Pulmonary Embolism

Pulmonary Embolism

• Occurs when a thrombus forms (most commonly in a deep vein),

detaches, travels to the right side of the heart, and then lodges in
a branch of the pulmonary artery
• Clients prone to pulmonary embolism are those at risk for deep
vein thrombosis, including those with prolonged immobilization,
surgery, obesity, pregnancy, heart failure, advanced age, or a
history of thromboembolism.
• Fat emboli can occur as a complication following fracture of a long
bone and can cause pulmonary emboli.
• Treatment is aimed at prevention through risk factor recognition
and elimination.
Pulmonary Embolism
 Pulmonary Embolism
Assessment Findings:
• Apprehension and restlessness
• Blood-tinged sputum
• Chest pain
• Cough
• Crackles and wheezes on auscultation
• Cyanosis
• Distended neck veins
• Dyspnea accompanied by anginal and
pleuritic pain, exacerbated by inspiration
• Feeling of impending doom
• Hypotension
• Petechiae over the chest and axilla
• Shallow respirations
• Tachypnea and tachycardia
 Pulmonary Embolism
Diagnostic Evaluations:
• ABG levels show decreased PaO2 is usually found, due to perfusion abnormality
of the lung. (respiratory alkalosis and hypoxemia).
• Blood chemistry test reveal an increased Lactate Dehydrogenase (LD) level.
• Chest X-ray shows dilated pulmonary arteries, pneumo-constriction, and
diaphragm elevation on the affected side. (normal or possible wedge-shaped
infiltrate).
• Ventilation-Perfusion (V/Q) lung scans –perfusion scan investigates regional
blood flow to determine presence of perfusion defects; ventilation scan may be
done in patient with large perfusion defects.
• Pulmonary angiogram show location of the embolism and the filling defect of
pulmonary artery.
• ECG shows tachycardia, non-specific ST-segment changes.
• Spinal CT scanning may identify a thrombus in the pulmonary vasculature.
 Pulmonary Embolism
Nursing Diagnosis:
• Impaired Gas exchange
• Ineffective tissue perfusion (cardiopulmonary)
• Anxiety
• Deficient knowledge related to disease condition and therapy

Nursing Planning and Goals:

• Adequate gas exchange
• Improved tissue perfusion
• Use support systems to assist with coping
• Verbalize understanding of the disease and treatment regimen

Nursing Evaluation: Expected Outcomes

• Adequate gas exchange and cardiac perfusion as evidenced by stable vital signs.
• Demonstrate calm behavior and appropriate coping skills
• Verbalizes understanding of the underlying disease, causative factors, prevention, and treatment.
 Pulmonary Embolism
Treatment:
 Emergency Management:
• For massive pulmonary embolism, goal is to stabilize cardio-respiratory status.
• Oxygen is administered to relieve hypoxemia, respiratory distress and cyanosis.
• An intravenous route started for drugs and fluids.
• Vasopressors, inotropic agents: dopamine, and antidysrhythmic agents may be
indicated to support circulation if the patient is unstable.
• ECG is monitored continuously for right-sided heart failure, which may have a
rapid onset.
• Small doses of I.V. morphine are given to relieve anxiety, alleviate chest
discomfort (which improves ventilation), and ease adaptation to mechanical
ventilator, if this is necessary.
• Pulmonary angiography, hemodynamic measurements, ABG analysis, and other
studies are carried out.
 Pulmonary Embolism
Treatment:
 Subsequent Management–Anticoagulation and Thrombolysis
• I.V. Heparin –stops further thrombus formation and extends the clotting time of
the blood; it is an anticoagulant and antithrombotic.
• I.V. loading dose via drip infusion or intermittently every 4-6 hours.
• Protamine sulfate may be given to neutralize heparin in event of severe bleeding
• Oral anticoagulation with warfarin (Coumadin) is usually used for follow-up
anticoagulant therapy after heparin therapy has been established; interrupts the
coagulation mechanism by interfering with the vitamin K –dependent synthesis of
prothrombin and factors VII, IX and X.
• Thrombolytic agents: streptokinase, may be used in patients with massive
pulmonary embolism.
• Newer clot-specific thrombolytics (tissue plasminogen activator, streptokinase
activator complex, single-chain urokinase) are preferred.
 Pulmonary Embolism
Treatment:
• Diuretic: furosemide if right ventricular failure develops
 Surgical Intervention
• When anticoagulation is contraindicated or patient has recurrent
embolization or develops serious complications from drug therapy.
• Interruption of vena cava –reduces channel size to prevent lower
extremity emboli from reaching lungs.
• Ligation, plication, or clipping of the inferior vena cava.
• Placement of transvenously inserted intraluminal filter in inferior
vena cava to prevent migration of emboli; inserted through femoral
or jugular vein by way of catheter.
• Embolectomy (removal of pulmonary embolic obstruction)
 Pulmonary Embolism
Nursing Interventions:
 Actions to take if a pulmonary embolism is suspected
• Notify the rapid response team.
• Reassure the client and elevate the head of the bed.
• Prepare to administer oxygen.
• Obtain vital signs and check lung sounds.
• Prepare to obtain an arterial blood gas.
• Prepare for the administration of heparin therapy or other
therapies.
• Document the event, interventions taken, and the client’s
response to treatment.
 Pulmonary Embolism
• Signs and symptoms of a pulmonary embolism include the sudden onset of
dyspnea, apprehension and restlessness, a feeling of impending doom, cough,
hemoptysis, tachypnea, crackles, petechiae over the chest and axillae, and a
decreased arterial oxygen saturation.
• If suspected, the nurse immediately notifies the Rapid Response Team. The nurse
stays with the client, reassures the client, and elevates the head of the bed. The
nurse prepares to administer oxygen and obtains the vital signs and checks lung
sounds.
• The nurse continues to monitor the client closely, prepares the client for tests
prescribed to confirm the diagnosis, and prepares to obtain an arterial blood gas.
• When prescribed, the client is prepared for the administration of heparin
therapy or other therapies such as embolectomy or placement of a vena cava
filter if necessary.
• Finally, the nurse documents the event, interventions taken, and the client’s
response to treatment.
 Pulmonary Embolism
Nursing Interventions:
• Assess respiratory status to detect respiratory distress.
• Assess cardiovascular status to identify complications.
• Monitor laboratory studies to identify possible problems.
• Maintain PTT at 1 ½ to 2 times control in clients receiving heparin. Maintain PT at
1 ½ to 2 times control or INR at 2 to 3 for the client receiving warfarin.
• Monitor ABGs for evidence of pulmonary compromise.
• Monitor and record central venous pressure [CVP]. CVP may rise if right-side
failure develops
• Monitor and record intake and output to detect fluid volume overload and renal
perfusion.
• Assess for positive Homan’s sign to detect thromboembolism as a cause of
pulmonary embolus.
• Administer oxygen to enhance arterial oxygenation.
 Pulmonary Embolism
Nursing Interventions:
• Assist with turning, coughing, and deep breathing to mobilize secretions and
clear the airways.
• Keep the client in high-fowler’s position to enhance ventilation.
• Provide suctioning and monitor and record color, consistency and amount of
sputum to assess for complications.
• A productive cough and blood-tinged sputum may be present with pulmonary
embolism.
• Administer IV fluids as ordered, to maintain hydration.
• Administer medications, as prescribed, to enhance tissue oxygenation.
• Assess for bleeding and prevent trauma to the client to decrease the incidence of
bleeding while on anticoagulant therapy.
• Provide client teaching to decrease the incidence of thrombophlebitis and
embolism.