OUTLINE: PULMONARY EMBOLISM

I.
Definition/Types PULMONARY EMBOLISM refers to the obstruction of the pulmonary a
rtery or one of its branches by a thrombus that originates somewhere in the veno
us system or in the right side of the heart.
II.
Etiologic factors It is a common disorder and is often associated with trauma, s
urgery, pregnancy, heart failure, age older than 50 years, hypercoagulable state
s and prolonged immobility. It may also occur in apparently healthy people. a. M
odifiable b. Non-modifiable
III.
Assessment a. b. c. d. Inspection Palpation Percussion Auscultation
IV.
Diagnostic and Laboratory Test Findings a. Chest X-ray-usually normal but may sh
ow infiltratrates, atelactasis, elevation of diaphragm on the affected side, or
a pleural effusion. b. ECG-usually shows sinus tachycardia, PR interval depressi
on, and non-specific T-wave changes
c.
Peripheral Vascular Studies-may include impedance plethysmography, Doppler ultra
sonography or venography.
d. Arterial Blood Gas Analysis- may show hypoxemia and hypocapnia
e. Ventilation-Perfusion (V/Q) scan f. Pulmonary angiography
V.
Pathophysiology and Complications Pulmonary Embolism is due to blood clot or thr
ombus. However, there are other types of emboli: air, fat, amniotic fluid and se
ptic. Although most thrombi originate in the deep veins of the legs, other sites
include the pelvic vein and the right atrium of the heart. Venous thrombosis ca
n result from the slowing blood flow secondary to damage to the blood vessel wal
l or changes in the blood coagulation mechanism. Atrial fibrillation can also ca
use PE. An enlarged right atrium in fibrillation causes blood to stagnate and fo
rm clots in this area. These clots are prone to travel into pulmonary circulatio
n. When thrombus completely or partially obstructs a pulmonary artery or its bra
nches, the alveolar dead space is increased. The area, although continuing to be
ventilated, receives little or no blood flow. Therefore gas exchange is impaire
d or absent in this area. In addition, various substances are released from the
clot and the surrounding area that causes regional blood vessels and bronchioles
to constrict resulting to increase pulmonary vascular resistance. This reaction
compounds the ventilation-perfusion imbalance.
COMPLICATIONS
The hemodynamic consequences are increased pulmonary vascular resistance due to
the regional vasoconstriction and re4duce size of the pulmonary vascular bed. Th
is results in an increased pulmonary arterial pressure and, in turn, an increase
in right ventricular work to maintain pulmonary blood flow. When the work requi
rement of the right ventricle exceeds its capacity, right ventricular failure oc
curs, leading to a decrease in cardiac output followed by a decrease in systemic
blood pressure and the development of shock. VI. Nursing Diagnosis VII. Treatme
nt a. Surgical Management Surgical embolectomy It is an invasive procedure that
involves removal of the actual clot and must be performed by cardiovascular surg
ical team with patient on cardiopulmonary Anxiety
bypass.
Transvenous catheter embolectomy A technique in which a vacuum-cupped catheter i
s introduced transvenously into the affected pulmonary artery.
b. Medical Management
General measures to improve respiratory and vascular status Anticoagulation ther
apy Thrombolytic therapy Surgical intervention
c.
Pharmacologic Management Anticoagulant therapy may be prescribed for patients wh
o are older than 40 years of age, whose hemostasis is adequate and who are under
going major elective abdominal or thoracic surgery to reduce the risk of postope
rative DVT and PE. Heparin should be administered subcutaneously 2 hours before
the surgery and continued 8 to 12 hours until the patient is discharged. Thrombo
lytic therapy resolves the thrombi or emboli more quickly and restores more norm
al hemodynamic functioning of the pulmonary circulation, thereby reducing pulmon
ary hypertension and improving perfusion, oxygenation and cardiac output. These
are used particularly to patients who are compromised. However bleeding is a sig
nificant side effect. Contraindications include CVA within the past 1 months, ot
her intracranial processes, active bleeding, surgery within 10 days, recent labo
r and delivery, trauma or severe hypertension.
d. Nursing Management VIII. Minimizing the risk of Pulmonary Embolism Asses
potential for Pulmonary Embolism Monitoring Thrombolytic therapy Managing pain M
anaging oxygen therapy Relieving anxiety Monitoring for complications Providing
post-operative nursing care
Client Education Before hospital discharge and at follow-up visits to the clinic
, the nurse instructs about preventing recurrence and reporting signs and sympto
ms. Most effective approach for prevention is to prevent deep venous thrombosis.
a. b. c. d. e. f. g. Active leg exercises Early ambulation Use of elastic compr
ession stockings Avoid sitting with legs crossed or sitting for prolonged period
s of time Drink fluids, especially while travelling and in warm weather Do not w
ear constrictive clothing Legs should not be dangled while the patient sits on t
he edge of the bed
IX.
Reference
Guyatt GH, Akl EA, Crowther M. et al. Executive Summary: AntithromboticTherapy a
nd Prevention of Thrombosis, 9th ed: American College of Chest Physicians Eviden
ce-Based Clinical Practice Guidelines. Chest. 2012;141(2suppl):7s-47s. Righini M
, Le Gal G, Aujesky D, et al. Diagnosis of pulmonary embolism by multidetector C
T alone or combined with venous ultrasonography of the leg: a randomised non-inf
eriority trial. Lancet. 2008;371(9621):1343-1352. Weitz JI. Pulmonary embolism.
In: Goldman L, Schafer AI,eds. Cecil Medicine. 24th ed. Philadelphia, PA: Saunde
rs Elsevier; 2011:chap 98. http://www.nlm.nih.gov/medlineplus/ency/article/00013
2.htm http://allnurses.com/pulmonary-nursing/having-trouble-nursing-187187.html
http://www.patient.co.uk/doctor/Pulmonary-Embolism.htm http://en.wikipedia.org/w
iki/Pulmonary_embolism http://emedicine.medscape.com/article/300901-medication#1
Risk factors for Pulmonary Embolism
VENOUS STASIS Prolonged immobilization Prolonged periods of sitting/travelling V
aricose veins Spinal cord injury
HYPERCOAGULABILITY Injury Tumor Increased platelet count
VENOUS ENDOTHELIAL DISEASE Thrombophlebitis Vascular disease Foreign bodies
CERTAIN DISEASE STATES Heart disease Trauma
Postoperative state/ postpartum period Diabetes mellitus COPD