Pulmonary embolism

Nursing

1. Pulmonary Embolism
JUSTIN V SEBASTIAN, MSc N, RN, PhD Scholar

2. 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 right side of the heart.
Most commonly, PE is due to a blood clot or thrombus.
However, there are other types of emboli: air, fat, amniotic
fluid, and septic (from bacterial invasion of the thrombus).

3. Incidence
It is estimated that more than half a million people develop
PE yearly, resulting in more than 50,000 deaths.

4. Causes
Pulmonary embolism occurs when a clump of material, most often a blood clot,
gets wedged into an artery in lungs. These blood clots most commonly come
from the deep veins of legs, a condition known as deep vein thrombosis (DVT).
In many cases, multiple clots are involved in pulmonary embolism.
Occasionally, blockages in the blood vessels are caused by substances other
than blood clots, such as:
•Fat from the marrow of a broken long bone
•Part of a tumour
•Air bubbles

5. Risk factors
•Heart disease. Cardiovascular disease, specifically heart failure, makes
clot formation more likely.
•Cancer. Certain cancers — especially brain, ovary, pancreas, colon,
stomach, lung and kidney cancers, and cancers that have spread — can
increase the risk of blood clots.
•Surgery. Surgery is one of the leading causes of problem blood clots.
•Coronavirus disease 2019 (COVID-19). People who have severe
symptoms of COVID-19 have an increased risk of pulmonary embolism.

6. Risk factors
Prolonged immobility
Blood clots are more likely to form during periods of inactivity, such as:
•Bed rest. Being confined to bed for an extended period after surgery, a
heart attack, leg fracture, trauma or any serious illness makes more
vulnerable to blood clots.
•Long trips. Sitting in a cramped position during lengthy plane or car
trips slows blood flow in the legs, which contributes to the formation
of clots.

7. Risk factors
Other risk factors
•Smoking. For reasons that aren't well understood, tobacco use predisposes
some people to blood clot formation, especially when combined with other
risk factors.
•Being overweight. Excess weight increases the risk of blood clots —
particularly in people with other risk factors.
•Pregnancy. The weight of the baby pressing on veins in the pelvis can slow
blood return from the legs. Clots are more likely to form when blood slows
or pools.

8. Pathophysiology
When a thrombus completely or partially obstructs a pulmonary artery or its branches, the alveolar dead space is
increased.
Thus, gas exchange is impaired or absent in this area.
In addition, various substances are released from the clot and surrounding area, causing regional blood vessels and
bronchioles to constrict.
This results in an in- crease in pulmonary arterial pressure and, in turn, an increase in right ventricular work to
maintain pulmonary blood flow.
When the work requirements of the right ventricle exceed its capacity, right ventricular failure occurs, leading to a
decrease in cardiac output followed by a decrease in systemic blood pressure and the development of shock.

9. Symptoms
Pulmonary embolism symptoms can vary greatly, depending on how much lung is involved, the size of
the clots, and whether have underlying lung or heart disease.
Common signs and symptoms include:
•Shortness of breath. This symptom typically appears suddenly and always gets worse with exertion.
•Chest pain. The pain is often sharp and felt when breathe in deeply, often stopping from being able to
take a deep breath. It can also be felt when cough, bend or stoop.
•Cough. The cough may produce bloody or blood-streaked sputum.
Other signs and symptoms that can occur with pulmonary embolism include:
•Rapid or irregular heartbeat
•Lightheadedness or dizziness
•Fever
•Leg pain or swelling, or both, usually in the calf caused by a deep vein thrombosis
•Clammy or discoloured skin (cyanosis)

10. Diagnosis
Blood tests
•Doctor may order a blood test for the clot-dissolving substance D dimer.
High levels may suggest an increased likelihood of blood clots, although
many other factors can also cause high D dimer levels.
•Blood tests also can measure the amount of oxygen and carbon dioxide
in blood. A clot in a blood vessel in lungs may lower the level of oxygen
in blood.
•In addition, blood tests may be done to determine whether have an
inherited clotting disorder.

11. Diagnosis
Chest X-ray
Ultrasound
A noninvasive test known as duplex ultrasonography (sometimes
called duplex scan or compression ultrasonography) uses sound
waves to scan the veins in thigh, knee and calf, and sometimes in
arms, to check for deep vein blood clots.
CT scan

12. Diagnosis
Pulmonary angiogram
In a pulmonary angiogram, a flexible tube (catheter) is inserted into a large
vein — usually in groin — and threaded through heart and into the
pulmonary arteries. A special dye is then injected into the catheter, and X-
rays are taken as the dye travels along the arteries in lungs.
MRI
MRI is a medical imaging technique that uses a magnetic field and
computer-generated radio waves to create detailed images of the organs and
tissues in body.

13. Treatment
Treatment of pulmonary embolism is aimed at keeping the blood clot from getting bigger and
preventing new clots from forming. Prompt treatment is essential to prevent serious complications
or death.
Medications
Medications include different types of blood thinners and clot dissolvers.
•Blood thinners (anticoagulants). These drugs prevent existing clots from enlarging and new
clots from forming while body works to break up the clots. Heparin is a frequently used
anticoagulant that can be given through the vein or injected under the skin.
•Clot dissolvers (thrombolytics). While clots usually dissolve on their own, sometimes
thrombolytics given through the vein can dissolve clots quickly. Because these clot-busting
drugs can cause sudden and severe bleeding, they usually are reserved for life-threatening
situations.

14. Surgical and other procedures
•Clot removal. If have a very large, life-threatening clot in lung, doctor
may suggest removing it via a thin, flexible tube (catheter) threaded
through blood vessels.
•Vein filter. A catheter can also be used to position a filter in the body's
main vein (inferior vena cava) that leads from legs to the right side of
heart. This filter can help keep clots from going to lungs. This procedure
is typically reserved for people who can't take anticoagulant drugs or
when they have had recurrent clots despite use of anticoagulants. Some
filters can be removed when no longer needed.

16. Prevention
Preventing clots in the deep veins in legs (deep vein thrombosis) will help prevent
pulmonary embolism. For this reason, most hospitals are aggressive about taking
measures to prevent blood clots, including:
•Blood thinners (anticoagulants).
•Compression stockings. Compression stockings steadily squeeze legs, helping veins
and leg muscles move blood more efficiently. They offer a safe, simple and inexpensive
way to keep blood from stagnating during and after general surgery.
•Leg elevation. Elevating legs when possible and during the night also can be very
effective. Raise the bottom of bed 4 to 6 inches (10 to 15 cm) with blocks or books.
•Physical activity. Moving as soon as possible after surgery can help prevent pulmonary
embolism and hasten recovery overall.

17. Nursing Diagnosis
Impaired Gas Exchange related to decreased lung perfusion caused
by the obstruction of pulmonary arterial blood flow by the embolus.
•Assess the skin color, nail beds, and mucous membranes for color
changes.
•Monitor for any changes in vital signs.
•Assess for the signs and symptoms of hypoxia (such as confusion,
headache, diaphoresis, restlessness, tachycardia, and pale skin).
•Monitor for any changes in the ABGs.

18. Nursing Diagnosis
Ineffective Breathing Pattern may be related to Chest pain
•Assess the respiratory rate, rhythm, and depth.
•Assess for any increase in the work of breathing: shortness of
breath, and the use of accessory muscle.
•Assess the characteristics of pain, especially in association with
the respiratory cycle.
•Position the client in a sitting position, and change the position
every 2 hours.

19. Nursing Diagnosis
Deficient Knowledge may be related to New medical condition
•Assess the client’s knowledge of pulmonary embolus: its
severity, prognosis, risk factors, and therapy.
•Provide information on the cause of the problem, common risk
factors, and effects of PE on body functioning.
•Instruct the client about medications, their actions, dosages, and
side effects.