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Pulmonary Embolism

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tina regnani

on 8 June 2015

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Transcript of Pulmonary Embolism

PULMONARY EMBOLISM
~THE CLIENT~
46 year old, married female
2 children
Employed 3/4 time
Busy family, involved with kids at school
Strong faith, looking for new church
Lumbar laminectomy 8/31/13
Onset of pain 2 days prior to admit-9/18/13
Family History (mother: hx recurrent DVT, PE)
Inherited thrombophillia
By: Tina Regnani
PATHOPHYSIOLOGY~
PE: obstruction of pulmonary artery
Blood, air, or other material
tumor cells
foreign objects
broken catheters
injected particles
Fat emboli, oil
Client is often anxious-hypoxemia/pain
Blood Gases often not normal
Hyperventilation - respiratory alkalosis
shunting of blood from right to left without O2 delivery
CO2 rises-results in respiratory acidosis
Later-metabolic acidosis from lactic acid buildup
Emboli may not cause hypoxemia
Overview:
Client Diagnosis/
Pathophysiology
CTPA - Computed Tomography Pulmonary Angiogram
used most often for diagnosis
revealed PE - both lower lobes
mod-mild masses-blocked blood flow
possible infarct RLL- necrotic tissue/anoxia
PE - Pulmonary embolism

clots/thrombi begin in deep leg veins
travel from original source
lodge in small arteries of lungs
often silent or asymptomatic
trapped emboli lead to reduced O2, pain
blockage of moderate sized arteries - respiratory impairment
fluid fill alveoli of involved area
increase of BV pressure d/t vc within lungs
Anatomical
dead space
vs.
Physiological dead space
Air in conducting portion of lung
never reaches alveoli
How does PE impair efficient transfer of O2 and CO2?
Anatomic and alveolar dead space compartments have been combined into the total (physiologic) dead space
MEDICATION
ENOXAPARIN
/LOVENOX: Anticoagulant
(high alert)
85 mg, SQ, Q12 H (1mg/kgQ12h)
LMWH (preparation of molecules shorter
than unfractionated heparin)
A: preferential inactivation of factor Xa &
prothrombin
I: treatment of DVT w/ or w/out PE (with
warfarin)
Admin: Only SQ, plasma levels predictable, no lab
monitoring
ASSESSMENT
: signs of bleeding and hemorhhage,
nosebleed, bruising, black tarry stools
fall in HCT or BP





WARFARIN
/COUMADIN: Anticoagulant
(high alert)
5 mg QD, PO
A: interfers with hepatic synthesis of Vit. K
dependant clotting factors (II, VII, IX, and X).
I: Prophylaxis and treatment of PE
Admin: Evaluate recent INR or PT prior to admin,
Administer same time each day
ASSESSMENT:
signs of bleeding and hemorhhage,
nosebleed, bruising, black tarry stools
fall in HCT or BP


RATIONALE
Allows for long-term anticoagulation in at-risk patients to prevent the development of future clots (Ignatavicius & Workman p. 666).
Approved for prevention of DVT in patients at high risk or history of pulmonary embolism, (Lehne, p. 52). To allow for hospital discharge before complete switch to oral anticoagulants ( per hospital records/eMAR).
MEDICATION
RATIONALE
HEAD TO TOE
ASSESSMENT

Lab Values
NURSING DIAGNOSIS #1
CARE PLAN
TEACHING PLAN
DISCHARGE PLAN
References
ABNORMAL ? ASSESSMENT
FINDINGS
.
VS
Time: 1100
0800
T: 37.1
36.8
HR: 78
80
RR: 20
20
BP: 98/64
98/68
Pain: 4/0-10, intermittent
3/0-10
O2 saturation : 93
92
mode of O2 delivery: RA
RA

Safety/Environment
1. Safety concerns/issues. Fall Risk. The patient is placed on the hospital’s protocol for fall risk, is receiving IV pain medications that may cause confusion, sedation, dizziness that put her at risk for fall, no outright balance deficits, is weak and fatigued due to effects of PE and hospitalization, is hypoxic with ambulation.
Client appears somewhat improved today. She states “I’d like to sit in the chair for awhile this morning and take a shower”. Patient remains of medications that may affect her balance and is hypoxic with ambulation

*
2. Equipment:
Patient was on RA, monitored pulse oximetry was connected and on, saline lock in right ac , tubing is free of kinks and signs of breakdown, patency not checked by nursing student, call light was within reach. No alarm was necessary at this time.
Saline lock in right ac. All else unchanged

3. Immediate environment
(temp., noise, stimuli type) 74°, low light and noise (from TV)
Environment unchanged, patient more active in morning, resting more in afternoon.

B. Neurological
1. Level of consciousness Drowsy – alert.
alert and active in morning, increased drowsiness throughout day.
2. Level of orientation to person, place, time, and situation A/O X4
A/O X4
3. Pupils PERRLA PERRLA
4. Sensation and perception (consider sharp/dull, gross touch, etc.) Patient able to detect sharp/dull/gross touch b/l.
No change from yesterday
5. Circulation/movement/sensation findings: Patient had adequate pedal pulses (2+/0-1+) b/l. Adequate movement in all four extremities. Patient is free of any deficits in sensation in all four extremities b/l. Able to dorsiflex.
No change
6. No additional findings
C. Cardiovascular
1. Heart sounds:
a. Rate (apical x1 min), rhythm, quality HR: 80 bpm, regular, Heart sounds are strong.
HR: 80
bpm, regular, Heart sounds are strong,
b. Heart sounds heard S1 and S2 heart sounds heard.
Unchanged
c. Abnormal sounds heard No murmurs/abnormal sounds.
Unchanged
2. Peripheral pulses (quality, rhythm, location, strength) using scale-focus radial and DP or
focus for situation. Radial, dorasalis pedis, posterior tibial pulses 2+, regular b/l.
No
change from yesterday.
3. Edema None noted.
Unchanged
4. Neck vein distension Neck vein distention absent at 30-45°.
Unchanged
5. Capillary refill Less than 3 seconds at fingernails/toenails
Unchanged
6. Calf pain Patient denied calf pain upon gentle calf squeeze.
Unchanged.

D. Respiratory
1. Chest movement (rate, depth and rhythm of respirations, use of accessory muscles, shape of
chest) 20/minute, shallow breathing pattern, w/out use of accessory muscles. AP-
transverse 1:2.
20/minute, expansion normal.
2. Auscultation of breath sounds
a. Breath sounds (type, location) Vesicular breath sounds heard over lung periphery.
Bronchovesicular sounds heard between scapula. Breath sounds diminished in bases due to
shallow breathing due to pain of PE.
Vesicular breath sounds heard over lung periphery.
Bronchovesicular sounds heard between scapula. Breath sounds diminished in bases due to
pain of PE, but improved from yesterday
b. Adventitious sounds heard and location No adventitious sounds heard.
Unchanged
c. No Additional assessment findings noted either day.
3. Cough: No cough,productive or otherwise noted.
Unchanged
E. Gastrointestinal
1. Abdomen shape and size Abdomen is round, symmetric, soft .
Unchanged.
2. Bowel sounds auscultated (active, hypo, hyper and area on abd. where
sounds were heard)Bowek sounds active in all four quadrants.
Unchanged
3. Palpation No masses found upon palpation. Patient denies any pain or
tenderness.
Unchanged.
4. Percussion :

Not indicated
5. Assess current and past bowel function: Patient denies BM 2-3 days. Last
BM normal for patient, firm and brown. Patient states she has had flatus x
2-3 today.
Unchanged, patient requesting aid.


F. Genitourinary
1. Genitalia NA
2. Bladder palpation/percussion NA
3. Urine (color and character, amount, frequency, burning, continence) NA
a. Catheter (type, patency, positioned appropriately) NA

G. Motor
1. Extremities
a. Movement Full ROM in all four extremities.
Unchanged
b. Muscle strength, tone, and mass Able to overcome resistance, no
hypertrophy, has resting muscle tone it all four extremeties. No muscle
tenderness.
Unchanged.
2. Coordination and balance Patient appears steady when ambulating,
encouraged to use call light when toileting and is necessary for application of
gait belt to provide safety.
Unchanged.
3. Activity restrictions Activity is encouraged as tolerated. Ambulation to
include O2
4. Functional capacity with ADLs (what activities does client need assistance
with and type of assistance is needed). Risk for falls Patient can perform
ADLs as tolerated. Patient is not on hospital risk for falls official protocol.
Patient is encouraged to use call light for assistance to reduce risk
of fall when toileting. Patient continues to be encouraged to use call light for
toileting and showering. Patient found to need O2 with ambulation as Sao2
dropped to 87-88% with afternoon ambulation.

Integumentary
1. Color and condition of skin and mucous membranes Skin is pink, warn and dry. Mucous membranes
pink and moist, no lesions.
Unchanged
2. Turgor No tenting.
No tenting.
3. Skin breakdown, incisions, lesions . Lumbar incision without redness, swelling. No other lesions,
redness or skin breakdowns.
Unchanged.
4. Hair distribution (extremities and head) Patient has full head of short, dark hair, even distribution on
head and body.
Unchanged.
5. Color and condition of nails Nail beds pink, well groomed.
Unchanged
6. Factors predisposing skin breakdown/Braden Scale Patient is most comfortable in oblique/supine
position. While this stationary position, and lumbar incision predispose her to skin breakdown, she
changes position slightly and frequently to maximize her comfort which may reduce the risk of
pressure ulcers due to pressure being relieved often. Braden Scale: 21
Unchanged

I. Psychosocial/Spiritual
1. What methods does the client use as coping strategies? Do these methods seem to be
effective? Patient communicates clearly, has strong supportive family that communicates well.
Not talkative today, but responds to inquiries and instructions. Patient talked about the family
looking for a new church, she watched TV some to help "reduce her anxiety".
Family and friends visited for several hours today, patient shared she was happy after their visit
Why or why not? Coping methods appear to be effective, she is happy family and friends were with
her.
2. Usual communication strategies? Are they effective? Unsure of usual strategies. Difficult to assess
effectiveness. However, patient appears to cope and function well.
3. To what social system(s) does the client belong? What is the involvement of the
family/significant other? This patient is most likely in the lower middle class. Family is very
nvolved and has visited frequently. Relationships appear therapeutic.

J. Nutritional Assessment
1. Usual dietary habits r/t food pyramid. Patient east a well balanced diet. She states that she likes to
eat more carbs and sweet foods than she should and realizes she is overweight.
Unchanged
2. Prescribed diet/rationale; Regular diet. Patient is on no restriction.
Unchanged.
3. Appetite Patient has an excellent appetite. Eating 95-100% of meals.
Unchanged
4. Condition of mouth, teeth, gums Teeth are straight, white with pink gums, shiney with no lesions or
soreness, 27 teeth.
Unchanged
5. Ability to chew, swallow, and gag No problems with chewing or swallowing. Gag reflex intact.
Unchanged.
6. Alterations (e.g., nausea, vomiting) Patient has complained of nausea, antiemetic given
.No complaint
of nausea today.
7. Weight: 84.9 kg; Ht; 5-5, BMI: 31.1. Patient stated ideal weight to be ~ 150.

unchanged


8. Nutritional analysis: Patient eating a well balanced diet is important to improve current diagnosis and
to maintain health. Patient is aware of her over weight status and would like to remedy with weight loss. No lab work done related to nutritional analysis, is: Cholesterol, lipids, etc.

MEDICATION
RATIONALE
NURSING DIAGNOSIS #2
ASSESSMENT contd
Coumadin 7.5 mg daily P.O.
Follow-up visit 2 days
PT/INR
Lovenox 85 mg SQ, Every 12 hrs
client instructed on self-administration
Oxycodone 5 mg every 4 hrs prn pain
Continue supplements
Instructed to call physician
recurrent SOB
chest pain
bleeding difficulties




Objectives:

• Nurse will provide information on complications and risks of PE
• Patient will increase understanding of risk factors of PE and anticoagulation therapy.
• Patient will verbalize relaxation techniques.
• Patient will verbalize understanding of complications, risk factors, and anticoagulation
therapy

Strategies: Written Materials
• Handout defining Pulmonary Emboli, why they are dangerous, symptoms of PE in lungs,
legs, and how PE is treated.
• Handouts for Pulmonary embolism overview with risk factors and inherited
thrombophilia

Beginning with defining the client’s diagnosis, these handouts will help her in understanding PE Knowledge of problem will help to decrease complications ad risks and improve self management

Content Outline:
• Nurse will begin by defining the diagnosis.
• Nurse will inform patient about the risks and complications of PE.
• Nurse will review signs and symptoms of PE in lungs and legs
• Nurse will review diagnostics and treatment of PE
• Nurse will instruct client on relaxation techniques
• Nurse will provide time for Questions?

Evaluation:
What worked well? Integrating education into normal course of care. Plan with patient to set aside time specifically for education was very beneficial for increasing content and focus.
What could work better in future? Reducing education plan and focus on less material. Realizing patient needs to rest, but that education is a priority for self care.

Signature: Tina Regnani Date: 9/20/13

Reference of information:
Retrieved from: http://www.uptodate.com/contents/pulmonary-embolism-blood-clot-in-the-lungs-the basics.


NURSING DIAGNOSIS
#1: Risk or impaired gas exchange related to impaired pulmonary
blood flow AEB CTAP’s demonstration of mild to moderate clot both bases

Subjective Data:
Client c/o pain right posterior chest, SOB with activity, intermittent nausea.
Objective Data:
VS: P-78, BP-98/64, T-37.1, R: 20, shallow, SPO2 92% at rest on RA, Pain reported as 4/0-10. Lungs sounds are clear, breathing pattern shallow, without apparent distress, no hemoptysis noted., client responding well to pain meds with reports of mild, intermittent nausea with increased movement.

Long Term Outcome
: Patient to maintain SPO2 above 90% and ABG’s within normal ranges:
PaO2 80-100, PCO2 35-45, pH 7.35-7.45, HCO3- 22-26 by 9/22/13.
Short Term Outcomes
:
STO #1: PT & INR to remain within therapeutic range: INR: 3.0-4.0, PT: 3Xcontrol
value/>20 by 9/22/13
STO #2: Patient to verbalize and demonstrate effective relaxation techniques and verbalize
reduced anxiety by 9/22/13
STO #3: Patient to verbalize patient education discussed: define PE, risk factors and
complications of PE, adherence to medication and lab monitoring, by 9/22/13
Interventions:

Intervention #1: (LTO) Nurse will monitor SPO2 and ABG’s
Rationale: SPO2 and ABG’s are a reflection of patient’s pulmonary gas exchange
(Thelan’s, p. 638).
Intervention #2: (STO #1) Nurse to administer Lovenox 85mg every 12 hrs SQ, and
Warfarin 5 mg every day P.O.
Rationale: Lovenox and Warfarin prevent recurrence of PE by interference of both
intrinsic and extrinsic clotting pathways (Thelan’s, p. 636).
Intervention #3: (STO #2) Nurse will teach client relaxation techniques to reduce anxiety.

Rationale: Anxiety reduction will decrease hyperventilation and promote gas exchange
(Thelan’s, p. 665).
Intervention #4: (STO #3) Nurse will instruct client on importance of medication
adherence and post discharge follow-up visits for lab monitoring.
Rationale: Lovenox and Warfarin prevent recurrence of PE by interference of both
intrinsic and extrinsic clotting pathways (Thelan’s, p. 636).

Evaluation:
LTO: partially met. SPO2 remained above 90% until ambulated
STO #1: OOOOOOOOO fill this in!!
STO #2: Met- Client able to verbalize and demonstrate effective relaxation techniques
STO #3: Met- Client able to verbalize focus of education discussions re: PE treatment and
follow-up.

Overall evaluation:
Patient responding well to current course of treatment. Breathing still
shallow. SPO2 decreased to 88% with ambulation. Will ambulate with O2 /Dr’s
orders. Client’s SPO2 and ABG’s maintained within normal ranges.


NURSING DIAGNOSIS #2
CARE PLAN
NURSING DIAGNOSIS #2
: Impaired comfort related to pulmonary embolism AEB client
verbalizing pain level of 4/0-10.
Subjective Data:
Client states “pain level 4/0-10 while resting and higher with activity”.
Objective Data
: Pain reported as 4/0-10. Client often noted with grimace while at rest, or
with movement.
Long Term Outcome
: Client’s pain to be maintained at level acceptable to client: 2/0-10,
by 9/22/13
Short Term Outcomes:
STO #1: Client will identify and verbalize 3 non-pharmacological factors that
help to increase pain tolerance by 9/22/13
STO #2: Client will report acceptable pain level of 2/0-10 within 30 minutes of pain
medication administration by 9/22/13
STO #3: Client will verbalize request for pain medication when approaching level of
3/0-10 by 9/22/13

Interventions:
Intervention #1: (LTO) Nurse to assess and monitor client’s pain level every hour and then
every ½ hour after pain medication administration.
Rationale: Frequent and detailed assessment allows nurse to better understand
client’s pain (Thelan’s, p. 1152).
Intervention #2: (STO #1) Nurse will educate patient on non-pharmacological
interventions : distraction, position change, guided imagery, music, back rubs, aromatherapy.
Rationale: Non-pharmacological interventions help with reducing muscle tension and
promote relaxation (Thelan’s, p. 1153)
Intervention #2: (STO) Nurse will administer Oxycodine HCI 5mg every 4 hours PRN pain,
P.O. and follow-up up with assessment within 30 minutes.
Rationale: Administer pain medication and evaluate the effectiveness (Thelan’s, p.
1153).
Intervention #3: Nurse will instruct clients of importance of requesting pain medication
when pain is beginning and not waiting until it is intolerable.
Rationale: If administering pain medication on as necessary (PRN) basis, give it when
client’s pain is just beginning rather than at its peak (Thelan’s, p. 1152).

Evaluation:

LTO: Partially met- client’s pain level report at 2-3/0-10.
STO #1: Met- Client able to identity and verbalize 3 non-pharmacological factors aiding
in pain tolerance.
STO #2: Met- Client reported pain level of 0-2/0-10 within 30 minutes of receiving pain
med.
STO #3: Met- Client requested next pain medication when approaching level 0f 3/0-10.

Overall evaluation:
Client’s comfort level improved with closely monitored pain level,
patient education and good nurse-client communication.

Reference
Urden, L.D., Stacy, K. M. (2006).
Thelan’s Critical Care: Nursing diagnosis and
management
. St. Louis: Mosby Elsevier.


American College of Physician's. (2011),
American
College of Physicians Recommends New Approagch toPrevent Venous Thromboembolism in Hospitalized Patients. American College of Physicians Recommends New Approach to Prevent Venous Thromboembolism in Hospitalized Patients.
Retreived from http://www.acponline.org/pressroom/vte.htm

Ignatavicius, D. D., Workman, M. L. (2013).
Medical-
Surgical Nursing, patient Collaborative Care
. (7th Ed.)St. Loius: Elsevier Saunders.

Lehne, R. A. (2013).
Pharmacology for Nursing Care.

(8th Ed.) St. Louis: Elsevier Saunders.

Rollins, G. (2011). The challenge of Diagnosing
Pulmonary Embolism.
Clinical Laboratory News.
37(12).

Urden, L.D., Stacy, K. M. (2006).
Thelan’s Critical
Care: Nursing diagnosis and management
. St. Louis: Mosby Elsevier.
OXYCODONE
/
Roxicodone- pain
opioid analgesic
5mg, every 4 hrs PRN pain, P.O.
A: Binds to opiate receptors in CNS,
alters pain response
I: Moderate -severe pain
Admin: Intx: Caution w/ concurrent MAOI
Assess type, location, intensity of pain
prior to/1 hr after admin. May give supplemental for break through. Assess BP, P, R, periodically druing admin. If RR is less than 10 assess sedation level.


ONDANSETRON
/Zofran- nausea
antiemetic
4 mg IV, every 4 hours PRN,
A: Blocks effects of serotonin at 5-HT3 receptors sites
in vagal nerve and chemoreceptor trigger zone
I: Prevention of N/V
Admin: Intxs w/ few meds, ie: dilantin, may decrease
effects, 1st dose given prior to event.
Assess: for N/V, abd. distention, bowel sounds before and after administration




The patient who has
optimal pain control
is better able to cooperate with the therapies and exercises to prevent complications and promote rehabilitation (Ignatavicius, p. 297).

Figure 1. Nurse at bedside
Figure 2. Pulmonary System
Figure 3. Dead Space
Figure 4. PE
Figure 5. Lung PE
Figure 6. Torso
Diagnosis
American Association for Clinical Chemistry (AACC)
PE is diagnostically challenging
presents similar to: chest pain, dyspnea, syncope, HF
Est. 650,000-900,000 cases/yr
As many as 200,000 die
Physcians have tools, but these remain problematic
D-Dimer misused
blood test measures small protein fragment released when blood clot breaks up
CXR
EKG
ABG's
Dopplers
Echocardiogram
CT
Doppler U/S
MRI
CTPA (most common)
Pulmonary Angiogram (most accurate)
Nausea and vomitting can be dangerous. If vomiting is prolonged, hypokalemia, hypochloremia, hyponatremia and dehydration may develop. Aspiration of emesis is a life threatening complication in a patient whose reflexes are blunted by medications (Thelan's, p. 273)
*All medications proved effective for patient as
evidence by her PT/INR, pain managment and
reduced nausea after only one administration.
Patient unable to find comfort in supine position, most often in left oblique position with knees bent and pulled toward chest
Resp Rate 20, shallow breaths
Pain reported as 4/0-10
O2 Sat 93% RA
Diminished breath sounds b/l bases due to shallow breathing pattern, no adventitous sounds heard.
Mild, diffuse tenderness revealed at both calves upon admission, pt. reported no tenderness during assessment
Although client's O2 at rest consistently revealed 92-96% O2 Sat. reduced to 87-88% with ambulation.
Dr. contacted, prescribed O2 with ambulation
If a patient is at risk for VTE and bleeding from blood thinners, American College of Physician's (ACP) does not recommend using graduated compression stockings. The evidence shows that they are not effective in preventing VTE or reducing death, and result in clinically important lower extremity skin damage.
Psychosocial, Mental, Cultural components of assessment: Client expressed concern with family roles as homemaker, caregiver, and employee. Misses her family. Demeanor much improved while family visiting. Experiencing increased anxiety related to pain with breathing and financial concerns with hospital stay
NO ABG's!!
Normal lab Values:
CBC
AST-evaluates suspected hepatocellular disease
enzyme found in high concentration in highly metabolic tissue (heart, liver, skel. muscles
cells lyse when diseased
ALT- id's hepatocellular disease
Total Protein-significant component in osmotic
pressure within vascular space
Albumin: maintains colloidal osmotic pressure
Alkaline Phospatase- detects/monitors bone disease
Mg: Critical to metabolic processes-most bound to ATP
PT

Date: Result: Result:
9/18 15.1
H
1.29
9/19 15.2
H
1.30
9/20 13.8
H
1.18
9/22 15.2
H
1.30

INR
11.0-12.5
0.8-1.1
PT is test converted through algorhythm to
standardized #: INR

normal
normal
Therapeutic range for INR with PE is 2.0-3.0
Figure 7. Pt w/ O2
Figure 8. Lab
Figure 9. Bedside
Figure 10. NRSG
Figire 11. Nurse
Figure 11. Homebound
Full transcript