Pulmonary embolism
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This document provides information on pulmonary embolism including its definition, incidence, types, etiology, risk factors, pathophysiology, clinical manifestations, diagnostic evaluation, complications, management, nursing management, prevention, health education, and nursing diagnoses. Pulmonary embolism is a blockage in the lungs caused by a blood clot that travels from the legs or pelvis and obstructs a pulmonary artery. It can be life-threatening and requires prompt diagnosis and treatment.
Pulmonary embolism
- 1. PULMONARY EMBOLISMPRESENTED BY: MR. RAMESH CHAUHAN 2nd YEAR Bsc. NURSING, ACHARYA COLLEGE OF NURSING, BANGALORE
- 3. INTRODUCTION A p u lm o n a r y e m b o lis m is a b lo c k a g e in o n e o f t h e b lo o d v e s s e ls in t h e lu n g s . I t h a p p e n s w h e n p a r t , o r a ll, o f a b lo o d c lo t b lo c k s t h e b lo o d s u p p ly t o t h e lu n g s . A p u lm o n a r y e m b o lis m is a s e r io u s , p o t e n t ia lly lif e -t h r e a t e n in g , c o n d it io n .
- 4. DEFINITION It refers to the obstruction of one or more pulmonary arteries by a thrombus(thrombi) originating usually in the deep veins of the leg,the right side of the heart,or,rarely,an upper extremity,which becomes dislodged and is carried to the pulmonary vasculature.
- 5. INCIDENCE: ● Every year,one in every 1000 people develops DVT. ● Around 10 people with untreated DVT will develop a pulmonary embolism.
- 6. TYPES: (1)MASSIVE PULMONARY EMBOLISM: Where the patient is shocked or hypotensive,this is defind as a systolic BP<90mmHg or a pressure drop of 40mmHg for >15 min not caused by new onset arrhythmia,hypovolaemia or sepsis. (2)NON MASSIVE PULMONARY EMBOLISM It occurs where patients are haemodynamically stable. (a)SUBMASSIVE PULMONARY EMBOLISM It is a subgroup of patient with non massive...
- 7. CONTD.... …..Pulmonary embolism,who have echocardiographic signs of right ventricular hypokinesis.This group has a poorer prognosis and may benefit from more aggressive treatment.
- 8. ETIOLOGY/RISK FACTOR: SURGERY: ● Major abdominal/pelvic surgery or Hip/knee replacement(risk lower if prophylaxis is used) ● Post-operative intensive care. CARDIOVASCULAR: ● Congenital heart disease ● Congestive heart failure ● Hypertension ● Paralytic stroke.
- 9. CONTD... OBSTETRICS: ● Late pregnancy ● Puerperium ● Caesarian section OESTROGEN: ● Combined oral contraceptive ● Hormone replacement therapy
- 10. CONTD... LOWER LIMB PROBLEMS ● Fracture ● Varicose veins:- previous varicose vein surgery;superficial thrombophlebitis HEMATOLOGICAL: ● Thrombotic disorder or any clotting factor disorder ● Myeloproliferative disorder
- 11. CONT.... MALIGNANCY: ● Abdominal/pelvic ● Advanced/metastatic REDUCED MOBILITY: ● Prolonged hospitalisation ● Institutional care
- 12. CONTD... RENAL: ● Nephrotic syndrome ● Chronic dialysis ● Paroxysmal nocturnal haemoglobinuria OTHERS: ● Major trauma ● COPD ● Neurological disability ● Long distance sedentary travel
- 13. PATHOPHYSIOLOGY: E/F Obstruction,either partial or full of pulmonary arteries Decreased or absent blood flow Present of ventilation but absent of perfusion Increased pulmonary vascular resistance
- 14. CONTD.... Increased right ventricular workload to maintain pulmonary blood flow Decreased cardiac output,decreased blood pressure with right ventricular failure. Shock.
- 15. CLINICAL MANIFESTATION ● Circulatory collapse in previously well patient:massive PE with right heart failure ● Pleuritic pain,possibly with haemoptysis ● Isolated dyspnoea,often of sudden onset ● Collapse in frail patient;usually in elderly patient with poor cardio-respiratory reserve,where a relatively small PE can be catastrophic.
- 16. POSSIBLE SYMPTOMS: ● None-PE may be silent ● Dyspnoea and pleuritic pain ● Substernal chest pain ● Haemoptysis ● Collapse or syncope ● Symptom of hypoxia:anxiety,restlessness,agitation and impaired consciousness
- 17. POSSIBLE SIGNS: ● There may be none ● Tachypnoea and tachycardia ● Pleural rub ● Sign of DVT
- 18. DIAGNOSTIC EVALUATION: ● History collection ● Physical examination ● ECG ● Chest X-ray:mainly useful to exclude other chest disease, and is needed for interpreting V/Q scans. It is usually normal, but may show: decreased vascular markings (so-called "Westermark's sign"), atelectasis or a small pleural effusion. An occasional late sign may be an homogeneous wedge-shaped area of pulmonary infarction in the lung periphery - Hampton's hump (with its base contiguous to a visceral pleural surface and its rounded convex apex directed toward the hilum). ● ABG analysis:Contd..,
- 19. CONTD... ● May show reduce paO2,reduced pCO2 due to hyperventilation or acidosis. ECHOCARDIOGRAPHY:show thrombus in proximal pulmonary arteries ● CARDIAC TROPONINS: Indicate right heart strain.
- 20. CONTD... ● D-dimer level:It is a special blood test used to detect pieces of blood clot that have been broken down and are loose in the blood stream. ● COMPUTERISED TOMOGRAPHY PULMONARY ANGIOGRAPHY(CTPA):Dye is injected in the blood vessel of the lungs and a CT scan is taken.If there is pulmonary embolism in the lungs,it will show up on the CT scan as a gap in the blood supply. ● VENTILATION PERFUSION SCAN(V/Q):It measures the amount of air and the blood flow in the lungs.If there is no blood flow that means embolus is present.
- 21. CONTD... ● LEG ULTRASOUND:To detect DVT. ● ISOTOPE LUNG SCANNING:To detect PE. ● CT SCAN ● MRI.
- 22. COMPLICATIONS: ● Portal hypertension ● Respiratory failure ● Haemoptysis ● Heart failure ● Heart palpitation ● Severe breathing difficulty ● Severe bleeding(usually a complication of treatment) ● Sudden death.
- 23. EMERGENCY MANAGEMENT: ● Oxygen is administered to relieve hypoxaemia,respiratory distress,and cyanosis. ● An infusion to started to open an IV route for drugs/fluids. ● Vasopressors,ionotropic agents such as dopamine(Intropin) and/or antidysrhythmic agents may be indicated to support circulation if the patient is unstable. ● The ECG is monitored continuously for right ventricular failure,which may have a rapid onset.
- 24. CONTD.... ● Small doses of IV morphine are given to relieve anxiety to alleviate chest discomfort(which improves ventilation),and to ease adaption to mechanical ventilator,if this is necessary. ● Pulmonary angiography,hemodynamic measurement,ABG determinations,and other studies are carried out.
- 25. MEDICAL MANAGEMENTS: THRMBOLYTIC THERAPY: ● Streptokinase ● Tissue plasminogen activator(t-PA) ● Single chain urokinase ANTI -COAGULANT THERAPY(BLOOD THINNER): ● Heparin ● warfarin(caumadin) ● Fondaparinux(arixtra) ANALGESICS: ● Morphine ● diclofenac
- 26. SURGICAL MANAGEMENTS: ● INTERRUPTION OF VENA-CAVA:Reduces channel size to prevent lower extremity emboli from reaching lungs. a)ligation,plication,or clipping of the inferior vena cava b)placement of transvenously inserted intraluminal filter in inferior vena cava to prevent migration of emboli.Inserted through femoral vein or jugular vein by way of catheter. ● EMBOLECTOMY:surgical removal of embolus
- 27. NURSING MANAGEMENT: ● Take nursing history with emphasis on onset of severity of dyspnoea and nature of chest pain. ● Examine the patient's leg carefully.Asses for swelling of leg,duskiness(dark skin),pain on pressure over gastrocnemius muscle,pain on dorsiflexion of the foot(positive Homan's sign),which indicates thrombophlebitis as source. ● Monitor respiratory rate-may be accelerated out of proportion to degree of fever and tachycardia. a)percuss for resonance,dullness and flatness. b)Auscultate for friction rub,crackles,rhonchi,and wheezing.
- 28. CONTD... c)Observe rate of inspiration and expiration. ● Auscultate heart;listen for splitting of second heart sound. ● Evaluate result of PT/PTT tests for patient on anticoagulants and report results that are outside of therapeutic range;anticipate a dosage change.
- 29. PREVENTIONS: ● Stop smoking ● Leg exercise ● Less intake of oral contraceptive pills ● Use stockings ● Avoid prolonged standing and sitting ● Regular check-up
- 30. HEALTH EDUCATION: ● Advise patient of the possible need to continue taking anticoagulant therapy for 6 weeks up to an indefinite period. ● Teach about signs of bleeding,especially of gums,nose,bruising,blood in urine and stools. ● For patients on anticoagulants,instruct to use soft toothbrush,avoid shaving with blade razor(use electric razor instead),and avoid aspirin-containing products.Notify health care provider of any bleeding or increased bruising. ● Instruct patient to tell dentist about taking an anticoagulant.
- 31. CONTD... ● Warn against taking medications unless approved by health care provider,because many drugs interact with anticoagulant. ● Warn against inactivity for prolonged periods or sitting with legs crossed to prevent recurrence. ● Warn against sports/activities that may cause injury to legs and predispose to a thrombus. ● Encourage wearing a Medic-Alert bracelet identifying patient as anticoagulant user. ● Instruct to loose weight if applicable;obesity is a risk factor for women.
- 32. CONTD.... ● Discuss contraceptive methods with patient if applicable;female patients are advised against taking oral contraceptives.
- 33. NURSING DIAGNOSIS: ● Ineffective breathing pattern related to acute increase in alveolar dead airspace and possible changes in lung mechanic from embolism. ● Acute pain related to diminished arterial circulation and oxygen of tissue with production of lactic acid in tissue as manifested by tenderness,aching/burning. ● Altered tissue perfusion related to decreased blood circulation. ● Impaired gas exchange related to altered blood flow to alveoli or to major portion of the lung as manifested by dyspnoea,restlessness.
- 34. CONTD.... ● Anxiety related to dyspnoea,pain and seriousness of disease condition. ● Risk for injury related to altered haemodynamic factor and anti-coagulant therapy. ● Deficit knowledge regarding condition treatment programme,self care and discharge needs related to misinterpretation of information as manifested by statement of misconception.