Pulmonary embolism

1. PULMONARY EMBOLISM
Mr. ANILKUMAR B R , LECTURER , MEDICAL-SURGICAL
NURSING

2. Definition
 Pulmonary embolism (PE) refers to the
obstruction of the Pulmonary artery or one of
its branches by a thrombus (or thrombi) that
originates somewhere in the venous system or
right side of the heart.

3. Pulmonary embolism

4.  Pulmonary embolism is a common disorder
and often is associated with trauma, surgery
(orthopedic, major abdominal, pelvic,
gynecologic) pregnancy, heart failure, age
older than 50 years and prolonged immobility.

5. PULMONARY EMBOLISM

6. Risk factors for Pulmonary embolism
A) Venous stasis (slowing of
blood flow in veins)
1) Prolonged immobilization (especially
postoperative)
2) prolonged periods of sitting or traveling
3) varicose veins
4) Spinal cord injury

7. Hypercoagulability ( due to release of tissue
thromboplastin after injury /surgery)
1) Injury
2) Tumor ( pancreatic, GIT, Genitourinary, breast and
lung tumor)
3) Increased platelet count (polycythemia)

8. Venous endothelial disease
1) Thrombophlebitis
2) vascular diseases
3) foreign bodies (iv/central venous catheters)

9. Certain disease states (combination of states,
coagulation Alterations, and venous Injury)
1) Heart disease (Heart failure)
2) Trauma ( Fracture of hip, pelvis, vertebra, lower
extremities)
3) Post operative state /postpartum period
4) Diabetes mellitus and COPD

10. Other predisposing factors
1) Advanced age
2) Obesity
3) Pregnancy
4) Oral contraceptive use
5) Constrictive clothing
6) History of previous PE

11. Clinical manifestations
 Clinical manifestations or symptoms depends
on the size of the thrombus :
1) DYSPNEA is the most frequent symptom
2) Tachypnea (very rapid respiratory rate) is the most
frequent sign.

12. Continue… ..
 Chest pain is common and is usually sudden and
pleurtic in origin.
 It may be substernal and may mimic angina
pectoris or may Myocardial infraction.

13. Other symptoms include
 Anxiety
 Fever, Tachycardia, apprehension, cough,
diaphoresis, hemoptysis and syncope.

14. Assessment and diagnostic findings
 Death from PE commonly occurs with in one hour
after the onset of symptoms :therefore early
recognition and diagnosis are priorities, a
diagnostic workup is performed to rule out other
diseases.

15. Continue ..
The initial diagnostic workup includes
1) Chest x-ray
2) ECG
3) Peripheral vascular studies
4) Arterial blood gas analysis (abg)
5) ventilation perfusion scan and Pulmonary
angiography

16. Medical management
 Because PE is often a medical emergency,
emergency management is of primary concern.
After emergency measures have been initiated and
the patient is stabilized, the treatment goal is to
dissolve the existing emboli and prevent new ones
from forming.

17. Treatment may include a variety of
modalities
 General measures to improve respiratory and
vascular status.
 Anticoagulation therapy
 Thrombolytic therapy
 Surgical intervention

18. Emergency management
 Massive PE is a life – threatening emergency
 The immediate objective is to stabilize the
cardiopulmonary system.

19. Emergency management consists of the
following actions
 Nasal oxygen is administered immediately to relive
hypoxemia, respiratory distress, and central
cyanosis.
 Establish IV Lines.
 Vasopressors ,inotropic agents such as dopamine
and anti dysrhythmic agents may be indicated to
support circulation if the client is unstable.
 Perfusion scan, Hemodynamic monitoring and ABG.

20. Continue
 Hypotension is treated by a slow infusions of
dobutamine.
 Continue monitoring ECG
 Blood is drawn for serum electrolytes, CBC etc

21. Continue
 If clinical assessment and ABG analysis indicate
the need, the patient is intubated and placed on a
mechanical ventilator.
 If the patient has suffered massive embolism and
is hypotensive, an indwelling urinary catheter is
inserted to monitor urinary output.

22. Continue
 Small doses of IV Morphine or sedative are
administered to relive patient anxiety.

23. General management
 Measure are initiated to improve respiratory and
vascular status.
 Oxygen therapy
 Use of elastic compression stocking or intermittent
pneumatic leg compression devices reduces
venous stasis.
 Elevating the leg above the level of heart

24. Elastic compression stocking

25. Intermittent pneumatic leg compression
devices

27. Pharmacologic therapy
 Anticoagulation therapy: (heparin, warfarin
Sodium) has traditionally been the primary method
for managing acute deep venous thrombosis and
PE.

28. Thrombolytic therapy
 Thrombolytic therapy: (urokinase, streptokinase,
alteplase and reteplase)

29.  Thrombolytic therapy resolves the thrombi or
emboli more quickly and restores more normal
Hemodynamic functioning of the Pulmonary
circulation, thereby reducing Pulmonary
hypertension and improving Perfusion,
Oxygenation, and cardiac output.

30. Continue
 Bleeding is a significant side effect.
Contraindications to Thrombolytic therapy include
a CVA within the past 2 months, or other active
intracranial processes, active bleeding, surgery
within 10 days of the Thrombolytic therapy, recent
delivery or labor and sever hypertension.

31. Continue
 Before start Thrombolytic therapy, INR. PTT ,
HEMATOCRIT, AND PLATELET counts are
obtained.
 Heparin is stopped prior to administration of a
Thrombolytic therapy.
 During therapy, all but essential invasive procedure
are avoidied because of potential bleeding.

32. Surgical management
 A surgical “EMBOLECTOMY” is rarely performed
but may be indicated if the patient has a massive
PE. Or Hemodynamic instability or if there are
contraindications to Thrombolytic therapy.

33. Nursing management patient with PE
 Minimize the risk of Pulmonary embolism
 Preventing thrombus formation ( early ambulation,
active and passive exercise, pumping exercise, not
to sit or lie Prolonged periods, avoid cross leg and
Constrictive clothing and IV cath and central line
cath should not be left in place for prolonged
periods)

34. Assessing potential for Pulmonary
embolism
 All patients are assessed and evaluated for risk
factors for thrombus formation and Pulmonary
embolism.
 Careful assessment of the patient’s health history,
family history and medication record
 Daily basis asked about patient pain or discomfort
in the exterminates and evaluate for warmth,
Redness, and Inflammation.

35. Monitoring Thrombolytic therapy
 Carefully and close monitoring of Thrombolytic
therapy and Anticoagulation therapy.
 During Thrombolytic infusions, while the patient
remains on bed rest, vital signs are assessed
every 2 hours and invasive procedure are avoided.
 Test to determine INR and PTT are performed
every 3 hours

36. Management of pain
 Adequate management of chest pain is essential
 A semi – fowler‘s Postion
 Administer opioid analgesic as prescribed for
severe chest pain

37. Managing oxygen therapy
 Pulseoximetry
 Deep breathing and incentive spirometry
 nebulizer therapy, percussion and Postral
drainage may be used for management of
secretions.

38. Reliving anxiety

39. Monitoring for complications
 Bleeding as a result of thrombolytic therapy
 Cardiogenic shock
 Pulmonary hypertension, cur pulmonale
 Respiratory failure

40. Providing post operative care
 Pulmonary artery pressure
 Urinary output

41. Prevention of Pulmonary embolism
 For patients at risk for PE, the most effective
approach for prevention is to prevent DVT (deep
venous thrombosis).
 Active leg exercise to avoid venous stasis.
 Early ambulation is necessary.
 Use elastic compression stocking.

42.  Anticoagulation therapy may be prescribed for
patients who are older than 40 years of age.
 Heparin may administered before going to surgery
especially elective abdominal and thoracic surgery
 Use sequential compression devices (SCD,s)