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05.05 Nursing Care and Pathophysiology for Pulmonary Embolism

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Overview

  1. A pulmonary embolism is a life-threatening blood clot in the lungs caused by an embolus (usually blot clot) from a vein in the lower extremity, or from clots that form after surgery.
  2. Causes decreased perfusion, hypoxemia, and if large enough, right-sided heart failure.
  3. Management includes stabilizing the cardiopulmonary system and anticoagulant therapy.

Nursing Points

General

When a blood clot breaks free and travels through the vascular system, it has the potential to become lodged and block blood flow. 

With a pulmonary embolism, this blood clot breaks free and travels through the right side of the heart and gets lodged in the pulmonary blood vessels, preventing blood from becoming oxygenated (and thereby decreasing perfusion to lung tissue). This is a life-threatening emergency and must be handled quickly, and precautions are always indicated.

Assessment

  1. Signs/Symptoms
    1. Anxiety
    2. Dyspnea/Tachypnea
    3. Chest pain
    4. Hypoxemia
    5. Rales
    6. Fever
    7. Diaphoresis
    8. Hemoptysis
  2.  Diagnostic Testing
    1. Vital signs
    2. ABG
    3. CXR
    4. V/Q lung scan
    5. D-dimer
      1. Negative D-dimer used to rule out PE on patients with a low likelihood of a DVT.
      2. If positive, further testing necessary
    6. Imaging with contrast dye
      1. Spiral CT
      2. Pulmonary angiogram

Therapeutic Management

  1. Therapeutic Management
    1. Cardiopulmonary stabilization
      1. Monitor for hypoxemia
      2. Assess vital signs
      3. Listen to lung sounds frequently
        1. Rales
      4. Heart sounds
      5. Assess circulation
        1. Peripheral edema
        2. Distended neck veins
      6. Monitor for feelings of anxiety/fear
      7. HOB elevated
      8. Oxygen as ordered
      9. Analgesics
        1. Morphine
    2. Anticoagulation
      1. Baseline labs
        1. Platelet count
          1. DO NOT administer if <100,000/mm
          2. If value drops to half of baseline, consider HIT
        2. Hemoglobin/Hematocrit
          1. A drop can indicate hemorrhage
        3. aPTT
          1. Reflects response to treatment for titration of heparin
      2. Monitor for bleeding
        1. Bruising
        2. Bloody stools
        3. Hematuria
        4. Gums/teeth
        5. Flank pain
  1.  

Nursing Concepts

Clotting, Gas exchange, Oxygenation

Patient Education

  1. Oral anticoagulants
    1. Side effects
    2. Bleeding precautions
    3. Follow up appointments
  2. Pain management
    1. Clot may still exist at discharge
      1. ~4 weeks to dissolve
    2. Pain medications as ordered
  3. Activity
    1. As tolerated

Reference Links

Study Tools

Video Transcript

Hey guys, welcome to the lesson on pulmonary embolisms today, we are going to cover the journey of an embolus. And so what we mean by that is where does this embolus originate and how does it get to the point where it causes a big problem and becomes a PE we’re also going to discuss some signs and symptoms of a patient that has a pulmonary embolism, and then also cover nursing management for this patient with a PE all right, guys. So to start, let’s go over the pathophysiology of an embolus. So first of all, I want you to know that in order to have a PE or a pulmonary embolism, an embolus needs to form. Now, this is most commonly going to be a blood clot. And so for all intents and purposes here today, we’re going to refer to it as a blood clot. However, I do want you to know that a PE can also form from a fat embolism, such as when a long bone breaks and a little piece of fat gets into the circulation. 

It can form from a tumor, a piece of a tumor breaking off and getting into the circulation or even, um, air. So you can have a pulmonary air embolism as well, but for all intents and purposes today, and the most common one, we will refer to it as the blood clot. All right. So an embolus forms and then this embolus, or this clot is going to circulate. So here we have our happy person and with one eye there’s two eyes. Okay. So they have a DVT, let’s say, so this is the most common source of a pulmonary embolism is a DVT. So let’s say they have this DVT and then a little clot breaks off and begins to circulate in the veins going up toward the heart, right? So it circulates. And here we have a bigger picture showing the right side of the heart. 

And so this blood clot is going to follow the flow of blood into the right atrium. It’s going to then enter the right ventricle and be pushed toward the pulmonary circulation. Then depending on the size of this clot, okay, there can be a big one or a small one. It is going to lodge at some point in the pulmonary circulation. So here, this doesn’t show it very well, but here’s the bifurcation of the pulmonary artery. And if the clot is large enough, it will lodge right here. So as you can see, this is going to cause immediate emergency. All right, this is called a saddle PE. And I can, you can see where it gets its name a little bit, because it’s kind of like a saddle here, lodged at the bifurcation area, right? So this is going to cause immediate hemodynamic compromise in this patient is in big trouble. 

If the clots little smaller, it’s going to keep on traveling and get lodged somewhere closer to the lung tissue. So here you see this one, and this is a great visual because it shows that all this area, all the vasculature that is downstream from this clot lodging is compromised. Okay. And it’s compromised in two ways. So number one, we are causing circulation issues. Okay. Compromised circulation. But number two, we are causing tissue lung tissue, death. Okay. So the tissue right here, that’s also depending on the circulation to, um, keep it perfused is going to die. So you can have lung tissue, death as well as compromised circulation. So that is why a PE is not good news. It’s very dangerous for the patient. All right. So what are we going to see in our patient who has a pulmonary embolism? So to start, this patient is going to be anxious. 

All right, this patient suddenly feels short of breath. Like they can’t breathe and maybe they have some pains. So this patient is very anxious and that’s one of the first signs. Then the patient is going to be dyspneic and to Kip Nick. Okay. So this dyspnea refers to difficulty breathing and to Kip, Nia is fast breathing. So the patient’s going to be rapidly breathing really shallow and fast, and they’re going to have trouble breathing next. There they may or may not, but most likely most patients have chest pain. Okay. What’s interesting is when you have a large saddle PE that lodges right there on the bifurcation, the patients often don’t have any pain. Actually. They are going to have rapid hemodynamic compromise, however they’re not hurting. And versus the patient who has a tinier clot that gets further down and lodges. If self closer to the alveoli, this patient is actually going to have pain because it’s going to cause irritation there’s pleuridic pain. And they’re going to may even be coughing up blood. Additionally, we’re going to see hypoxemia in these patients. So when we take their oxygen sat, it is going to be low. And then finally, when we listen to their lung sounds, these patients are going to have rails or just really large sounding crackles in their lungs. 

All right. So you’re the nurse you’re taking care of a patient with a PE, how do we manage this patient? Number one, we are going to check their vital signs and listen to their lung. Sounds. We want a baseline. And we want to know, is this getting worse better? Is this patient stable? So we’re going to take vital signs and lung sounds right away.

Next we’re going to provide reassurance to this patient. So the best way for a patient to respond to treatment is when they are calm. Okay? Yes. This is a life threatening situation. Yes, your patient is anxious and it is up to you, the nurse to be a calming presence with this patient so that they can best respond to treatment. Next, we’re going to prepare the patient for diagnostic testing and testing ranges anywhere from absolutely noninvasive, like taking vital signs up to a pretty invasive process with imaging and contrast dye. So we’ll get into this on the next slide, but we do have to be watching for orders for diagnostic tests and preparing the patient, um, both informing them and making sure they’re ready to go. We anticipate giving the patient with a PE anticoagulants. And so if they’re sick enough to be in the hospital, the most common anticoagulant that this patient is going to receive is a heparin drip. 

Okay. And one thing with heparin drips, you’re the nurse, which means you are the very last and final safety check for that patient. And so sometimes pharmacy will calculate the dose based on the patient’s weight. However, it is also up to you to make sure that you have calculated the dose and that it is appropriate. Okay. So again, nurse is the final safety check for anticoagulate. Another thing is when the patient is in a lot of pain, they will have analgesics ordered. This may be in the form of a narcotic, such as morphine, or it could be as mild as Tylenol, either way. We want to make sure that we are managing this patient’s pain appropriately. And I just wanted to tell a little story. So I’ve taken care of ICU patients who have this large saddle PE and they’re totally fine. They have no pain at all, right. 

They have this huge one. And then you take, and then I’ve also taken care of med surge patients who have the tiniest little pee and every time they breathe, those patients are crying out in pain and needing more pain meds. So it’s just interesting that there’s such a wide range of patients from no pain at all to 10 out of 10 pain because of a tiny pulmonary embolism, regardless, we are going to take the patient’s word for it. And we are going to treat their pain appropriately. All right, what are some nursing considerations? What do we need to look for with our patient? Who’s getting a heparin drip. We’re going to look for signs and symptoms of bleeding. And we’re also going to teach the patient to look for the same. So bruising, bloody stools, blood in the urine, bleeding from the teeth and gums, and then flank pain, which can indicate bleeding in the kidneys. 

All right. So some of the priority nursing concepts that we went through today are clotting gas exchange and oxygenation. And so all of these are priorities. When you are thinking of treating a patient who has a PE key points real quick to go over. So a PE blocks blood flow to the lungs. Some of the signs and symptoms are anxiety dyspnea in our patient, chest pain and a low oxygen sat. Nursing management includes maintaining oxygenation and then giving anti-coagulants and for patient education, we want to make sure that they can manage their oral anticoagulant when they go home, including routine lab tests, pain meds, and they can do activity as tolerated. All right, guys, that is it. We love you guys now go out and be your best selves today. And as always happy nursing.

 

 

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