while supporting oxygenation.

Noninvasive ventilation (NIV)

A method of assisting breathing without intubation, including techniques like HFNC.

HFNC

High-Flow Nasal Cannula, delivering humidified oxygen through nasal prongs that wash out dead space.

Oxygenation improvement in ARDS

Elevation of blood oxygen levels through various support strategies, crucial in ARDS management.

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ECMO Function

Extracorporeal Membrane Oxygenation circulates blood through an artificial lung for oxygenation outside the body.

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Complications of ECMO

Risks associated with ECMO include bleeding and infection due to its invasive nature.

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Prone positioning in ARDS

Placing a patient face down to improve lung function and oxygenation during ventilation.

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V/Q mismatch

A discrepancy between ventilation and perfusion in the lungs, often seen in ARDS.

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Pulmonary embolism (PE)

Obstruction of pulmonary artery branches by material from elsewhere in the body.

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Nonthrombotic pulmonary embolus (NTPE)

Pulmonary embolus caused by non-clot materials like tumor pieces, air, or fat.

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Deep vein thrombosis (DVT)

Formation of blood clot in a deep vein, which is a major risk for PE.

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Virchow's triad

Three factors: venous stasis, vessel wall damage, hypercoagulability that increase DVT risk.

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Amniotic fluid embolus (AFE)

Life-threatening condition when amniotic fluid enters maternal circulation during delivery.

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Clinical manifestations of ARDS

Signs of ARDS include refractory hypoxemia, pulmonary edema, and lung damage.

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Work of breathing

Increased effort to breathe, often seen in dyspnea and tachypnea.

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Auscultation findings in ARDS

Initial crackles indicate pulmonary edema, later may show diminished breath sounds.

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Hypoxemia effects

Low oxygen levels can lead to anxiety, agitation, and confusion.

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Respiratory alkalosis in ARDS

Occurs due to hyperventilation early in ARDS.

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Impaired gas exchange

Disrupted pulmonary function leading to less oxygen reaching the blood.

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Sedation assessment tool (RASS)

Tool used to evaluate sedation levels for patient comfort in ARDS.

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Neuro assessment in ARDS

Checking consciousness and pupils due to risk from hypoxemia and CO2 retention.

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Heparin

An anticoagulant used to prevent and treat blood clots.

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Enoxaparin

A low-molecular-weight heparin that prevents deep vein thrombosis.

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Bleeding Precautions

Safety measures to prevent excessive bleeding in patients on anticoagulants.

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Glucocorticoids

Steroids that suppress inflammation and immune response in critical illness.

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Methylprednisolone

A glucocorticoid medication administered via IV push for inflammation.

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Insulin

A hormone that helps cells absorb glucose, often needed in critical illness.

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Fentanyl

A potent opioid used for sedation in critically ill patients on ventilators.

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Naloxone

An opioid antagonist used as a reversal agent for opioid overdose.

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Prone Positioning Benefits

Improves oxygenation, lung recruitment, and decreases VILI.

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Implementation Timing

Prone positioning should start within 72 hours of diagnosis.

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Recommended Duration

Patients should be in prone position for up to 20 hours daily.

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Pressure Injury Prevention

Eye care and padding are crucial to prevent injuries during proning.

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Contraindications

Conditions like spinal instability or increased ICP make prone unsafe.

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Monitoring Oxygenation

Post-proning changes in oxygen levels require an ABG test.

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Family Education

Inform family about benefits and risks of proning.

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Emergency Protocols

Have a plan for rapid return to supine if complications arise.

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Pulmonary Vascular Resistance (PVR)

The resistance that blood encounters when flowing through the pulmonary circulation.

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Left Ventricular Preload

The volume of blood in the ventricles at the end of diastole, before the heart contracts.

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Hypotension

Low blood pressure that can lead to inadequate blood flow to organs.

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Pulmonary Hypertension

High blood pressure in the pulmonary arteries that can result from increased PVR.

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Massive Pulmonary Embolism

A sudden blockage in the pulmonary artery, obstructing over 50% of blood flow.

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Submassive Pulmonary Embolism

A pulmonary embolism with heart dysfunction but no hemodynamic instability.

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Saddle Pulmonary Embolism

An embolus that straddles the bifurcation of the pulmonary artery.

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Clinical Manifestations of PE

Signs of pulmonary embolism, including dyspnea, chest pain, and tachypnea.

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Study Notes

PULMONARY EMBOLISM (PE)

  • PE is the obstruction of one or more branches of the pulmonary artery (PA) by a blood clot or other matter originating elsewhere in the body.
  • Most commonly caused by a thrombus, but also can be caused by a piece of tumor, amniotic fluid, air, or fat.
  • Amniotic fluid embolus (AFE) has a 17% rate of failure to rescue and is fatal to the mother in two-thirds of cases. This rises to over 30% when combined with other complications.
  • The greatest risk factor for PE is the presence of a deep vein thrombosis (DVT).
  • Virchow's triad (venous stasis, vessel wall damage, and hypercoagulability) is a major factor in DVT development.
  • Prolonged immobility is the most common cause of DVT.

Sources of Pulmonary Emboli

  • Deep vein thrombus: Clots from the deep veins of the leg or pelvis travel to the pulmonary vasculature.
  • Fat: Often results from long-bone fractures, osteomyelitis, or liposuction.
  • Air: Can occur during central venous catheter (CVC) insertion or disconnection from a fluid source, or during cardiopulmonary bypass.
  • Tumor: Tumor sloughs off and travels to the pulmonary vasculature.
  • Amniotic fluid: Amniotic fluid can enter the vascular system during delivery.

Epidemiology of PE

  • Prior to 2020, incidence in the US was approximately 1 to 2 per 1,000 persons.
  • PE was estimated to cause 50,000–100,000 deaths per year.
  • SARS-CoV-2 virus has been associated with a higher risk of PE (over 15% of cases), and more than 40% of patients with PE also have DVT.
  • Older adult patients undergoing hip or knee replacement surgery are at higher risk due to limited mobility and age-related changes.

Pathophysiology

  • A blood clot or other matter lodging in the pulmonary artery (PA) impairs blood flow to the lungs.
  • This causes a ventilation-perfusion (V/Q) mismatch.
  • A massive PE can rapidly cause right-ventricular failure and death.
  • A saddle embolism straddles the bifurcation of the PA, often leading to sudden death.
  • A central PE is located in the main or major branches of the PA; a peripheral PE is in smaller branches.
  • These obstructions can lead to hypoxia (low blood oxygen) and decreased cardiac output/hypotension.
  • Inadequate tissue perfusion and hypoxia/reduced cardiac output can worsen into right-heart failure.

Clinical Manifestations of PE

  • Sudden onset of intense dyspnea, pleuritic chest pain, and tachypnea.
  • Possible jugular vein distention (JVD) with massive PE.
  • Hypotension and tachycardia can also occur.
  • Possible anxiety, confusion, restlessness.
  • Hemoptysis (bloody sputum).

Pulmonary Embolism Classification

  • Massive or high risk: Prolonged hypotension, and right and/or left ventricular dysfunction, shock, or cardiac arrest.
  • Submassive or intermediate risk: Normal blood pressure, right ventricular dysfunction (evidenced by echocardiogram), myocardial necrosis (elevated troponin I and elevated BNP).
  • Low risk: Normal blood pressure, no right ventricular dysfunction, and normal biomarkers.

Imaging Studies

  • ECG is done to rule out myocardial infarction (MI).
  • Chest x-ray to rule out alternative causes of respiratory distress.
  • Spiral computerized tomography (CT) scan with intravenous contrast – most common test.
  • Pulmonary angiography - definitive study, but rarely used as it is invasive.
  • Lower extremity venous ultrasound to assess for DVT.

Laboratory Testing

  • D-dimer level – positive results indicate a clot. This is an initial screen, but not conclusive
  • Arterial blood gas (ABG) analysis – often reveals hypoxemia and respiratory alkalosis initially.
  • Blood test for elevated troponin I and BNP are suggestive of myocardial damage.

Treatment

  • Supportive care (oxygen, fluids, and monitoring).
  • Curative care to remove/reduce clot.
  • Anticoagulation medication therapy (e.g., heparin, warfarin, factor Xa inhibitors) to prevent further clot growth.
  • Thrombolytic therapy (e.g., alteplase) for symptomatic patients, if hemodynamically unstable, and to dissolve existing thrombi.
  • Surgery and catheter embolectomy are options for severe cases
  • IV or subcutaneous low-molecular-weight heparin, vitamin K, factor Xa inhibitors used for anticoagulation treatment after discharge.

Nursing Management

  • Assessment of vital signs and respiratory status.
  • Identification of risk factors for thrombus formation.
  • Nursing interventions for treatment and monitoring.
  • Patient/family education about disease, medications, and precautions.

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Pulmonary Embolism Explained PDF

Description

Explore the various causes and risk factors associated with pulmonary embolism (PE), including post-liposuction complications, long-bone fractures, central venous catheter (CVC) insertion, and postpartum risks. Understand Virchow's triad in relation to deep vein thrombosis (DVT) and the benefits of prone positioning for ARDS patients.

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