Care of Patient With Pulmonary Embolism

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Care of Patient With Pulmonary Embolism

(PE)

Dr. Belal Hijji, RN, PhD

October 29, 2011


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Learning Outcomes

At the end of this lecture, students will be able to:

Describe PE, its pathophysiological changes, and discuss itsclinical manifestations.

Identify the diagnostic test that may be used to diagnose PE.

Discuss the medical and nursing management of PE.


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Introduction

Pulmonary embolism (PE) is an obstruction of the pulmonary

artery (next slide) or one of its branches by a thrombus (orthrombi) that originates somewhere in the venous system.

The types of emboli could be a blood clot (most common), air,fat, amniotic, fluid, and septic (from bacterial invasion of thethrombus).

PE is often associated with trauma, surgery (orthopedic),pregnancy, heart failure, age > 50 years, hypercoagulablestates, and prolonged immobility.

Most thrombi originate in the deep veins of the legs; other sites

include the pelvic veins and the hearts right atrium. An enlarged right atrium in fibrillation causes blood to

stagnate[ ] and form clots that may travel into thepulmonary circulation causing PE.


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Pathophysiology

When there is a complete or partial obstruction of a pulmonaryartery or its branches by a thrombus, the alveolar dead space(next slide) is increased. The area, although continuing to beventilated, receives little or no blood flow, resulting inimpaired or absent gas exchange.

In addition, various substances are released from the clot andsurrounding area, causing regional blood vessels and

bronchioles to constrict. This causes an increase in pulmonaryvascular resistance. This results in an increase in pulmonaryarterial 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 decreasein cardiac output followed by a decrease in systemic blood

pressure and the development of shock.


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Alveolar dead space: A well-ventilated part of the lung is not

receiving blood flow. The air reaching that region of the lung is

therefore wasted since it cannot participate in gas exchange, thus the

alveoli are considered dead.


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Clinical Manifestations

The symptoms of PE depend on the size of thethrombus and the area of the pulmonary artery

occluded by the thrombus. Dyspnea is the most frequent symptom; while

tachypnea is the most frequent sign. Chestpain is common and is usually sudden andpleuritic. Other symptoms include anxiety,

fever, tachycardia, apprehension, cough,diaphoresis, hemoptysis, and syncope.

Deep venous thrombosis is closely associatedwith the development of PE. Typically,

patients report sudden onset of pain and/orswelling and warmth of the proximal or distalextremity, skin discoloration, and superficialvein distention.


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Assessment and Diagnostic Findings

Early recognition and diagnosis of PE are priorities as death

commonly occurs within 1 hour of symptoms. The diagnostic workup includes a ventilationperfusion scan,

pulmonary angiography, chest x-ray (may show infiltrates,atelectasis, elevation of the diaphragm on the affected side, ora pleural effusion), ECG (sinus tachycardia, PRintervaldepression, and nonspecific T-wave changes), and arterial

blood gas analysis (may show hypoxemia and hypocapnia(from tachypnea)).

If lung scan results are not definitive, pulmonary angiography

is the gold standard for the diagnosis of PE.


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Medical Management

Emergency management.

Nasal oxygen to relieve hypoxemia, respiratory distress, andcentral cyanosis.

Intravenous infusion lines to administer medications or fluids.

A perfusion scan, arterial blood gas determinations are

performed. Pulmonary angiography may be performed. Hypotension is treated by a slow infusion of dobutamine

(Dobutrex).

The ECG is monitored continuously for dysrhythmias which

may occur suddenly.

Digitalis glycosides, intravenous diuretics, and antiarrhythmic

agents may be indicated.

Blood is drawn for serum electrolytes and complete blood count.

Intubation and mechanical ventilation may be performed based

on clinical assessment and arterial blood gas analysis.


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Emergency management (Continued).

In case of hypotension, a Foleys catheter is inserted to monitorurinary output.

Small doses of intravenous morphine to relieve the patientsanxiety, to alleviate chest discomfort, to improve tolerance of theendotracheal tube, and to ease adaptation to the mechanicalventilator.

Pharmacologic therapy. (Anticoagulation)

Heparin is used to prevent recurrence of emboli. The dose is anintravenous bolus of 5,000 to 10,000 units, followed by acontinuous infusion at a rate of 18 U/kg per hour. The rate isreduced in patients with a high risk of bleeding. Heparin isusually administered for 5 to 7 days.

Warfarin sodium administration is begun within 24 hours afterinitiation of heparin therapy because its onset of action is 4 to 5days. Warfarin is usually continued for 3 to 6 months.Anticoagulation therapy is contraindicated in patients who are atrisk for bleeding (eg, those with gastrointestinal conditions or

with postoperative or postpartum bleeding).


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Pharmacologic therapy (Continued). Thrombolytic

therapy

Streptokinase may be used in patients who are hypotensive and

have significant hypoxemia. It resolves the thrombi or embolimore quickly and reduces pulmonary hypertension and

improves perfusion, oxygenation, and cardiac output.

Is initiated after stopping heparin. During therapy, all but

essential invasive procedures are avoided because of potential

bleeding.

Cessation necessitates the initiation of anticoagulants.


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Nursing Management

Minimizing The Risk of Pulmonary Embolism A major responsibility of the nurse is to identify patients at high

risk for PE and to minimize the risk of PE in all patients.

Therefore, the nurse must give attention to conditions

predisposing to a slowing of venous return (i.e. prolonged

immobilization, prolonged periods of sitting/traveling, varicoseveins, spinal cord injury), hypercoagulability due to release of

tissue thromboplastin after injury/surgery (i.e. pancreatic, GI, GU,

breast, or lung tumor, increased platelet count in polycythemia),

venous endothelial disease (i.e. thrombophlebitis, foreign bodies

such as IV/central venous catheters)


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Preventing Thrombus Formation. The nurse: encourages ambulation and active and passive leg exercises to

prevent venous stasis in patients on bed rest and to help increase

venous flow.

discourages the patient against sitting or lying in bed for

prolonged periods, crossing the legs, and wearing constricting

clothing. Legs

discourages legs dangling or feet placed in a dependent position

while sitting on the edge of the bed; instead, the patients feet

should rest on a chair. Should not leave intravenous catheters in place for prolonged

periods.


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Assessing Potential For Pulmonary Embolism. The nurse

should:

examine patients who are at risk for developing PE for a positive

Homans sign (pain in the calf as the foot is sharply dorsiflexed),

which may or may not indicate impending thrombosis of the leg

veins. A positive Homans sign may indicate DVT.


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Monitoring Thrombolytic Therapy. The nurse:

keeps the patient on bed rest

assesses vital signs Q2H.

ensures that tests to determine prothrombin time or partial

thromboplastin time are performed 3 to 4 hours after the

thrombolytic infusion is started to confirm that the fibrinolyticsystems have been activated.

ensures that only essential venipunctures are performed because

of the prolonged clotting time, and manual pressure is applied to

any puncture site for at least 30 minutes. uses pulse oximetry to monitor changes in oxygenation.

immediately discontinues the infusion if uncontrolled bleeding

occurs.


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Managing Chest Pain. The nurse:

Places the patient in a semi-Fowlers position which is more

comfortable for breathing.

continues to turn the patient frequently and repositioning him to

improve the ventilationperfusion ratio in the lung.

Administers opioid analgesics as prescribed for pain.


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Managing Oxygen Therapy. The nurse:

gives careful attention the proper use of oxygen and ensures that

the patient understands the need for continuous oxygen therapy.

assesses the patient frequently for signs of hypoxemia and

monitors the pulse oximetry values to evaluate the effectiveness of

the oxygen therapy. encourages deep breathing and performs incentive spirometry to

minimize or prevent atelectasis and improve ventilation.


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Managing Anxiety. The nurse:

encourages the stabilized patient to talk about any fears or

concerns related to this frightening episode.

answers the patients and familys questions concisely and

accurately.

explains the therapy, and describes how to recognize untowardeffects early.

Documents

Care of Patient With Pulmonary Embolism