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Pulmonary Embolism

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Ryan Buszek

on 10 September 2013

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Transcript of Pulmonary Embolism

Pathophysiology of pulmonary embolism (PE)
“Collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels”
(Ignatavicius & Workman, 2013, p. 663).
Most often “occurs when a blood clot froms a venous thromboembolism (VTE), especially a deep vein thrombosis (DVT) in a vein in the legs or the pelvis, breaks off and travels through the vena cava into the right side of the heart” and “then lodges in the pulmonary artery or within one or more of its branches”
(Ignatavicius & Workman, 2013, p. 663).
Factors that contribute to thrombus formation (Virchow’s triad):

• Venous stasis- immobility, HF, dehydration, varicose veins
• Hypercoagulability- trauma, surgery, malignancy, oral contraceptives
• Damage to vein wall

Other less common causes of PE:
• Fat emboli
• Air emboli
• Amniotic fluid emboli

“Large emboli obstruct pulmonary blood flow, leading to reduced oxygenation, pulmonary tissue hypoxia, and potential death” (Ignatavicius & Workman, 2013, p. 663).

Risk Factors for Thromboembolism

Strong Risk Factors
•Fracture of the hip, pelvis, or leg
•Hip or knee replacement
•Major general surgery
•Spinal cord injury/paralysis
•Major trauma
Moderate Risk Factors
•Arthroscopic knee surgery
•Central venous lines
•Malignancy
•Heart or respiratory failure
•Hormone replacement therapy, oral contraceptives
•Paralytic stroke
•Postpartum period
•Previous venous thromboembolism
•Thrombophilia

Weak Risk Factors
•Bed rest for more than 3 days
•Immobility due to sitting
•Increasing age
•Laparoscopic surgery
•Obesity
•Antepartum period
•Varicose veins
(Morton & Fontaine, 2013, p. 244)



Classic Symptoms
•Dyspnea, sudden onset
•Sharp, stabbing chest pain
•Apprehension, restlessness
•Feeling of impending doom
•Cough
•Hemoptysis

Signs
•Tachypnea
•Crackles
•Pleural friction rub
•Tachycardia
•S3 or S4 heart sound
•Diaphoresis
•Fever, low-grade
•Petechiae over chest and axillae
•Decreased arterial oxygen saturation (SaO2)
•Distended neck veins
•Syncope
•Cyanosis
•Hypotension
(Ignatavicius & Workman, 2013, p. 664)
Risk factors for our patient:
•Hx of varicose veins
•Overweight
•Oral contraceptives
•Recent surgery
•DVT (swollen, warm, tender, positive Homan’s, confirmed with Doppler flow study)

Manifestations of PE in our patient:
•Dyspnea, SOB
•Tachypnea
•Sharp chest pain
•Restlessness and anxiety
•Tachycardia
•Low-grade fever

Possible testing and results
Doppler Flow Study aka Doppler Velocimetry

What: “Doppler flow is a type of ultrasound that uses sound waves to measure the flow of blood through a blood vessel.” (LPCH, 2013)
Why: Left calf pain, edema, erythema. Positive Homans sign.
Result: Left popliteal deep vein thrombosis.

Arterial Blood Gas

What: A blood sample drawn from the radial artery by RT assessing the pH and the amounts of O2 and CO2.
Why: A collapsed lung can result in impaired gas exchange leading to diminished perfusion.
Result: Increased pH and PaCO2.

PH 7.52 ↑
PaCO2 28 ↑
PaO2 131
SaO2 99%

Since Ms. James pulmonary embolus was caused from a venous thromboembolism. Her pulmonary embolus is managed by:
1. Anticoagulation
2. Thrombolytic enzymes
3. Inferior Vena Cava interruption
4. Embolectomy

Objectives of Treatment:
1. Prevent further growth or multiplication of thrombi in the lower extremities
2. Prevent embolization from the upper or lower extremities to the pulmonary vascular system
3. Provide cardiopulmonary support if indicated

Treatment plan of Ms. James involves:
Anticoagulant drugs prevent additional clots formation and halts existing blood clots from enlarging:
Heparin, Low Molecular Weight Heparin (LMWH), Warfarin

Thrombolytic drugs break up and dissolve blood clots:
Streptokinase, Alteplase (tPA)

Other treatments:
Since Ms. James' oxygen levels are below therapeutic range she is treated with oxygen.
Ms. James will be treated with analgesics to relieve pain.
Administration of IV fluids and certain drugs if Ms. James becomes hypotensive.
Mechanical ventilation may be needed if Ms. James shows signs of respiratory failure.

Inferior vena cava interruption: Filters are used as the most common procedure for IVC interruption. There are two types of filters namely permanent or retrievable. A pulmonary angiography is done prior to the surgery to rule out an embolus. IVC interruption is done under fluoroscopic guidance where a filter is placed into the inferior vena cava beneath the renal vein.

Pulmonary embolectomy: Clot is removed either surgically or a catheter is used. Preoperative angiography is done to confirm the pulmonary embolism. IVC filter is placed after embolectomy.

Long Term Prevention:
Risk level assessment
Weight Loss
Increased physical activity levels
Smoking cessation
Medication compliance

Nursing Diagnosis:
1. Impaired gas exchange related to altered oxygen supply secondary to ventilation perfusion mismatch.

2.Acute Pain R/T inflammatory process caused by thrombus formation.

Pulmonary Embolism
Ryan Alsbrooks
Ryan Buszek
Mir Khan
Matt Peterson
Also, “platelets collect on the embolus, triggering the release of substances that cause blood vessel constriction” in the lungs which further impairs gas exchange (Ignatavicius & Workman, 2013, p. 663).
CASE STUDY
Sandra James is a 32 y. o. female with a history of varicose veins. She is a 5'2" and 150 lbs. Ms. James has two children ages 6 and 4. Her current method of birth control is oral contraceptives.
 
She is currently hospitalized following excision of internal and external hemorrhoids. All other history is insignificant.
 
Ms. James’post operative course is uneventful until the second day when she complains of pain in her left calf. On examination you find the calf swollen and warm to the touch.
L >R. Homans sign is positive
You inform the primary physician and a doppler flow study is performed. The results reveal a left popliteal deep vein thrombosis.
 
Ms. James is placed on bed rest and anticoagulation therapy via a continuous heparin infusion. She does well on heparin for 2 days after which she begins to c/o shortness of breath and left anteior chest pain that worsens with deep inspiration. She is restless and afraid and says, “Am I going to die?”

Physical assessment reveals the following:
 
BP 160/88
HR 120
Resp 34 and labored
Temp 99EF

PT and PTT

What: Venous blood test to assess the capacity of blood to clot.
Why: Patient is on coagulation therapy with scheduled angiogram.
Result: Increased coagulation time. Angiogram postponed.

PT 16.7 sec. PTT 46.9 sec.
Control 1.7 sec. Control 25.3 sec.
Ventilation Perfusion Scan

What: Nuclear imaging test to assess the movement of blood and air through the lungs.

Why: Ordered when when a pulmonary embolus is suspected. Also used to assess lung function of COPD patients and shunt detection.

Result: Anterior and posterior left upper lobe perfusion defects.
Chest X-ray

What: Noninvasive Interventional Radiology using ionizing radiation ordered when a mass or fluid is suspected in the chest.

Why: Shortness of breath, left anterior chest pain exacerbated by deep inspiration, restlessness, anxious, high BP, tachycardia, tachypnea, elevated temperature.

Result: Left lower lobe atelectasis.
References

Ignatavicius, D. D and Workman, M. L. (2013). Medical-Surgical nursing: Patient-Centered collaborative care, (7th ed.). New York, NY: W.B. Saunders Company (Elsevier).

Lucile Packard Children’s Hospital. (2013). Doppler Flow Studies. Retrieved from http://www.lpch.org/DiseaseHealthInfo/HealthLibrary/hrpregnant/dfs.html .

Morton, P. & Fontaine, D. (2013). Essentials of critical care nursing: A holistic approach. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Williams.

National Institute of Health. (2013). Pulmonary Ventilation/Perfusion Scan. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/003828.htm .

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2010). Davis’s Drug Guide for Nurses, (13th ed.). Philadelphia, PA: F. A. Davis.

Seeley, R. R., Stephens, T. D., & Tate, P. (2008). Anatomy & Physiology, (8th ed.). New York, NY: McGraw Hill.

Nursing interventions for preventing PE:
Frequent ambulation
Pneumatic Leg Compression Devices
Pharmacologic interventions
Proper IV set up
Discontinuation of oral contraceptives
Patient education
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