Pulmonary Embolism

Pulmonary Embolism for adult nursing

1. PULMONARY EMBOLISM Prepared by: RN Arpana Bhusal BNS

2. Content layout Introduction Definition Incidence Types Risk factors Pathophysiology Clinical features 7/24/2022 3

3. Diagnostic evaluation Management Emergency management Pharmacological management Surgical management Nursing management Complications Prevention 7/24/2022 4

4. Blood supply 7/24/2022 5

5. Introduction A pulmonary embolism is a potential cardiovascular emergency where a blood clot develops in a blood vessels elsewhere in a body( most commonly from the legs), travels to an artery fin lungs, and forms an occlusion(blockage) of the artery. 7/24/2022 6

6. Defin i tion Pulmonary embolism (PE) refers to the obstruction of the Pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the I right side of the heart. It can damage part of the lung due to restricted blood flow, decrease oxygen levels in the blood, and affect other organs as well. Large or multiple blood clots can be fatal. 7/24/2022 7

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8. Pulmonary embolism 7/24/2022 9

9. Incidence Approximately 15% patients died, causing, contributing or accompanying in hospital related to pulmonary embolism for the past 40 years. Recent large, contemporary observational studies of PE have reported an overall 3 months mortality of 17% and an hospital mortality of 31%when PE associated with hypotension. 7/24/2022 10

10. Types Thrombotic: blood Non thrombotic: fat, air, tumor, amniotic fluid. 7/24/2022 11

11. Risk factors for Pulmonary embolism Venous stasis (slowing of blood flow in veins ) Prolonged immobilization (especially postoperative) prolonged periods of sitting or traveling varicose veins Spinal cord injury 7/24/2022 12

12. Risk factors contd … Hypercoagulability ( due to release of tissue thromboplastin after injury /surgery ) Injury Tumor ( pancreatic, GIT, Genitourinary, breast and lung tumor) Increased platelet count (polycythemia) 7/24/2022 13

13. Risk factors contd … Venous endothelial disease Thrombophlebitis vascular diseases foreign bodies (iv/central venous catheters) 7/24/2022 14

14. Risk factors contd … Certain disease states (combination of states, coagulation Alterations, and venous Injury) Heart disease (Heart failure) Trauma ( Fracture of hip, pelvis, vertebra, lower extremities) Post operative state /postpartum period Diabetes mellitus and COPD 7/24/2022 15

15. Other predisposing factors Advanced age Obesity Pregnancy Oral contraceptive use Constrictive clothing History of previous PE 7/24/2022 16

16. Pathophysiology P.T.O 7/24/2022 17

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18. Pathophysiology 7/24/2022 19

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20. Pathophysiology contd.. 1.When an emboli travel to the lungs, they lodge in the pulmonary vasculature. 2.The size of emboli determine the location Blood flow is obstructed, leading to decreased perfusion of the section of the lung supplied by the vessel. 3. The client continues to ventilate the lungs portion, but because the tissue is not perfused, resulting in hypoxemia. 7/24/2022 21

21. Pathophysiology contd.. 4.If an embolus lodges in a large pulmonary vessel, it increases proximal pulmonary vascular resistance, causes atelectasis, and eventually reduces cardiac output. 5.The arterioles constrict because of platelet degranulation, accompanied by a release of histamine, serotonin, catecholamine and prostaglandins. 7/24/2022 22

22. Pathophysiology contd.. 6.These chemical agents result in bronchial and pulmonary arterial constriction. 7.Vasoconstriction 8.Pulmonary embolism 7/24/2022 23

23. Clinical manifestations 7/24/2022 24

24. Clinical manifestations Clinical manifestations or symptoms depends on the siz e of the emboli and the size and number of blood vessels occluded. Most common manifestations are : DYSPNEA is the most frequent symptom Tachypnea (very rapid respiratory rate) is the most frequent sign. 7/24/2022 25

25. Continue… .. Chest pain is common and is usually sudden and pleurtic in origin. It may be substernal and may mimic angina pectoris or may Myocardial infraction. 7/24/2022 26

26. Other symptoms include Anxiety Fever, Tachycardia, apprehension, cough, diaphoresis, hemoptysis and syncope. 7/24/2022 27

27. Sign and symptoms according to size of embolus In massive emboli, Shock Pallor Severe dyspnea Crushing chest pain Pulse is rapid and weak Bp is low ECG indicates right ventricular strain 7/24/2022 28

28. Sign and symptoms according to size of embolus contd … In medium sized emboli, Pleuritic chest pain Dyspnea Slight fever Productive cough with blood streaked sputum 7/24/2022 29

29. Sign and symptoms according to size of embolus contd … In small emboli, Pulmonary hypertension ECG and chest X- ray indicates right ventricular hypertrophy 7/24/2022 30

30. Diagnostic evaluation History taking Physical examination Venous studies Chest x-ray Continuous ECG monitoring ABGs analysis CBCs D- dimer level 7/24/2022 31

31. Diagnostic evaluation contd … Lungs scan ( ventilation and perfusion ) Pulmonary angiography CT scan MRI 7/24/2022 32

32. Diagnostic evaluation contd … History taking and physical examination There always needs to be a high a level of suspicion that a pulmonary embolus may be the cause of chest pain or shortness of breath. The health care professional will take a history of the chest pain, including its characteristics, its onset, and any associated symptoms that may direct the diagnosis to pulmonary embolism 7/24/2022 33

33. Diagnostic evaluation contd … It may include asking about risk factors for deep vein thrombosis. Coughing up blood sputum may be a sign of pulmonary embolism. 7/24/2022 34

34. Diagnostic evaluation contd … Physical examination will concentrate initially on the heart and lungs, since chest pain and shortness of breath may also be the presenting complaints for heart attack , pneumonia , pneumothorax (collapsed lung), dissection of an aortic aneurysm , among others. 7/24/2022 35

35. Diagnostic evaluation contd … With pulmonary embolism, the chest examination is often normal, but if there is some associated inflammation on the surface of the lung , a rub may be heard. The surfaces of the lung and the inside of the chest wall are covered by a membrane (the pleura) that is full of nerve endings. 7/24/2022 36

36. Diagnostic evaluation contd … When the pleura becomes inflamed, as can occur in pulmonary embolus, a sharp pain can result that is worsened by breathing, so-called pleurisy or pleuritic chest pain. The physical examination may include examining an extremity, looking for signs of a DVT, including warmth, redness, tenderness, and swelling. 7/24/2022 37

37. Homan’s sign 7/24/2022 38

38. Deep vein thrombosis 7/24/2022 39

39. Diagnostic evaluation contd … 2.D- dimer blood test This test detects the presence of a protein produced when a blood clot breaks down somewhere in the body. A negative results is a good indicator that a clot is not present. A positive result suggests that clots, may be present, but more testing is needed to confirm. 7/24/2022 40

40. Diagnostic evaluation contd … 3 . ABGs analysis A sudden drop in the blood oxygen level may suggest a pulmonary embolism. 7/24/2022 41

41. Diagnostic evaluation contd … 4.Coagulation profile Additional blood work should include coagulation studies to evaluate for a hyper coagulable state, if clinically indicated. A prolonged prothrombin time or activated partial thromboplastin time does not imply a lower risk of new thrombosis. progression of DVT and PE can occur despite full therapeutic anticoagulation in 13% of patients. 7/24/2022 42

42. Diagnostic evaluation contd … 5.Chest X-rays 7/24/2022 43

43. Diagnostic evaluation contd … Chest X-rays 7/24/2022 44

44. Diagnostic evaluation contd … 6.Lungs scan This test, called a ventilation perfusion scan, uses small amount of radioactive material to study airflow( ventilation) and blood flow ( perfusion) in the lungs. First, patient inhale a small amount of radioactive material while a special camera designed to radioactive substances records air movement in lungs. 7/24/2022 45

45. Diagnostic evaluation contd … Then a small amount of radioactive material is injected into a vein via arm. Images taken after the injection show whether patient have a normal or diminished flow of blood to the lungs. 7/24/2022 46

46. Diagnostic evaluation contd … 7.Pulmonary angiogram During this test, a flexible tube ( catheter is inserted into large vein- usually in the femoral vein- and threaded through the heart’s right atrium and then into pulmonary arteries. A special dye is injected into the catheter, and X-rays are taken as dye travels along the arteries in the lungs. It also measure pressure in the right side of the heart. 7/24/2022 47

47. Diagnostic evaluation contd … 8.Ultrasound A noninvasive sonar test known as duplex venous USGs ( sometimes called duplex scan or compression ultra- sonography) uses high-frequency sound waves to check for blood clots in the lower limb veins.( thighs) 7/24/2022 48

48. Diagnostic evaluation contd … 9.Magnetic resonance imaging MRI scans use radio waves and a powerful magnetic field to produce detailed images of internal structures. 7/24/2022 49

49. Medical management Because PE is often a medical emergency, emergency management is of primary concern. After emergency measures have been initiated and the patient is stabilized, the treatment goal is to dissolve the existing emboli and prevent new ones from forming. 7/24/2022 50

50. Emergency management Massive PE is a life – threatening emergency The immediate objective is to stabilize the cardiopulmonary system. 7/24/2022 51

51. Emergency management consists of the following actions :- O xygen is administered immediately to relive hypoxemia, respiratory distress, and central cyanosis. Establish IV Lines. Vasopressors ,inotropic agents such as dopamine and anti dysrhythmic agents may be indicated to support circulation if the client is unstable. Perfusion scan, Hemodynamic monitoring and ABG. 7/24/2022 52

52. Con td … Hypotension is treated by a slow infusions of dobutamine. Continue monitoring ECG Blood is drawn for serum electrolytes, CBC etc If clinical assessment and ABG analysis indicate the need, the patient is intubated and placed on a mechanical ventilator. 7/24/2022 53

53. Contd … If the patient has suffered massive embolism and is hypotensive, an indwelling urinary catheter is inserted to monitor urinary output. Small doses of IV Morphine or sedative are administered to relive patient anxiety. 7/24/2022 54

54. General management Measure are initiated to improve respiratory and vascular status. Oxygen therapy Use of elastic compression stocking or intermittent pneumatic leg compression devices reduces venous stasis. Elevating the leg above the level of heart . 7/24/2022 55

55. Elastic compression stocking 7/24/2022 56

56. Intermittent pneumatic leg compression devices 7/24/2022 57

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58. Treatment may include a variety of modalities General measures to improve respiratory and vascular status. Anticoagulation therapy Thrombolytic therapy Surgical intervention 7/24/2022 59

59. Pharmacologic therapy Anticoagulation therapy: (heparin, warfarin Sodium) has traditionally been the primary method for managing acute deep venous thrombosis and PE. 7/24/2022 60

60. Pharmacologic therapy contd … Thrombolytic therapy: (urokinase, streptokinase, alteplase and reteplase ) Thrombolytic therapy resolves the thrombi or emboli more quickly and restores more normal Hemodynamic functioning of the Pulmonary circulation, thereby reducing Pulmonary hypertension and improving Perfusion, Oxygenation, and cardiac output. 7/24/2022 61

61. Pharmacologic therapy contd … Bleeding is a significant side effect. Contraindications to Thrombolytic therapy include a C V A w ithin t he past 2 months, or other active intracranial processes, active bleeding, surgery within 10 days of the Thrombolytic therapy, recent delivery or labor and sever hypertension. 7/24/2022 62

62. Pharmacologic therapy contd … Before start Thrombolytic therapy, INR. PTT , HEMATOCRIT, AND PLATELET counts are obtained. Heparin is stopped prior to administration of a Thrombolytic therapy. During therapy, all but essential invasive procedure are avoidied because of potential bleeding. 7/24/2022 63

63. Surgical management Pulmonary embolectomy It is the emergency surgical removal of emboli which are blocking blood circulation. It usually involves removal of thrombi, and is then reffered to as thrombectomy. 7/24/2022 64

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65. Vein filter A catheter can also be used to position a filter Vein filter. A catheter can also be used to position a filter in the body's main vein called the inferior vena cava that leads from your legs to the right side of the heart. This filter can help keep clots from being carried into lungs. This procedure is typically reserved for people who can't take anticoagulant drugs or when anticoagulant drugs don't work well enough or fast enough. Some filters can be removed when they are no longer needed. 7/24/2022 66

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67. Nursing management Nursing assessment Take history with emphasis on onset and severity of dyspnea and nature of chest pain. Examine the patient leg carefully. Assess for swelling of leg, duskiness, warmth, pain on pressure over gastrocnemius muscle, pain on dorsiflexon of the foot( positive homan’s sign), which indicate thrombophlebitis as source. 7/24/2022 68

68. Monitor respiratory rate may be accelerated out of proportion to degree of fever and tachycardia. Observe the rate of inspiration to expiration. Percuss for resonance, dullness, and flatness. Ascultate for friction rub, crackles, ronchi , and wheezing. Ascultate heart; listen for splitting of second heart sound. Evaluate results of PT/PTT tests for patients on anticoagulants 7/24/2022 69

69. Nursing diagnosis Ineffective breathing pattern related to acute increase in alveolar dead air space and possible changes in lungs mechanics from embolism. Ineffective tissue perfusion(pulmonary) related to decresed blood circulation. Acute pain(pleuritic) related to congestion, possible pleural effusion, possible lungs infraction. 7/24/2022 70

70. Nursing diagnosis contd … 4.Anxiety related to dyspnea, pain and prognosis of disease. 5.Risk for injury related to altered hemodynamic factors and anticoagulant therapy. 7/24/2022 71

71. Nursing interventions Correcting breathing pattern Assess for hypoxia, headache, restlessness, apprehension, cyanosis, behavioral changes. Monitor vital signs, ECG, oximetery , and ABG analysis for oxygenation. Monitor patients response to IV fluids/vasopressors 7/24/2022 72

72. Nursing interventions contd.. Monitor oxygen therapy used to relieve hypoxemia. Prepare patient for assisted ventilation when hypoxemia is due to local areas of pneumo-constriction and abnormalities of V/Q ratios. 7/24/2022 73

73. Nursing interventions contd.. Improving tissue perfusion Closely monitor for shock decreasing blood pressure, tachycardia, cool, clammy skin. Monitor prescribed medications given to preserve right ventricular filling pressure, increased BP. 7/24/2022 74

74. Nursing interventions contd.. Patient should be kept in bedrest to reduce oxygen demand and risk of bleeding. Monitor urinary output hourly, because there may be reduced renal perfusion and decreased GFR. 7/24/2022 75

75. Nursing interventions contd.. Relieving pain Watch patient for signs of discomfort and pain. Ascertain if pain worsens with deep breathing and coughing: auscultate for friction rub. Give prescribed morphine, and monitor for pain relief and signs of respiratory depression. Position with head of bed slightly elevated( unless contraindicated by shock) and with chest splinted for deep breathing and coughing. 7/24/2022 76

76. Nursing interventions contd.. Evaluate patient for sign of hypoxia thoroughly when anxiety, restlessness, and agitation of new onset are noted, before administering as needed sedatives. Consider physician evaluation when these signs are present, especially if accompanied by cyanotic nail beds, circumoral pallor, and increased respiratory rate. 7/24/2022 77

77. Nursing interventions contd.. Reducing anxiety Correct dyspnea and relief physical discomfort. Explain diagnostic prcedures and the patients role :correct misconception. Listen to patiet concers ; attentive listening relieves anxiety and reduces emotional distress. Speak calmly and slowly. 7/24/2022 78

78. Patient education and health maintenance Advise patient of the possible need to continue taking anticoagulant therapy for 6 weeks up to an indefinite period. Teach about the sign of bleeding, especiallyof gums, nose, bruising, blood in urine and stools. For patient on anti coagulants, instruct to sue soft toothbrush, avoid shaving with blade razor, and avois aspirin containing products. Notify health care provider of bleeding and bruishing . 7/24/2022 79

79. Patient education and health maintenance contd.. Warn against taking medications unless approved by health care provider, because many drugs interact with anticoagulants. Instruct patient to tell dentist about taking an anticoagulant. Warn against inactivity for prolonged periods or sitting with leg crossed to prevent recurrence. 7/24/2022 80

80. Patient education and health maintenance contd.. Warn against sports/activities that may cause injury to legs and predispose to a thrombus. Encourage wearing a medical alert bracelet identifying patient on anti coagulant. 7/24/2022 81

81. Complications Cardiac arrest Shock Abnormal heart rhythms Pulmonary infraction Pleural effusion Paradoxical embolism Pulmonary hypertension Respiratory failure 7/24/2022 82

82. Prevention of Pulmonary embolism For patients at risk for PE, the most effective approach for prevention is to prevent DVT (deep venous thrombosis). Active leg exercise to avoid venous stasis. Early ambulation is necessary. Use elastic compression stocking. 7/24/2022 83

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84. References Smeltzer.S.G . Bare.B.G . Hinkle.J.G . Cheezer K.H.(2010) “Brunner & Suddarth’s Textbook of medical- surgical nursing”.volume 1. (12 th edition).New Delhi,Kluwer India. Pvt. Ltd. 2078/03/12 at 12:00 pm Mandal G.N (2016) “A Textbook of Medical Surgical Nursing”. 5 th edition. Kathmandu.Makalu Publication House.2078/03/11 at 4:30 pm 2019. Mayo Foundation of Medical Foundation and Research. Pulmonary embolism. https://www.mayoclinic.org@2021/06/25 at 2pm. October 23, 2018. pulmonary-embolism. https://www.slideshare.net/GAMANDEEP@2021/06/25 at 2pm 7/24/2022 85

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