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Thursday, October 15, 2020

Pulmonary embolism: High Risk Factors and Management

 Pulmonary Embolism


  • Pulmonary embolism(PE) occurs when a substance( solid,  gaseous, or liquid ) enters venous circulation and forms a blockage in the pulmonary vasculature.
  • Emboli originating from deep-vein thrombosis (DVT)  are most common cause. Tumours,  bone marrow, amniotic fluid, and foreign matter also can become emboli. 
  • Increased hypoxia to pulmonary tissue and impaired blood flow can result from a large embolus. A PE is a medical emergency. 
  • Prevention, rapid recognition, and treatment of a PE are essential for a positive outcome. 
Health promotion and disease prevention 

  • Promote smoking cessation. 
  • Encourage maintenance of appropriate weight for height and body frame. 
  • Encourage a healthy diet and physical activity. 
  • Prevent deep-vein thrombosis (DVT) by encouraging clients to do leg exercise, wear compression stockings, and avoid sitting for long periods of time. 

  • Risk factors 
    • Long-term immobility 
    • Oral contraceptive use and estrogen therapy 
    • Pregnancy 
    • Tobacco use
    • Hypercoagulability ( elevated platelet count)
    • Obesity 
    • Surgery ( especially orthopaedic surgery of the lower extremities or pelvis )
    • Heart failure or chronic atrial fibrillation 
    • Autoimmune hemolytic anaemia 
    • Long bone fracture 
    • Advanced age
Subjective data

  • Anxiety 
  • Feeling of impending doom
  • Pressure in chest
  • Pain upon inspiration and chest wall tenderness 
  • Dyspnea and air hunger 
Objective data
  • Physical assessment findings 
    • Pleurisy
    • Pleural friction rub
    • Tachycardia 
    • Hypotension 
    • Tachycardia 
    • Adventitious breath sounds(crackles) and cough
    • Heart murmur in S3 and S4
    • Diaphoresis 
    • Low-grade fever
    • Decreased oxygen saturation level,  low Spo2, cyanosis
    • Petechiae ( red dots under the skin) over chest and axillae. 
    • Pleural effusion 
  • Laboratory test 
  • ABG analysis 
    • PaCO2 levels are low due to initial hyperventilation. 
    • As hypoxaemia progresses, respiratory acidosis occurs
  • CBC analysis to monitor haemoglobin and hematocrit 
  • D- dimer
    • Elevated above expected reference range in response to clot formation and release of fibrin degradation products 
Diagnostic procedures 
  • Chest X-ray and computed tomography (CT) scan
    • These provide initial identification of a PE. A CT scan most commonly used. A chest X-ray can show a large PE
  • Ventilation- perfusion (V/Q) scan
    • Images show the circulation of air and blood in the lungs and can detect a PE
  • Pulmonary angiography 
    • This is the most thorough test to detect a PE,  but it is invasive and costly. A catheter is inserted into the vena cava to visually see a PE
    • Pulmonary angiography is a higher risk procedure than a V/Q scan
Patient-centred care

Nursing care
  • Administer oxygen therapy as prescribed to relieve hypoxaemia and dyspnea. 
    • Position client to maximize ventilation (high-Fowler's 90%)
  • Initiate and maintain IV access 
  • Administrator medication as prescribed 
  • Provide emotional support and comfort to control client anxiety 
  • Monitor changes in level of consciousness and mental status 
  • Anticoagulants: enoxaparin (Lovenox), heparin, warfarin 
    • Anticoagulants ate used to prevent clots from getting larger or additional clots from forming.
  • Nursing considerations 
    • Assess for contraindications (active bleeding, peptic ulcer disease, history of stroke, recent trauma )
    • Monitor bleeding time- prothrombin time (PT) and international normalized ratio (INR) for warfarin, partial thromboplastin time (aPTT) for heparin, and complete blood count (CBC)
    • Monitor for side effects of anticoagulant ( e.g. thrombocytopenia, anaemia, haemorrhage)
  • Thrombolytic therapy- alteplase (activase) and streptokinase
    • Used to dissolve blood clots and restore pulmonary blood flow
    • Similar side effects and contraindications as anticoagulants 
  • Surgical intervention 
    • Embolectomy: surgical removal of embolus 
    • Vena cava filter: Insertion of a filter in the vena cava to prevent further emboli from reaching the pulmonary vasculature
  • Decreased cardiac output - blood volume is decreased 
    • Monitor for hypotension, tachycardia, cyanosis, jugular venous distension, and syncope 
    • Assess for the presence of  S3 and S4 heart sounds
    • Initiate and maintain IV access 
    • Monitor urinary output
    • Administer IV fluids to replace vascular volume 
    • Continuously monitor the ECG
    • Administer inotropic agents ( milrinone, dobutamine, to increase myocardial contractility 
    • Vasodilators may be needed if pulmonary artery pressure is high enough that it interferes with cardiac contractility 
  • Hemorrhage  - Risk for bleeding increase due to anticoagulant therapy 
    • Assess for oozing, bleeding or bruising from injection and surgical sites.
    • Monitor cardiovascular status 
    • Monitor CBC and bleeding times
    • Administer IV fluids and blood products as required 
    • Monitor internal bleeding ( measure abdominal girth and abdominal or flank pain)

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