NCM 106 SY 2020-2021

Union Christian College

School of Health and Sciences
City of San Fernando
La Union

CASE
STUDY:
PULMONA
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RY
EMBOLISM

Submitted by:

ACENA, Jobelle C.

I. Introduction

Pulmonary embolism (PE) refers to the obstruction of the pulmonary artery or one of its
branches by a thrombus (or thrombi) that originate somewhere in the venous system or in the
right side of the heart. Deep venous thrombosis (DVT), a related condition, refers to thrombus
formation in the deep veins, usually in the calf or thigh, but sometimes in the arm, especially in
patients with peripherally inserted central catheters. Venous thromboembolism (VTE) is a term
that includes both DVT and PE.

PE is a common disorder and often is associated with trauma, surgery (orthopedic, major
abdominal, pelvic, gynecologic), pregnancy, heart failure, age older than 50 years,
hypercoagulable states, and prolonged immobility. It also may occur in apparently healthy
people.

Most commonly, PE is due to a blood clot or thrombus. However, there are other types of
emboli: air, fat, amniotic fluid, and septic (from bacterial invasion of the thrombus). When a
thrombus completely or partially obstructs a pulmonary artery or its branches, the alveolar dead
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space is increased. The area, although continuing to be ventilated, receives little or no blood
flow. Therefore, gas exchange is impaired or absent in this area. In addition, various substances
are released from the clot and surrounding area that cause regional blood vessels and bronchioles
to constrict. This results in an increase in pulmonary vascular resistance. This reaction
compounds the ventilation–perfusion imbalance.

Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery
occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the
duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is
common and is usually sudden and pleuritic in origin. It may be substernal and may mimic
angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia,
apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea
(very rapid respiratory rate).

II. Anatomy and Physiology

Pulmonary Artery

The main pulmonary artery, also called

the pulmonary trunk, is a vessel that emerges
from the heart. It divides into the left and right
pulmonary arteries, which carry blood with
relatively low oxygen content and high carbon
dioxide content into the lungs. There, it is
replenished with inhaled oxygen and excess
carbon dioxide is "dropped off" to be released
from the body via exhalation.

The pulmonary arteries are part of the

pulmonary circulation, which also
includes pulmonary veins and pulmonary
capillaries. The purpose of the pulmonary
circulation is to transfer oxygen and carbon
dioxide between the blood in the body and the
air that's inhaled and exhaled in the lungs. The
specific role of the pulmonary arteries is to carry blood that's low in oxygen and high in carbon
dioxide waste to the pulmonary capillaries of the lungs, where this exchange takes place. When
the blood is enriched with oxygen and cleared of carbon dioxide waste, it flows back through
your pulmonary veins to your heart's right ventricle. From there, the blood is pumped to the left
ventricle and finally dispersed through the aorta to the arteries that carry the oxygen-rich blood
throughout the body. 

A Pulmonary Embolus is a condition in which a blood clot lodges in the pulmonary

artery, blocking blood flow to the lungs. A PE can occur when a blood clot forms in a vein (such
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as in the legs) and travels through the heart, eventually becoming lodged in a pulmonary artery.
A pulmonary embolism is a life-threatening medical emergency that must be treated with blood
thinners or an interventional procedure.

III. Pathophysiology

Precipitating Factors
Predisposing Factors
 Stroke
 History of DVT or
 Heart disease or surgery
Pulmonary Embolism
 Cancer

Damage to the endothelium

Vasoconstriction

Platelets adhere to damage vessel wall

Formation of platelet plug

Coagulation cascades is activated

Activation of the protein fibrinogen to fibrin

Clot formation

Increase pressure in the vein

Thrombus/embolus

Migrates to IVC  RA  RV
 lodges in Pulmonary Artery
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Pulmonary Embolism

IV. Laboratory and Diagnostic Tests

Complete Blood Count and Serum Chemistries

Reference Range Interpretation

WBC 4.30-10 x 10 9/L Having a higher or lower number of WBCs than
(White Blood Cell) normal may indicate an underlying condition.

Elevated WBC is seen in response to infection,

stress, inflammatory disorders, or abnormal
production as in leukemia.

A decrease in WBC could mean our body may not

be able to fight infection the way it should.
ESR Male: ≤22 mm/hr The sed rate test measures the distance red blood
(Erythrocyte Female: ≤ 29 mm/hr cells fall in a test tube in one hour. The farther the
Sedimentation red blood cells have descended, the greater the
Rate) inflammatory response of your immune system.

LDH 140-280 u/L The lactate dehydrogenase (LDH) test looks for

(Lactate signs of damage to the body’s tissues.
Dehydrogenase)
Higher LDH levels in blood may be a sign of
tissue damage or disease.
AST 5-40 u/L AST (SGOT) is normally found in a variety of
(Aspartate tissues including liver, heart, muscle, kidney, and
Aminotransferase) the brain. It is released into the serum when any
one of these tissues is damaged

Elevation of AST can occur as a result of other

injured tissues.
D-dimer Enzyme- < 250 ng/mL or Elevated D-dimer levels reflect on-going
linked < 0.4 mcg/mL activation of the hemostatic and thrombolytic
Immunosorbent system.
Assay
A positive D-dimer may not indicate a PE, but a
negative D-dimer can help rule out a suspected PE
in cases where the probability of PE is small to
begin with
Troponin 0-0.4 ng/mL This test measures the amount of the protein
troponin in your blood.
Troponin is found in cells in your heart muscle.
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When these cells are injured—most often because

the heart isn't getting enough oxygen and nutrients
—they can release troponin and other substances
into the blood.

Even a slight increase in the troponin level will

often mean there has been some damage to the
heart. Very high levels of troponin are a sign that a
heart attack has occurred. 
Arterial Blood pH – 7.35-7.45 In PE:
Gas mean: 7.40
Acid Alka Fully compensated respiratory alkalosis with
moderate hypoxemia
PCO2 – 35-45
mean: 40
Alka Acid

HCO3 – 22-26
mean: 24
Acid Alka

PaO2 – 90-100%

DIAGNOSTIC TESTS

 Electrocardiography
o Sinus Tachycardia
o Non-specific S-T-T wave changes axis + 80
o Atrial arrhythmias

 Chest X-Ray
o Pulmonary infarct shows triangular, wedge-shaped defect
o Lung markings (primarily blood vessels) are diminished in area supplied by
clotted artery
o Right heart enlargement
o Atelectasis, pleural effusion, pulmonary infiltrates, elevated hemidiaphragm may
be seen
o Fleischner sign: prominent pulmonary artery caused by vessel distention due to a
large pulmonary embolus

 V/Q Scans (Lung Perfusion Scan)

o Perfusion failure in the normally ventilated pulmonary area (mismatch) suggests
PE
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 CT Pulmonary Angiography
o Visible intraluminal filling defects of pulmonary arteries
o Wedge-shaped infarction with pleural effusion is almost pathognomonic for PE

 Spiral CT Scan
o the emboli are multiple, with intraluminal filling defects observed in the larger
central arteries and in the segmental and subsegmental vessels

 Echocardiography (ECHO)
o Trivial tricuspid regurgitation
o Venous reflux with dilatation of IVC (with corresponding liver congestion seen
on ultrasound of the abdomen)
o Increase pulmonary artery systolic pressure
o Dilatation and hypokinesis of the right ventricle
o McConnell sign

 Venous Duplex Ultrasound

o Revealed deep vein thrombosis of the left lung

 MRI
o Partial or complete pulmonary artery filling defects
o Lack of vessel enhancement
o Main pulmonary artery dilatation
o Change in the caliber of the vessels with dilatation post-stenosis

V. MEDICAL/SURGICAL/NURSING Management

Surgical Management

Pulmonary Embolectomy

Surgical removal of a pulmonary embolism. This procedure is generally performed only

in severe situations in which the PE is very large, the patient either cannot receive
anticoagulation and/or thrombolytic therapy due to other medical considerations or has not
responded adequately to those treatments, and the patient's condition is unstable. A major
surgery requiring heart-lung bypass machine.

Procedure:
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 Catheter-based procedures involve passing a small tube (catheter) through a small

incision in the groin to the clot site. Your doctor uses special instruments to break up or
remove the clot. The procedure may also involve injecting a clot dissolving medication
through the catheter (thrombolysis). Your doctor may also place a mesh stent device in
the blood vessel to support it and keep it open.
 Open surgery involves making a large incision in the area of the blood clot through the
blood vessel to remove it. Open surgery allows your surgeon to directly view and access
the surgical area. Open surgery generally involves a longer recovery and more pain than
catheter surgery because it requires cutting and displacement of muscle and other tissues.
Open surgery is not common, but may be the best choice for emergencies to save an
organ and may be safer or more effective in certain other cases.

Indication

 massive PE, confirmed on angiography if possible

 hemodynamic instability despite anticoagulation therapy and resuscitative efforts
 failure of thrombolytic therapy or a contraindication to its use
 in critical patients with insufficient time for systemic thrombolysis to be effective

Contraindications

 persistent high risk of pulmonary hypertension

 right heart failure
 intractable pulmonary haemorrhage

Complications

 Damage to blood vessels

 Development of another blood clot in the treated blood vessel
 Heart arrhythmias
 Heart attack
 Low blood pressure
 Movement of the blood clot to another area of the body while trying to remove it
 Pulmonary embolism
 Stroke

VENA CAVA FILTER

An IVC filter is a small metal device that can stop blood clots in your veins from moving.
It’s used for conditions in which there’s a chance that a blood clot could enter your lungs, such
as deep vein thrombosis (DVT). It’s placed in your body’s main vein, called the inferior vena
cava (IVC). This vein runs through your belly. It sends blood from the lower half of your body
back to the heart. A doctor inserts the filter during a short surgery.

Procedure
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Using image guidance, a catheter is inserted through the skin into a large vein in the neck
or upper leg and advanced to the inferior vena cava in the abdomen. Contrast material will be
injected into the vein to assess for proper positioning of the IVC filter. The IVC filter is then
placed through the catheter and into the vein. Once it is in the correct position, the interventional
radiologist will release the filter, allowing it to fully expand and attach itself to the walls of the
blood vessel.

Indications

 Diagnosed with deep vein thrombosis (DVT).

 With pulmonary embolus.
 Who are trauma victims
 Who are immobile

Contraindications

 A too-small inferior vena cava vein

 Bacteria in the blood or sepsis, a dangerous condition caused when your body reacts to an
infection
 Blood clotting problems
 A blood clot that clogs the entire vena cava vein

Complications

 Bleeding: In up to 15% of cases, there’s bleeding at the vein where the doctor inserts the
catheter.
 Problems placing the filter: If it’s put in the wrong part of the vein or at an incorrect
angle, your doctor may need to do the surgery again.
 The filter moves or breaks: It may travel to your heart or lungs, which can lead to injury
or even death. You’ll need surgery to remove it.
 Infection: As with all surgeries, there’s a risk of an infection.
 The filter breaks the vein: It may pierce the inferior vena cava walls. This can damage
one of the nearby organs.
 Blood flow blockage: The filter may slow or stop the blood flow in the inferior vena
cava. This may cause your legs to swell.
 DVT: Although IVC filters protect against pulmonary embolisms, they may lead to DVT.
One study found that they raised the risk of DVT by 40%.

VI. Evaluation
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After rendering holistic care, the patient and the nurse will be able to achieve the specific
objectives. It is important to monitor progress toward outcomes, working with both the client and
the family. Continuing medications even after symptoms abate is recommended. Continue
encouraging the client to verbalizes and express his feelings, this would always be effective and
therapeutic to the client.

VII. Implication

Nursing Practice

This case study would make a contribution to the practice of medical nursing as it would
serve as a documentation that would then contribute to the appropriate plan of care in patients
with pulmonary embolism. This would also provide information about pulmonary embolism
(PE) and nursing interventions and therapeutic techniques used with patients who have this
condition. It also provides information about the plan of care for patients who have this condition
for efficient nursing care.

Nursing Education

To nursing education, this case study would help by providing information about the
disease condition, pulmonary embolism. The student nurses, as well as the clinical instructors
could gain additional information about this condition, so that it could better equip them for
efficient nursing care in the future. This study would explain the future nurses’ adequate
background knowledge regarding medical nursing before one is to be exposed to the clinical
setting. This would help expand knowledge regarding the disease and would correct
misconceptions toward this case. It would then promote awareness.

Nursing Research

Research is now an integral part of nursing. Through research, betterment or

improvement of nursing education to be practiced competitively in the clinical setting will be
achieved. In Nursing Research, this case study may broaden the scope or extent of research done
previously for pulmonary embolism. This may lead to another breakthrough study in the details
of the condition. This can also contribute in upgrading and updating the interventions made for
this condition.

VIII. Recommendations
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 Change your body position or move around often. Move and stretch in your seat
several times each hour if you travel by car or work at a desk. In an airplane, get up and
walk every hour.

 Exercise regularly to help increase your blood flow. Walking is a good low-impact

exercise. Talk to your healthcare provider about the best exercise plan for you.

 Maintain a healthy weight. Ask your healthcare provider how much you should weigh.
Ask him or her to help you create a weight loss plan if you are overweight.

 Do not smoke. Nicotine and other chemicals in cigarettes and cigars can damage blood
vessels and increase your risk for another PE. Ask your healthcare provider for
information if you currently smoke and need help to quit. E-cigarettes or smokeless
tobacco still contain nicotine. Talk to your healthcare provider before you use these
products.

 Ask about birth control if you are a woman who takes the pill. A birth control pill
increases the risk for blood clots in certain women. The risk is higher if you are also
older than 35, smoke cigarettes, or have a blood clotting disorder. Talk to your
healthcare provider about other ways to prevent pregnancy, such as a cervical cap or
intrauterine device (IUD).

References

 https://www.healio.com/cardiology/learn-the-heart/ecg-review/ecg-topic-reviews-and-
criteria/pulmonary-embolism
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 https://courses.lumenlearning.com/boundless-ap/chapter/hemostasis/#:~:text=Contrary
%20to%20popular%20belief%2C%20clotting,in%20the%20blood
%20vessels'%20endothelium.&text=Von%20Willebrand%20factor%20causes
%20them,the%20walls%20of%20the%20vessel
 https://ceufast.com/course/pulmonary-embolism-and-deep-vein-thrombosis
 http://www.elearnonline.net/area51/courses/Course592/docs/PulmonaryEmbolism2008-
download.pdf
 https://brvsc.com/thrombectomy-and-embolectomy/
 https://nursestudy.net/pulmonary-embolism-pe-nursing-care-plan/