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Pulmonary Embolism
Definition – Pulmonary embolism (PE) is a potentially life-threatening medical
condition characterized by the sudden blockage of one or more arteries in the
lungs, usually by a blood clot that has traveled from elsewhere in the body,
most commonly from the deep veins of the legs
Preventing pulmonary embolism- it involves reducing risk factors such as
staying active, avoiding prolonged sitting or immobility, maintaining a healthy
weight, and managing conditions such as high blood pressure or diabetes that
can increase the risk of blood clots. For individuals at high risk, such as those
with a history of DVT or certain medical conditions, preventive measures like
blood thinners may be recommended.
Risk factors - prolonged immobility (such as during long flights or bed rest),
surgery, trauma, pregnancy, heart failure, hormone therapy, or underlying
medical conditions that affect blood clotting.
Pathophysiology-
1. Formation of a blood clot (thrombus): The process usually begins with a
blood clot forming in a deep vein, most commonly in the lower
extremities.
2. Embolization: If a portion of the blood clot breaks off (embolizes), it can
travel through the venous system toward the heart. The embolus moves
through the right side of the heart and enters the pulmonary circulation
via the pulmonary artery.
3. Lodging in the pulmonary artery: eventually embolus reaches branches
that are too narrow for it to pass through, causing it to become lodged.
This obstructs blood flow to a portion of the lung, leading to reduced
oxygenation of the blood and potentially causing tissue damage.
4. Hemodynamic effects: The obstruction of blood flow in the pulmonary
artery can lead to several hemodynamic effects, including increased
pulmonary vascular resistance, decreased cardiac output, and impaired
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gas exchange. These effects can result in symptoms such as shortness of
breath, chest pain, and hemodynamic instability.
5. Inflammatory response: The presence of the embolus in the pulmonary
circulation triggers an inflammatory response, which can further
contribute to vascular injury and constriction. This inflammatory
response may also lead to the release of vasoactive substances and
activation of the coagulation cascade, potentially exacerbating the
clotting process
Clinical manifestations –
Sudden shortness of breath, chest pain (which may worsen with deep
breaths or coughing), rapid heartbeat, coughing up blood, and feeling
lightheaded or dizziness.
Diagnostic evaluation
1. Clinical Assessment:
Medical history: Symptoms suggestive of DVT
Risk factors: Assessment of risk factors for venous
thromboembolism (VTE), such as recent surgery, immobilization,
pregnancy, history of DVT or PE, cancer, oral contraceptive use,
smoking, and genetic predisposition.
2. Imaging Studies:
Computed Tomography Pulmonary Angiography (CTPA).
Ventilation-Perfusion (V/Q) Scan: This nuclear medicine imaging
test evaluates the ventilation (airflow) and perfusion (blood flow)
in the lungs. A V/Q scan is an alternative to CTPA, especially when
CT is contraindicated or unavailable.
Chest X-ray
3. Laboratory Tests:
D-dimer:. A positive D-dimer
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University College of Nursing
Arterial Blood Gas (ABG): hypoxemia and hypocapnia.
4. Electrocardiogram (ECG): While not specific for PE, an ECG may reveal
findings suggestive of right heart strain or acute cor pulmonale, such as
right axis deviation, T-wave inversion in leads V1-V4, or the presence of
a S1Q3T3 pattern
Medical Management- focuses on stabilizing the patient, preventing further
clot propagation, and reducing the risk of recurrence.
Emergency management-
1. Anticoagulant Therapy:
Heparin: Intravenous unfractionated heparin or subcutaneous
low-molecular-weight heparin (LMWH) is often initiated
immediatel to prevents further clot formation.
Warfarin or Direct Oral Anticoagulants (DOACs): Once the patient
is stabilized, oral anticoagulation with warfarin (a vitamin K
antagonist) or DOACs (e.g., rivaroxaban, apixaban, dabigatran,
edoxaban) is typically started and continued for several months to
prevent recurrence.
2. Supportive Care:
Supplemental Oxygen:
Pain Management: Analgesics may be administered for chest pain
relief, typically with nonsteroidal anti-inflammatory drugs
(NSAIDs) or acetaminophen.
Fluid Management:
3. Interventions:
Thrombolytic Therapy: In patients with massive PE causing
hemodynamic instability or in whom anticoagulation alone is
deemed inadequate, thrombolytic therapy (e.g., alteplase,
tenecteplase) may be considered to rapidly dissolve the clot.
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University College of Nursing
Thrombolytics are reserved for patients at high risk of mortality
due to PE and are associated with an increased risk of bleeding.
Embolectomy or Catheter-directed Thrombolysis: In select cases
where thrombolytic therapy is contraindicated or unsuccessful,
surgical embolectomy or catheter-directed thrombolysis may be
performed to physically remove or dissolve the clot.
Long-term Management:
Anticoagulation: at least 3 to 6 months
Assessment of Risk Factors: Identification and management of
underlying risk factors for venous thromboembolism (VTE).
Follow-up and Monitoring:
Clinical Follow-up: to monitor for signs of recurrence, bleeding
complications, and long-term sequelae such as chronic
thromboembolic pulmonary hypertension (CTEPH).
Imaging Studies: Repeat imaging studies, such as Doppler
ultrasound of the lower extremities or ventilation-perfusion (V/Q)
scan, may be performed to assess for resolution of clot burden
and evaluate for underlying causes of PE.
Nursing Management
1. Impaired Gas Exchange related to ventilation-perfusion inequality
secondary to pulmonary embolism
Assessment cues: Dyspnea, tachypnea, decreased oxygen
saturation, abnormal arterial blood gas (ABG) values.
Interventions: Monitor respiratory rate, oxygen saturation, and
ABGs. Administer supplemental oxygen as prescribed. Assist with
positioning to optimize ventilation.
2. Acute Pain related to pleural irritation secondary to pulmonary
embolism
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University College of Nursing
Assessment cues: Chest pain, worsened with deep breathing or
coughing.
Interventions: Assess pain intensity and characteristics. Administer
analgesics as prescribed. Teach relaxation techniques to help
manage pain.
3. Risk for Impaired Skin Integrity related to immobility secondary to
pulmonary embolism
Assessment cues: Prolonged bed rest, limited mobility.
Interventions: Implement a turning schedule to prevent pressure
ulcers. Encourage regular repositioning and skin inspections.
Provide skin care and moisturization.
4. Anxiety related to the diagnosis and potential complications of
pulmonary embolism
Assessment cues: Restlessness, fear, verbal expressions of worry.
Interventions: Provide emotional support and reassurance.
Encourage open communication about feelings and concerns.
Teach relaxation techniques and coping strategies.
5. Risk for Ineffective Peripheral Tissue Perfusion related to decreased
cardiac output secondary to pulmonary embolism
Assessment cues: Tachycardia, hypotension, cool extremities.
Interventions: Monitor vital signs closely. Assess peripheral
perfusion regularly. Elevate lower extremities if appropriate.
Collaborate with the healthcare team to optimize hemodynamic
status.
6. Medication Administration:
Administer anticoagulant medications (e.g., heparin, LMWH,
DOACs) as prescribed, ensuring accurate dosing and timing.
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University College of Nursing
Monitor for signs of bleeding complications, such as hematuria,
melena, or bruising, and report promptly to the healthcare
provider.
7. Risk for Impaired Physical Mobility related to weakness and fatigue
secondary to pulmonary embolism
Assessment cues: Fatigue, decreased activity tolerance.
Interventions: Assess mobility status and functional abilities.
Encourage early ambulation and gradual increase in activity level.
Provide assistive devices as needed. Collaborate with physical
therapy for mobility training.
8. Knowledge Deficit related to pulmonary embolism and its
management
Assessment cues: Lack of understanding about the condition,
treatment plan, and self-care measures.
Interventions: Provide education about the pathophysiology of PE,
signs and symptoms of recurrence, medication regimen (including
anticoagulant therapy), activity restrictions, and lifestyle
modifications. Use teach-back method to assess comprehension
9. Education and Discharge Planning:
Educate patients and families about the signs and symptoms of PE
recurrence and the importance of adherence to anticoagulant
therapy.
Provide instructions on medication management, including the
proper administration of anticoagulants, potential side effects,
and strategies to minimize bleeding risk.
Discuss lifestyle modifications and risk factor modification
strategies to prevent future thromboembolic events, such as
smoking cessation, weight management, and regular physical
activity.
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University College of Nursing
Develop a discharge plan that includes follow-up appointments,
medication reconciliation, and coordination of care with other
healthcare providers as needed.
Complications
Chronic Thromboembolic Pulmonary Hypertension (CTEPH)
Acute Respiratory Failure
Cardiogenic Shock
Pulmonary Infarction:
Recurrent Venous Thromboembolism
Post-thrombotic Syndrome
Bleeding Complications: Anticoagulant therapy intracranial hemorrhage,
gastrointestinal bleeding, and retroperitoneal hemorrhage.
Arrhythmias
Systemic Hypotension
Death
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