MSMSIIIIII

MSMSIIIIII

PULMONARY PULMONARY EMBOLISMEMBOLISM

PULMONARY PULMONARY EMBOLISMEMBOLISM

University of BoholGraduate School & Professional Studies Department

Tagbilaran City, Bohol, Philippines 

Mary Ann Adiong, RN, USRN - Mary Ann Adiong, RN, USRN - MasterandMasterand

ORGANS INVOLVEDORGANS INVOLVEDORGANS INVOLVEDORGANS INVOLVED

ORGANS INVOLVED (cont’d)ORGANS INVOLVED (cont’d)ORGANS INVOLVED (cont’d)ORGANS INVOLVED (cont’d)

• A pulmonary embolism (PE) is a potential cardiovascular emergency wherein a blood clot develops in a blood vessel elsewhere in the body (most commonly from the leg), travels to an artery in the lung, and forms an occlusion (blockage) of the artery.

• The lungs and the breathing system are called the pulmonary system. A clot in the lungs is called a pulmonary embolism. The arteries going to the lungs get progressively smaller. This allows carbon dioxide to leave the blood and go to the air we breathe out. It also allows the oxygen to enter the blood from the air we breathe in.

• The pathway of a PE from the lower part of the body: inferior vena cava, to right atrium, to right ventricle, to the pulmonary artery. This might eventually obstruct blood flow to the lung.

• Pulmonary embolism is a serious condition that can cause damage to the lung. This is because the part of the lungs that is fed by the blocked artery dies. PE also decreases the capacity of the blood to pick up oxygen. Since the blood picks up less oxygen, the body will have less oxygen level. This in turn can damage other organs such as the heart. The heart will have to work harder to pump more blood so the body can get the oxygen it needs. A big clot that blocks a larger artery in the lungs can be fatal. A small clot may not be fatal but may still cause significant damage.

© Copyright 2004 McGraw-Hill. All rights reserved. 7–4

PATHOPHYSIOLOGYPATHOPHYSIOLOGYPATHOPHYSIOLOGYPATHOPHYSIOLOGY

SIGNS AND SYMPTOMSSIGNS AND SYMPTOMSSIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

Signs and symptoms of pulmonary embolism (PE) include:

unexplained shortness of breath problems breathing chest paincoughing, or coughing up bloodan arrhythmia (irregular heartbeat) also may suggest that you have PE.swelling of the leg or along a vein in the legpain or tenderness in the lega feeling of increased warmth in the area of the leg that's swollen or tenderred or discolored skin on the affected leg.feelings of anxiety or dreadlight-headedness or fainting rapid breathingsweatingincreased heart rate

See your doctor right away if you have any signs or symptoms of PE or DVT. It's also possible to have PE and not have any signs or symptoms.

MEDICAL/NURSING MANAGEMENTMEDICAL/NURSING MANAGEMENTMEDICAL/NURSING MANAGEMENTMEDICAL/NURSING MANAGEMENT

Diagnostic Test/Laboratory Procedures:Diagnostic Test/Laboratory Procedures:

Reasons for Test:

Chest X-rays are often done on patients with shortness of breath to help rule-out other causes, such as congestive heart failure and rib fracture. Chest X-rays in PE are rarely normal, but usually lack signs that suggest the diagnosis of PE.

Nursing Considerations:

You will be asked to remove all jewelry from the waist up. You will also put on a hospital gown. A lead apron may be placed over your abdomen and pelvis. This is done to minimize the risk of radiation.

VQ SCANVQ SCANVQ SCANVQ SCAN

REASONS FOR TEST:REASONS FOR TEST:This test is most commonly done in order to check for the presence of a blood clot or abnormal blood flow inside the lungs (such as a pulmonary embolism or PE), although computed tomography with radioactive dye is now more commonly used for this purpose.

NURSING CONSIDERATIONS:•A VQ Scan requires injection of radioactive contrast dye. Explain to the patient that this test evaluates blood flow in the lungs. Tell the patient who will perform the test, where and when it will be done and that it takes about30 minutes.

•Tell the patient that first he will lie in a supine position on a table as radioactive dye is injected into the arm vein. While he remains in supine, a large camera will take pictures, continuing as he lies on his side, lies prone and sits up. When a patient is in prone, more dye will be injected.

•Reassure him that the amount of radioactivity in the dye is minimal. However, he may experience some discomfort from the venipuncture and from lying on a cold, hard table. He may also feel claustrophobia when surrounded by the camera equipment.

CT Pulmonary AngiogramCT Pulmonary AngiogramCT Pulmonary AngiogramCT Pulmonary Angiogram

CT pulmonary angiogram (CTPA) is a medical diagnostic test that employs computed tomography to obtain an image of the pulmonary arteries. Its main use is to diagnose pulmonary embolism (PE). It is a preferred choice of imaging in the diagnosis of PE due to its minimally invasive nature for the patient, whose only requirement for the scan is an intravenous line. A CT angiogram procedure is also known as angiography. This procedure allows your physician to locate plaque build-up or narrowed arteries at an earlier stage, helping you to possibly avoid a heart attack.

NURSING CONSIDERATIONS:•Explain to the patient that CT will be used to diagnose or evaluate his respiratory disorder. Tel him who, where and when it will be done. CTPA usually takes 1 ½ hours. Note the radioactive dye will be used to enhance the cross-sectional images of his chest.

•If a contrast dye will be used, instruct the patient to fast for 4 hours before the test. Remove all jewelry before the CTPA.

•Tell the patient that he’ll lie on a large, noisy, tunnel-shaped machine. When the dye is injected into his arm vein, he may experience transient nausea, flushing, warmth and a salty taste. The equipment may make him claustrophobic. Tell him not to move during the test but to relax and breathe normally. Movement may invalidate the results and require repeat testing. Reassure him that radiation exposure during the test is minimal.

Images of Pulmonary Embolism in CTPAImages of Pulmonary Embolism in CTPA

ULTRASONOGRAPHY/DOPPLER ULTRASONOGRAPHY/DOPPLER STUDIESSTUDIES

ULTRASONOGRAPHY/DOPPLER ULTRASONOGRAPHY/DOPPLER STUDIESSTUDIES

NURSING CONSIDERATIONSNURSING CONSIDERATIONS: :

1.Explain to the patient that Doppler ultrasonography is used to evaluate blood flow in the arms and legs or neck. Tell him who will perform the test and when. Reassure the patient that the test doesn’t involve risk or discomfort.

2.For peripheral arterial evaluation in the leg, the usual test sites are the common and superficial femoral, popliteal, posterior tibial, and dorsalis pedis arteries.

3.Brachial blood pressure is measured, and the transducer is placed at various points along the test arteries.

4.The signals are monitored, and the waveforms are recorded for later analysis.

5.The blood flow velocity is monitored and recorded over the test artery.

6.Segmental limb blood pressures are obtained to localize arterial occlusive disease.

7.Remove the conductive gel from the patient’s skin.

8.Assist the patient to a comfortable position.

9.Make sure that the Doppler probe isn’t placed over an open or draining lesion.

LABORATORY TESTSLABORATORY TESTSLABORATORY TESTSLABORATORY TESTS

1. 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 result 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.

2. Arterial blood gas analysis. A sudden drop in the blood oxygen level may suggest a pulmonary embolism.

3. Coagulation Profile. Additional blood work should include coagulation studies to evaluate for a hypercoagulable 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.

PHARMACOLOGIC MANAGEMENTPHARMACOLOGIC MANAGEMENTPHARMACOLOGIC MANAGEMENTPHARMACOLOGIC MANAGEMENT

SURGICAL MANAGEMENTSURGICAL MANAGEMENTSURGICAL MANAGEMENTSURGICAL MANAGEMENT

EMBOLECTOMY is the emergency surgical  removal of emboli which are blocking blood circulation. It usually involves removal of thrombi (blood clots), and is then referred to as thrombectomy. Embolectomy is an emergency procedure often as the last resort because permanent occlusion of a significant blood flow to an organ leads to necrosis. 

INDICATIONS:

•Surgical embolectomy for massive pulmonary embolism (PE) has become a rare procedure and is often viewed as a last resort. 

•Surgical or catheter embolectomy is normally performed in patients with pulmonary embolism (formed from venous embolisms). Embolectomy is used for patients with persisting shock despite supportive care and who have an absolute contraindication for thrombolytic therapy. And although other treatments have improved urgent surgical embolectomy or catheter embolectomy may be a life saving procedure in severe pulmonary embolism.

• Embolectomies are performed for arterial embolisms in acute limb ischemia. It can also be used for other ischemias due to embolism for example mesenteric ischemia and stroke.

NURSING CONSIDERATIONS: NURSING CONSIDERATIONS: 1.1. Monitor peripheral circulation. Keep extremities warm (room Monitor peripheral circulation. Keep extremities warm (room

temperature). Ensure safety measures to prevent displacement of temperature). Ensure safety measures to prevent displacement of arterial and venous sheaths.arterial and venous sheaths.

2.2. Maintain bed rest.Maintain bed rest.

3.3. Keep cannulated extremity in neutral or slightly flexed position.Keep cannulated extremity in neutral or slightly flexed position.

4.4. Apply knee or leg immobilizer or soft restraint.Apply knee or leg immobilizer or soft restraint.

5.5. Assist with meals, use of bedpans and position changes appropriate to Assist with meals, use of bedpans and position changes appropriate to activity limitations.activity limitations.

6.6. Continue prescribed dose of medication. Check clotting times Continue prescribed dose of medication. Check clotting times periodically after start of infusion and after change in dose. Note for any periodically after start of infusion and after change in dose. Note for any signs of bleeding. signs of bleeding.

7.7. Do passive ROM exercises to unaffected extremities every 2-4 hours as Do passive ROM exercises to unaffected extremities every 2-4 hours as tolerated.tolerated.

8.8. Instruct patient to report presence of pain, numbness, tingling and Instruct patient to report presence of pain, numbness, tingling and decrease or loss of sensation and movement immediately.decrease or loss of sensation and movement immediately.

9.9. Immediately report to physician decrease or loss of pulse, change in skin Immediately report to physician decrease or loss of pulse, change in skin color, temperature, presence of pain, numbness, tingling, delayed color, temperature, presence of pain, numbness, tingling, delayed capillary refill and decreased and loss of sensation and motion.capillary refill and decreased and loss of sensation and motion.

PREVENTIONSPREVENTIONSPREVENTIONSPREVENTIONS

Clot prevention strategies in the hospital may include:

1.ANTICOAGULANT THERAPY. An anticoagulant, such as a heparin injection, is given to anyone at risk of clots before and after an operation — as well as to people admitted to the hospital with a heart attack, stroke, complications of cancer or burns. You might take oral warfarin for a few days before major elective surgery to reduce your risk of clots.2.GRADUATED COMPRESSION STOCKINGS. Compression stockings steadily squeeze your legs, helping your veins and leg muscles move blood more efficiently. They offer a safe, simple and inexpensive way to keep blood from stagnating after general surgery.3.USE OF PNEUMATIC COMPRESSION. This treatment uses thigh-high or calf-high cuffs that automatically inflate with air every few minutes to massage and squeeze the veins in your legs and improve blood flow.4.PHYSICAL ACTIVITY. Moving as soon as possible after surgery can help prevent pulmonary embolism and speed your overall recovery. This is one of the main reasons your nurse may push you to get up and walk as soon as one day after surgery.

NURSING CARE PLANSNURSING CARE PLANSNURSING CARE PLANSNURSING CARE PLANS

NURSING THEORYNURSING THEORYNURSING THEORYNURSING THEORY

Dorothea Orem’s Theory of Self CareDorothea Orem’s Theory of Self Care““Individuals, families, groups and communities need to be taught self-care” Individuals, families, groups and communities need to be taught self-care”

The overall purpose of Orem's theory is not just to view the person as a whole, but to utilize nursing knowledge to restore and maintain the patient's optimal health. This theory when applied to nursing practice could identify the self care requisites of the patient in various aspects. This is helpful to provide care in a comprehensive manner. The application of this theory in the management of patients will reveal how well the method of nursing assistance (acting and doing for, guiding, teaching, supporting, providing a developmental environment) and the nursing systems used (wholly compensatory, partly compensatory or supportive-educative) could be used to solve the identified problems of the patient with self care deficit.