Pulmonary Embolism (PE)

nursing assessments:

**health history** chest pain SOB other symptoms. onset, severity and precipitating factors. venous thrombosis or other risk fcators such as childbirth or malignancy and current medications

What is the primary and most emergent focus of nursing care for the client with pulmonary embolism

**promote oxygenation and gas exchange.** -pain management and reduction of the anxiety that often results from hypoxia

how long does heparin therapy is continued for?

- appropriately 5 days or until oral anticoagulant therapy has become fully effective.

Relieve Anxiety

-Assess anxiety level -Remain with client as much as possible-explain procedure and treatments, nursing short simple sentence providing clearly understood simple instructions reduces fear of the unknown -Reduce environmental stimuli, use calm reassuring manner -allow supportive family member to remain with the client as much as possible =Administer morphine sulfate as orders, reduce pain and anxiety

Promote Safety

-Assess signs of bleeding: bleeding gums, hematuria, occult blood in stool or vomiting, incision bleeding, bleeding or bruising of injection sites or with minor trauma joint pain or immobility: abdominal early signs of abnormal bleeding and prevent potential hemorrhage. -Report coagulation study results outside of range. -Keep PROTAMINE SULTFATE FOR HEPARIN THERAPY AND VITAMIN k AVAILABLE FOR WARFARIN (COUMADIN) THERAPY. -Avoid invasive procedures, injections and venous puncture when possible, particularly following fibronolytic therapy. -Maintain firm pressure on injections and venipuncture sits -maintain pressure for 30 mins, following arterial puncture -Maintain adequate fluid intake, administer stool softeners as ordered, help prevent constipation and straining, which may precipitate in bleeding of hemorrhoids. -

WHAT IS BEING DONE OR ASSESSED WHEN PE OCCURS?

-O2 therapy is initiated analgesics may be order to relieve severe pleuritic pain and anxiety Pulmonary artery and wedge pressure are monitored with a balloon catheter -cardiac outputs also may be assessed cardiac rhythm is monitored to detect dysrhythmias.

Chest CT with contrast

-PRINCIPLE Test used to diagnose pulmonary embolism. -Chest by effectively shows large central pulmonary emboli -Newer generation scanners also can detect peripheral emboli

clinical therapy pyrexia due to inflammatory process

-administer antipyretics -conduct laboratory testing to aid in diagnosis of causative agent -Administer antibiotics as ordered.

clinical therapy for alveolar collapse related to tissue necrosis and inflammatory process

-administer oxygen -re position client to facilitate adequate air exchange -promote use of an incentive spirometer to facilitate postural drainage -

what are the clinical therapies for hyoxia due to blockage

-administer oxygen -re-position client to decrease work of breathing -prepare client for the possibility to intubation d mechanical ventilation -begin anticoagulant therapy as ordered monitor lab values maintain a low stimulus environment to decrease oxygen demands

what are some of the nursing encouragement that I can teach to my patients?

-ambulate after surgery or illness applying compression -applying compression stocking pneumatic compression device, -teaching and encouraging leg exercise -discourage use of pillows under the knees all help prevent DVT and subsequent pulmonary emboli -get up every 1-2 hours during long car rides for brief stretch and walk -avoid sitting for long periods of time during work -avoid crossing legs -regular exercise -tell patients who stand of long periods to use use well-fitted elastic stockings, being careful to avoid hose that bind around the knee or thigh

Compensate for Impaired Gas Exchange

-assess client's respiratory status include RATE, DEPTH, EFFORT, LUNG SOUNDS AND OXYGEN exchange -o2 sats may be monitored -Place the client Fowler or high Fowler position with the bed, help facilitates maximal lung expansion and reduces venous return to the right side of the heart lowering pressure in the pulmonary vascular system -monitor ABG results, Arterial line may be inserted for monitoring arterial pressure and arterial blood sampling -Maintain client o b bed rest -Bed rest will reduce metabolic demands and tissue needs for oxygen

What are the goals of nursing CARE for the client with PULMONARY EMBOLISM

-client will demonstrate an oxygen saturation that remained -client will verbalize fears resulting from respiratory distress -client will obtain relief from pain to allow for adequate rest and comfort -client will demonstrate adequate tissue perfusion.

Evaluation of patient

-client will remain adequate tissue perfusion to promote oxygenation and healing -client maintain is controlled to facilitate rest and recovery -client maintains effective airway clearance.

Clinical manifestations

-develops abruptly over a period of minutes **Most common*** -dyspnea and SOB chest pain anxiety and apprehension cough tachycardia and tachypenes crackles (rales) low grade fever ***less common*** diaphoresis heooptysis syncope cyanosis s3 and or s4 gallop

clinical therapy for rupture of small arterioles due to arterial congestion

-explain hemoptysis to help alleviate client and family member of concerns -administer oxygen as ordered -maintain patent airway -suction PRN

Preserve Cardiac Output

-preserving adequate blood pressure and organ function until cardiopulmonary status stabilizes and may include the following. -Auscultate client's heart sounds every 2-4 hours, sounds of s3 and s4 gallop -Assess the client's skin color and temperature -monitor client's cardiac rhythm, drop in cardiac output and other hemodynamic alterations resulting from pulmonary embolism can precipitate dysrhythias. -Administer vasopressors (vasocontrictors) and other medication as ordered -Monitor client's pulmonary arterial pressures, neck vein distention, peripheral edema, report findings indicates right sided heart failure is a potential complications of pulmonary embolism because of increased pulmonary arterial pressures. -Instruct to report any chest pain or other symptoms, decreased cardiac output and increased work load resulting from pulmonary hypertension may cause anginal pain.

HOW IS A FAT EMBOLISM USUALLY OCCURS?

AFTER THE FRACTURE OF LONG BONE (TYPICALLY THE FEMUR) RELEASES BONE MARROW FAT INTO THE CIRCULATION. ADIPOSE TISSUE OR LIVER TRAUMA MAY ALSO LEAD TO FAT EMBOLI.

what is put on the legs for patients undergoing neurosurgery, urological surgery or major surgery of the hip or knee or when anitgoculant therpay is contraindicated?

EXTERNAL PNEUMATIC COMPRESSION OF THE LEGS

what are the most common nonthrombotic pulmonary emboli?

FAT EMBOLI

if patient has PE what therapy is initiated with an intravenous bolus of 5,000-10,000 U followed by continuous infusion at the rate of 1,000-1,500 U/hr.

HEPARIN THERAPY

Plasma D dimer

Highly specified to the presence of a thrombus. D-dimer is a fragment of fibrin formed during lysis of a blood clot elevated blood levels indicated thrombus

Nursing Diagnosis

Impaired gas exchange Decreased cardiac output Ineffective protection Anxiety

Lung scans

Including perfusion and ventilation scans Perfusion scans- intravenously injected with radio tagged albumin lungs are scanned to distribution of isotope Ventilation scans- radio tagged gas is inhaled and the lungs are scanned for gas distribution

What is the characteristics of PE?

Lungs may be ventilated but not perfused MISMATCHED VENTILATION:PERFUSION

what is the primary goal in treating PE?

PREVENTION

Diagnostics for PE

Plasma D diner Chest CT with contrast Lung scans

WHAT IS FIBRONOLTIC THERAPY

Streptokinase, urokinase or tissue plaminogen activators are used to lyse (disintegrate) the tissue plasminiogen activators are used to lyse (disintegrate) the embolus, restore pulmonary blood flow and reduce pulmonary artery and right heart pressures.

What is the early intervention for medical and surgical clients that is effective in mean OF prevention venous stasis and reducing the incidence of PE?

WALKING... AMBULATION..

what oral anticoagulants therapy is initiated at the same time as heparin?

WARFARIN SODIUM (COUMADIN)

Warfarin sodium works by

alters the synthesis of vitamin K-depended clotting factors and requires 5-7 days to fully effective.

what is the standard pharmacologic therapy treatment for preventing pulmonary emboli?

anticoagulant therapy

dead space

ares of the lung that are ventilated by not per-fuses or increases.

alveolar surfactant decreases, increasing the risk of

atelectasis

what are the risk associated with anticoagulant therapy?

bleeding

pulmonary angiography

definite test for pulmonary embolism when other less invasive tests are inconclusive and it's possible to detect very small envelope with angiography a contrast medium injected into the pulmonary arteries illustrates the pulmonary vascular system on x-ray

Less common source of emboli is

fatty tissues tha tenters the circulatory system as the result of surgery or trauma.

what is used to treat a Massive pulmonary EMBOLUS AND HYPOTENSION

fibronolytic therapy

when prevention treatment of anticogulant therapy initiated and in what kind of patient?

high risks who have no evidence of pulmonary embolism

Though firbonolytic therapy is beneficial, what are the risk and contraindications?

increase of bleeding in cerebral intracranial disease recent stroke active bleeding or bleeding disorder pregnancy severe hypertension recent surgery trauma

if infarction does occur what happens

infarct tissue becomes scarred and fibrotic

chest x-ray

is pulmonary infiltration and occasional pleural effusion

Physical examination

level of consciousness presence of respiration and pulse skin color temperature moisture vital signs including apical pulse and temp breath sounds and heart sounds oxygen saturation neck vein distention and peripheral edema

small emobli clinical manifestations

may be asymptomatic.

ETCO2 (Measure of carbon dioxide exhaled)

measurement of carbon dioxide exhaled maybe measure to valuate alveolar perfusion normal reading is 35 - 45 mmhg Well normally decrease with pulmonary perfusion is impaired

electrocardiography

order to rule out MI

Obstruction of pulmonary blood flow by an embolus affect both what?

perfusion and ventilation

what is the antidote for heparin?

protamine sulfate

In severe cases of PE can cause hypertension in what?

pulmonary hypertension and right ventricular heart failure.

AGB

shown hypoxemia respiratory alkalosis caused by tachypenia and hyperventilation

clinical manifestations are depended on the

size and location of the emboli

Risk factors for pulmonary embolus are

stasis of venous blood flow vessel wall damage altered blood coagulation prolonged immobility trauma hip femur fractures surgery MI and heart failure obesity advanced age woman who are on oral contraceptives or estrogen therapy are at risk women during pregnancy and child birth smoking cigarettes.

Clinical manifestations of a fat emboli are

sudden onset of cardiopulomary and neurological symptoms -dyspnea -tachypnea -tachycardia -confusion -deliriu -decreased level of consciousness

what is the leading cause of pulmonary embolisms?

thrombus arising from the deep veins of the legs is the leading cause of pulmonary embolism

If anit-coagulant therapy fails to prevent, what surgery intervention

umbrella like filter may be inserted into the inferior vena cava to trap large emboli while allowing continued blood flow.

Neurohumoral reflexes is /triggered by obstruction causing what

vasoconstriction increasing pulmonary vascular resistance.

what is the antidote for warfarin?

vitamin K