Pulmonary Embolism (PE)
Learning Activity
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PE
• A PE occurs when a substance (solid, gaseous, or liquid) enters venous
circulation and forms a blockage in the pulmonary vasculature.
• Emboli originating from deep vein thrombosis (DVT) are the most
common cause. Tumors, bone marrow, amniotic fluid, and foreign matter
can also become emboli.
• Increased hypoxia to pulmonary tissue and impaired blood flow can
result from a large embolus.
• A PE is a medical emergency.
• Prevention, rapid recognition, and treatment of a PE are essential for a
positive outcome.
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Risk Factors of Pulmonary Embolism
• Long-term immobility
• Oral contraceptive use and estrogen therapy
• Pregnancy
• Tobacco use
• Hypercoagulability (elevated platelet count)
• Obesity
• Surgery (especially orthopedic surgery of the lower extremities or
pelvis)
• Central venous catheters
• Heart failure or chronic atrial fibrillation
• Autoimmune hemolytic anemia (sickle cell)
• Long bone fractures
• Cancer
• Trauma
• Advanced age - certain pathological conditions and procedures that
predispose clients to DVT formation (peripheral vascular disease,
hypertension, hip and knee arthoplasty) are more prevalent in older
adults
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Manifestations of Pulmonary Embolism
• Anxiety
• Feelings of impending doom
• Pressure in chest
• Pain upon inspiration
• Dyspnea and air hunger
• Cough
• Hemoptysis
• Pleurisy
• Pleural friction rub
• Tachycardia
• Hypotension
• Tachypnea
• Adventitious breath sounds
(crackles) and cough
• Heart murmur in S3 and S4
• Diaphoresis, low grade fever
• Decreased oxygen saturation
levels
• Petechiae (red dots under the
skin) and cyanosis
• Pleural effusion (fluid in the
lungs)
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Laboratory Tests
• ABG analysis - PaCO2 levels will be low (the expected reference range
is 35 to 45 mm Hg) due to initial hyperventilation (respiratory alkalosis).
As hypoxemia progresses, respiratory acidosis occurs.
• CBC analysis
• D-dimer - elevated above expected reference range in response to clot
formation and release of fibrin degradation products (the expected
reference range is 0.43 to 2.33 mcg/mL).
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Diagnostic Procedures
• Chest x-ray and computed tomography (CT) scan: These provide initial
identification of a PE. A CT scan is most commonly used. A chest x-ray
can show a large PE.
• Ventilation and perfusion scan (V/Q scan) - images show the circulation
of air and blood in the lungs and can detect a PE.
• Pulmonary angiography: The most thorough test to detect a PE, but it is
invasive and costly. A catheter is inserted into the vena cava to visually
see a PE.
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Medications Used in the Treatment of Pulmonary Embolism:
• Anticoagulants: Enoxaparin, heparin, and warfarin
• used to prevent clots from getting larger or other clots from forming.
• Thrombolytic therapy– Alteplase and streptokinase
• used to dissolve blood clots and restore pulmonary blood flow
• Direct factor Xa inhibitor
• Rivaroxaban binds directly with the active center of factor Xa, which
inhibits the production of thrombin.
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Surgical Interventions
• Embolectomy - surgical removal • Vena Cava Filter
of embolus
• Vena cava filter - insertion of a
filter in the vena cava to prevent
further emboli from reaching the
pulmonary vasculature
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Complications
Decreased cardiac output Hemorrhage
• NURSING ACTIONS • NURSING ACTIONS
– Monitor ECG and Vital signs – Assess for oozing, bleeding, or
bruising from injection &
for hypotension, tachycardia, surgical sites at least every 2
cyanosis, jugular venous hr.
distention, and syncope. – Monitor cardiovascular status
– Assess for the presence of (blood pressure, heart rate and
S3 or S4 heart sounds. rhythm).
– Initiate and maintain IV – Monitor CBC (hemoglobin,
hematocrit, platelets) and
access. bleeding times (PT, aPTT, INR).
– Monitor urinary output – Administer IV fluids and blood
– Administer IV fluids products as required.
– Monitor pulmonary – Test stools, urine, and vomit for
occult blood.
pressures.
– Monitor for internal bleeding
– Administer inotropic agents (measure abdominal girth and
(milrinone,dobutamine) abdominal or flank pain) at
– Vasodilators may be needed least every 8 hr.
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Client Education: Treatment and Prevention of a Pulmonary Embolism
• Promote smoking cessation if the client smokes.
• Encourage the client to avoid long periods of
immobility.
• Encourage physical activity such as walking.
• Encourage the client to wear compression stockings to
promote circulation.
• Encourage the client to avoid crossing his legs.
• Advise the client to monitor intake of foods high in
vitamin K (green, leafy vegetables) if taking warfarin.
Vitamin K can reduce the anticoagulant effects of
warfarin.
• Advise the client to adhere to a schedule for
monitoring PT and INR, follow instructions regarding
medication dosage adjustments (for clients on
warfarin), and adhere with the need for weekly blood
draws. Remind the client taking warfarin of the
increased risk for bruising and bleeding.
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Learning Activity Review Questions
1. A nurse is caring for a client following a right femur fracture. What
signs/symptoms would indicate to the nurse that the client may be
experiencing a pulmonary embolism?
2. Which of the following clients are at increased risk for pulmonary
embolism? (Select all that apply.)
A. A client admitted with an exacerbation of asthma
B. A client who has been taking oral contraceptives for the past 20
years
C. A long-time smoker who has recently had surgery
D. A client with atrial fibrillation
E. A client a decreased platelet count
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