1. Pulmonary Embolism Henok Oncho BSN, RN, 2. Introduction The incidence of Pulmonary emboli (PE) in the North America is 100 persons in 100,000 population. This means currently one person is experiencing PE in every 1000 individuals. Death from PE is usually confirmed after autopsy results because PE is one of the most misdiagnosed or under diagnosed diseases. 3. What is pulmonary embolism? PE is an obstruction of blood vessels in the lungs, most often caused by a blood clot. However, PE also can also be caused by air, fat, or amniotic fluid. Obstruction of the lung arteries air , fat or amniotic fluid are rare when compared to blood emboli. The most common blood clot is formed in the lower extremities veins and travels to the heart through the vena cava that occludes the pulmonary arteries resulting decreased perfusion or dead zone. 4. Animation of PE Formation click on below 5. Pathophysiology of Pulmonary Embolism Under normal conditions:- There is a balance between activation of clotting factors and fibrinolysis Clotting = fibrinolysis Hypercoagulability can be resulted from + trauma + malignancy + pregnancy + surgery + use oral contraceptive 6. What does Pulmonary Embolism effect? The lungs ventilation is not affected; however, its perfusion is reduced. This is also called mismatched V/Q (ventilation-perfusion) ratio. The occluded part of the perfusion is commonly called dead zone. PE can be symptomatic or asymptomatic often depending on the size of the emboli and occluded or non perfused areas of the lung. The heart tries to compensate resulting in = tachycardia The lungs try to compensate for the shortage of oxygen in the cells resulting in = tachypnea 7. Pulmonary Embolism effect chain Pulmonary embolism obstructs blood flow to lung increased pressure on pulmonary artery and reflex constriction of pulmonary blood vessels poor pulmonary circulation pulmonary infraction 8. Question 1 Which physiologic effect of a pulmonary embolism would initially affect oxygenation? A. A blood clot blocks ventilation; perfusion is unaffected B. A blood clot blocks ventilation, producing hypoxia despite normal perfusion C.A blood clot blocks perfusion and ventilation, producing profound hypoxia D. A blood clot blocks perfusion, producing hypoxia despite normal or supernormal ventilation 9. ANSWER Answer D The clot blocks blood flow to a region of the lung tissue. That are remains ventilated but because blood flow is blocked, no gas exchange can occur in that region and a ventilation-perfusion mismatch is present. Ventilation isnt initially affected by a blood clot because air can still move normally through the bronchial tree. 10. Question 2 A client with a massive pulmonary embolism is scheduled to have arterial blood gas analysis performed. The nurse expects the analysis will identify: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis 11. ANSWER Answer D A client with massive pulmonary embolism will have a large region or lung tissue unavailable for perfusion. This causes the client to hyperventilate and blow off large amounts of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis 12. Symptoms of a Pulmonary Embolism Symptoms of a pulmonary embolism depend on the size of the clot and the location in the lungs where it becomes lodged. The most common symptom of a pulmonary embolism is shortness of breath. This may be gradual or sudden. 13. Other symptoms of a pulmonary embolism include:anxiety clammy or bluish skin coughing chest pain that may extend into your arm, jaw, neck, and shoulder fainting irregular heartbeat lightheadedness rapid breathing rapid heartbeat restlessness spitting up blood weak pulse 14. Risk Factors Thrombophlebitis Recent surgery Invasive procedures Immobility Obesity Myocardial infarction, heart failure Smoking Varicose veins Hormone replacement therapy 15. Question 3 A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed? A. The patient is somnolent with decreased response to the family. B. The patient suddenly complains of chest pain and shortness of breath. C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs. D. The patient has a fever, chills, and loss of appetite. 16. ANSWER Answer: B Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. A patient with pulmonary embolism will not be sleepy or have a cough with crackles on exam. A patient with fever, chills and loss of appetite may be developing pneumonia. 17. Question 4 A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respirations 18. ANSWER Answer A. The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. 19. Question 5 The nurse would identify which of the following clients as being at the highest risk for developing a pulmonary embolus? 1. A 19-year-old four days postpartum with an obstetrical history of placenta previa. 2. An obese 40-year-old man with multiple pelvic fractures from an auto accident two days ago. 3. A 65-year-old woman who had a fractured hip repaired 10 days ago and who is in physical therapy daily. 4. A 22-year-old leukemic client with a platelet count of 120,000/mm3 and a hemoglobin level of 9.0g. 20. ANSWER Strategy: Determine how each answer choice relates to pulmonary embolism. (1) at high risk for shock and bleeding complications (2) correctobesity, immobility, and pooling of blood in the pelvic cavity contribute to development of pulmonary emboli (3) client does not have a high risk for pulmonary emboli (4) at high risk for shock and bleeding complications 21. Picture of Pulmonary Embolism 22. Assessment Pulmonary Embolism is very difficult to diagnose due to its nonspecific signs and symptoms. Pulmonary embolism should be suspected with patients with new worsening dyspnea or sustained hypotension without other explanation. However, it is also common that a DVT or embolus produces no significant symptoms and may be an incidental finding when the patient undergoes imaging for other reasons (Morton & Fontaine, 2013, p.563). Because pulmonary embolism almost always occurs in conjunction with deep vein thrombosis, some doctors refer to the two conditions together as venous thromboembolism (VTE). 23. Assessment (subjective) Chest Pain: sub sternal, localized; type- crushing, sharp, stabbing with respirations Sudden onset of profound dyspnea. Restless, irritable, anxious Sense of impending doom 24. Assessment (Objective) Respirations: either rapid, shallow or deep gasping. Elevated temperature. Auscultation: friction rub, crackles; diminished breath sounds Cough; hemoptysis ECG changes that reflect right sided heart failure Echocardiogram shows increased pulmonary dynamics Shock Tachycardia Hypotension Skin, cold, clammy 25. Assessment findings Apprehension and restlessness Blood-tinged sputum Chest pain Cough Crackles and wheezes on auscultation Cyanosis Distended neck veins Dyspnea Feeling of impending doom Hypotension Petechiae over the chest and axilla Shallow respirations Tachypnea and tachycardia 26. Question 6 A client with a pulmonary embolism tells the nurse that he feels a sense of impending doom. The nurse recognizes that this manifestation is caused by what? A. Inflammatory reaction in the lung parenchyma B Loss of chest expansion C. Loss of lung tissue D. Sudden reduction in adequate oxygenation 27. ANSWER Answer D The client with a pulmonary embolism has a portion of the lung not involved in oxygenation, causing the client to feel apprehensive. If the area involved is large, the apprehension can be great, giving the client the feeling of impending doom. 28. How Is a Pulmonary Embolism Diagnosed? Diagnosing pulmonary embolism can be difficult, because there are many other medical conditions, such as a heart attack or an anxiety attack, that can cause similar symptoms. To diagnosis PE, diagnosis depends on an accurate and thorough medical history and ruling out other conditions. The doctor will need to know about the patients symptoms and risk factors for pulmonary embolism. This information, combined with a careful physical exam, will point to the initial tests that are best suited to diagnose a deep vein thrombosis or pulmonary embolism. 29. Diagnosis Tests pulmonary angiography: this test involves making a small incision so the doctor can guide specialized tools through the veins. A special dye is injected so that the vessels of the lung can be seen. This is the determining test for the diagnosis of Pulmonary Embolism. duplex venous ultrasound: this test uses radio waves to visualize the flow of blood and to check for blood clots in the legs. venography: this is a specialized X-ray of the veins of the legs. 30. One or more of the following tests is done in order to diagnose PE chest X-ray: this standard, noninvasive test allows doctors to see the heart and lungs in detail, as well as any problems with the bones around the lungs. electrocardiography (ECG): this test measures the hearts electrical activity. magnetic resonance imaging (MRI): this scan uses radio waves and magnetic field to produce detailed images. computed tomography (CT) scan: this scan gives the doctor the ability to see cross-sectional images of the lungs. 31. Question 7 A client is suspected of having a pulmonary embolism and asks the nurse how the doctor will definitively determine the diagnosis. The nurse anticipates that the physician will order. A. Arterial blood gas (ABG) analysis B. Chest X-Ray C. Pulmonary Angiogram D. Ventilation-perfusion scan 32. ANSWER Answer C A pulmonary angiogram is used to definitively diagnose a pulmonary embolism. A catheter is passed through the circulation to the region of the occlusion; the region can be outlined with an injection of contrast medium and viewed by fluoroscopy. This shows the location of the clot as well as the extent of the perfusion defect. 33. Overview of Management Treat with medicines, procedures, and other treatments The main goals of treatment Stop the blood clot from getting bigger Prevent new clots from forming 34. Medications Anticoagulants are prescribed when pulmonary embolism is diagnosed or suspected Heparin Warfarin Rivaroxaban Fondaparinux Most commonly the patient will take an anticoagulant for at least 3 months after pulmonary embolism to reduce the risk of having another blood clot. 35. Medications cont.. Thrombolytics or clot- dissolving medicines are not commonly used to treat pulmonary embolism unless in a life threatening situation. These drugs can greatly increase the risk of serious bleeding. Reteplase (Retavase) Alteplase (Activase, Cathoflo Activase) 36. Embolectomy The removal of a clot May be surgical or may be done with a minimal invasive procedure that uses a catheter. This treatment is used only in rare cases. 37. Other types of treatment If medicines dont work your doctor may suggest a vena cava filter. This keeps blood clots from traveling to your lungs. Used when anticoagulants are not an option, when clots form despite anticoagulant use, or when there is an increased risk of death or severely restricted lifestyle if another pulmonary embolism occurs. 38. Question 8 A definitive diagnosis of pulmonary embolism has been made for a client. The nurse anticipates which medication will be ordered? A. Warfarin (Coumadin) B. Heparin C. Streptokinase (Streptase) Acyclovir (Zovirax) 39. ANSWER Answer B Heparin is started I.V. once a pulmonary embolism is diagnosed to reduce further clot formation. When a therapeutic level of heparin is established, warfarin is started. It can take up to 3 days before a therapeutic level of warfarin is achieved. 40. Question 9 The nurse is teaching a client diagnosed with a pulmonary embolism about the prescribed heparin therapy. The nurse determines that teaching has been effective when the client states that heparin is given to: A. Dissolve the clot B. Break up the pulmonary embolism C. Slow the development of other clots D. Prevent clots from breaking off and embolizing to the lung 41. ANSWER Answer C Heparin slows the development of other clots. 42. Priority Nursing Actions 1. Notify the Rapid Response Team 2. Reassure the client and elevate the head of the bed 3. Prepare to administer oxygen 4. Obtain vital signs and check lung sounds 5. Prepare to obtain an arterial blood gas. 6. Prepare for the administration of heparin therapy or other therapies. 7. Document the event, interventions taken, and the clients response to treatment. 43. Nursing care goals Monitor for signs of respiratory distress Health teaching Prevent from further occurrence Need to continue medication Follow-up care 44. Question 10 Nursing management of a client with a pulmonary embolism will primarily focus on which action? A. Assessing oxygenation status B. Monitoring the oxygen delivery device C. Monitoring for other sources of clots D. Determining whether the client requires another ventilation-perfusion scan 45. ANSWER Answer A Nursing management of a client with a pulmonary embolism focuses on assessing oxygenation status and ensuring that treatment is adequate. If the clients status begins to deteriorate, its the nurses responsibility to contact the physician and attempt to improve oxygenation. 46. How Can Pulmonary Embolism Be Prevented? Preventing pulmonary embolism (PE) begins with preventing deep vein thrombosis (DVT). Knowing whether you're at risk for DVT and taking steps to lower your risk are important. Daily use of anticoagulant medicines may help prevent recurring pulmonary embolism by stopping new blood clots from forming and stopping existing clots from growing. If you've already had DVT or PE, you can take more steps to prevent new blood clots from forming. Visit your doctor for regular checkups. Also, use compression stockings to prevent chronic (ongoing) swelling in your legs from DVT (as your doctor advises). 47. Important steps to lower your risk of PE Exercise your lower leg muscles if you're sitting for a long time while traveling. Get out of bed and move around as soon as you're able after having surgery or being ill. The sooner you move around, the better your chance is of avoiding a blood clot. Take medicines to prevent clots after some types of surgery (as your doctor prescribes). Follow up with your doctor. 48. References Pulmonary Embolism-Medications. (2013, February 5). Retrieved September 15, 2014, from http://www.webmd.com/lung/tc/pulmonary-embolism Lisko, S. (2014). Respiratory Disorders. In NCLEX-RN questions & answers made incredibly easy (Sixth ed., pp. 112-114). Philadelphia, PA: Lippincott Williams & Wilkins. Morton, P. (2013). Common Respiratory Disorders. In Critical care nursing: A holistic approach (10th ed., pp. 561-565). Philadelphia, PA: Lippincott Williams & Wilkins. Silvestri, L. (2011). Respiratory System. In Saunders comprehensive review for the NCLEX-RN examination (5th ed., p. 743). St. Louis, Mo.: Elsevier/Saunders.