Pulmonary Embolism (PE)

Objectives Discuss the pathophysiology of pulmonary embolism. Discuss signs and symptoms of PE Discuss the treatments available Discuss the prognosis of PE

Pathophysiology A pulmonary embolism (PE) takes places when one of the arteries that supply the lungs is blocked and blood flow to the lungs is disrupted. Caused by blood clot (most common) Fat Tumors Amniotic fluid Foreign bodies (Urden, Stacy, Lough 2010)

Consequences of PE Pulmonary infarction Hypoxemia Pulmonary hypertension Cor pulmonale (Urden, Stacy, Lough 2010)

video http://www.youtube.com/watch?v=I0yJTkW9y 9s

Risk factors

Atrial fibrillation

Immobility

Atheroslerosis

smoking

surgery

PE and obesity According to an article, obese patients have a higher chance of developing a PE than those who are not. The risk is even higher in patients age 11-20 than those who are not obese. Stein, Matta, Goldman, 2011)

Signs and Symptoms Sudden shortness of breath Tachypnea Tachycardia Palpitations Sharp chest pain that gets worse when breathing or coughing Dizzy or light headedness Hemoptysis Thompson, G. MD, 2011)

Diagnosis D dimer test ABGs EKG Chest X ray Pulmonary angiogram Echocardiogram V/Q scan (Thompson, G 2011)

Treatments Anticoagulant therapy (warfarin & heparin)- prevent more clots from forming thrombolytics Venous filter Embolectomy (Thompson, 2011)

Prognosis Location Size Some people may die in a short period of time if cl0t is not treated quickly. If diagnosed early, patients have a good prognosis (Davis, C. MD, 2012)

Should thrombolytic therapy be used on unstable patients with PE ? According to a study from 1999-2008 which included 72,230 people, 30% of unstable patients who received thrombolytic drugs had lower fatalities incidence than those who did not received thrombolytic drugs. Also those patient who received both thrombolytic drugs and the vena cava filter had even a lower fatality rate and death than those who had the vena cava filter alone? According to the article TT are useful but underused. (Stein, Matta, Alrifai, Rahman, 2012)

Nursing diagnosis Impaired Gas Exchange related to ventilation/perfusion Acute Pain related to ischemic impulses Risk for Aspirations

Nursing interventions Oxygenation Position patient to promote perfusion Provide comfort Compression stockings Active passive range of motion exercises Ambulation Patient teaching (smoking cessation, leg exercises, stretches, avoid crossing legs, tight clothing, prolong sitting or standing) (Urden, Stacy, Lough 2010)

Patient scenario A 38 year old man presents to the emergency department with left posterior pleuritic chest pain. He had a DVT 8 years ago and his D-dimer levels are elevated. He is haemodynamically stable with normal oxygen saturations, ECG and chest Xray. You would like to rule out a pulmonary embolism, but it is 8pm. You wonder whether it would be safe to discharge the patient home overnight before his VQ scan tomorrow (Kovacs B., 1999)

NCLEX questions 1. 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 (O’Connor K., 2013)

NCLEX questions A female 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 respiratory (proprofs.com)

Conclusion PE is most common in patients who are bedridden or immobile The signs and symptoms are a sudden shortness of breath, chest pain that gets worse with breathing, tachycardia, and increase blood pressure. Inform the patient that s/he might be on anticoagulants for a few months and that they need to stay away from playing sports, use a soft toothbrush, and monitor for signs of bleeding. If treated on time, people can have a good prognosis.

Citations Stein P., Matta F., Alrifai A., Rahman A. Trends in case fatality rate in pulmonary embolism according to stability and treatment.Thrombosis Research, Volume 130, Issue 6, December 2012, Pages 841–846. Retrieved from http://www.sciencedirect.com/science/article/pii/S0002934311009120 Urden L., Stacy K., Lough, M., (2010). Critical Nursing Care. St. Louis Missouri. Elsevier. Thompson G., Gingsber, J., (2011). Pulmonary Embolism. WebMD. Retrieved April 5th, 2013 from http://www.webmd.com/lung/tc/pulmonary- embolism-topic-overview Stein, Matta, Goldman. (2011). Obesity and pulmonary embolism: the mounting evidence of risk and mortality paradox. Volume 128, issue 6. Retrieved on April 6th, 2013 from http://www.sciencedirect.com/science/article/pii/S0049384811005597 Kovacs, B. (1999). Outpatient investigation for pulmonary embolism. Retrieved on April 6th, 2013 from http://www.bestbets.org/bets/bet.php?id=463 O’Connor, K. (2013). NCLEX RN Practice Test 3. StudyGuideZone. Retrieved on April 6th, 2013 from http://www.studyguidezone.com/nclexrn_practice3.htm