Pulmonary Embolism PDF

9/23/2023 1 Pulmonary Embolism By: Kayla Owens 2 What is Pulmonary Embolism? • Obstruction of a pulmonary artery or one of its branches by a thrombus • Thrombus • Venous stasis • Injury to intima of vein • Innermost layer of a vein • Vasoconstriction of surrounding capillaries 3 Pathophysiolog...

9/23/2023 1 Pulmonary Embolism By: Kayla Owens 2 What is Pulmonary Embolism? • Obstruction of a pulmonary artery or one of its branches by a thrombus • Thrombus • Venous stasis • Injury to intima of vein • Innermost layer of a vein • Vasoconstriction of surrounding capillaries 3 Pathophysiology • Increased platelet clumping on valves in deep veins • Clot forms • Small piece of clot breaks off • Moves through right heart • Occludes pulmonary artery or its branches 4 Risk Factors • Venous Stasis • Hypercoagulability due to release of tissue thromboplastin after injury/surgery • Venous Endothelial Disease • Certain Disease States (heart disease, trauma, postoperative, DM, COPD, Cancers) • Other Predisposing Conditions (advanced age, obesity, pregnancy, oral contraceptive use, constrictive clothing, long air travel) • 5 Clinical Manifestations • Depends on size and area involved • Most frequent symptom dyspnea • Most frequent sign tachypnea • Chest pain • Tachycardia • Anxiety, apprehension • 6 Assessment/Diagnostics • D-dimer blood test • Elevated = indication for PE = do a CAT Scan • CAT scan – standard for diagnosing PE • V/Q scan – used when there is no access to CT or pulmonary angiography. • Pulmonary Angiography – reasonable alternative to CT allows visualization under fluoroscopy of the arterial obstruction and accurate assessment of the perfusion deficit. • Done if CAT scan is not available; • EKG- nonspecific ST-T wave abnormalities 1 9/23/2023 EKG- nonspecific ST-T wave abnormalities • Venous dopplers • To look at blood flow in the extremities 7 Medical Management • Emergency • If unstable emergent measures are initiated to improve respiratory and cardiovascular status • Anti-coagulation • Is indicated to prevent recurrence or extension of the thrombus and may continue for 10 days. • Initial anticoagulants are Enoxaparin, heparin, or direct thrombin inhibitor (dabigatran) • Thrombolytics • Dissolve the embolus and prevent new ones from forming • T-PA or other agents such as reteplase • Increase risk for bleeding • Need to check INR, aPTT, hematocrit, and platelet counts before starting therapy • Surgery • Rarely performed but may be indicated if there are contraindications to thrombolytic therapy 8 Nursing Management • Monitor thrombolytic therapy • Response to therapy • Vital signs are frequently assessed, and invasive procedures are avoided • INR and aPTT every 3-4 hours after thrombolytic infusion is started to confirm that the fibrinolytic systems have been activated. • Managing pain • Chest pain may be present, is usually pleuritic rather than cardiac in origin. • Nurse must continue to turn patient frequently and reposition to improve V/Q • Opioid analgesics as prescribed • Managing Oxygen therapy • Assess for sign of hypoxemia and monitor pulse oximetry values • Deep breathing and incentive spirometry are indicated for all patients to minimize and prevent atelectasis and improve ventilation. 9 Nursing Management Cont. • Relieving anxiety • Encourage the patient who is stabilized to talk about any fears or concerns • Answers patient and family questions concisely and accurately • Explain the therapy • Monitor for complications • Cardiogenic shock or right ventricular failure 10 Nursing Management Cont. • Post-operative nursing care • Early ambulation • Best for prevent recurrence of DVT and PE 2 9/23/2023 • Measures pulmonary arterial pressure and urinary output • Maintain blood pressure at a level that promotes perfusion • Isometric exercises, compression devices. • Discharge instructions • Discuses prevention education • Reporting signs and symptoms • 11 Prevention • Wear compression stockings • Avoid sitting with legs crossed or sitting for prolonged periods of time • When traveling, change positions regularly, walk occasionally, and do active exercises of moving legs and ankles while sitting • Drink fluids, especially while traveling and in warm weather, to avoid hemoconcentration due to fluid deficit. • Take anticoagulants as prescribed 12 Medications (pt’s at risk for DVT’s may go home with these) • Warfarin (Normal Value 2-2.5) • Requires regular blood draws for INR monitoring (normal range 2-2.5) • Higher bleeding risk • Vitamin K (reversal agent) • Dietary restrictions (avoid green leafy vegetables) • Direct oral anticoagulants ( dabigatran, rivaroxaban, apixaban) • Do not require regular blood test monitoring • More costly • Enoxaparin • Not usually given as long-term therapy since it is given subcutaneous • • 3