Med-Surg Respiratory System, part 10: Pulmonary Embolism
August 27, 2021 Updated: December 29, 2021 7 min read
In this article, we'll discuss pulmonary embolism or PE.
The Med-Surg Nursing video series follows along with our Medical-Surgical Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
What is a pulmonary embolism?
A pulmonary embolism, or PE, is a life-threatening blockage in the pulmonary vasculature, the blood vessels that transport blood from the heart to the lungs and back again.
A pulmonary embolism can occur when an embolus (blood clot) becomes lodged in one of the pulmonary arteries. Pulmonary vascular occlusion leads to impaired gas exchange and circulation.
Patients with DVT are at high risk for a pulmonary embolism, because a clot in their lower extremities (usually their legs) can travel up through the vascular system and lodge itself in the lungs.
The risk factors of a pulmonary embolism include immobility, smoking, combining oral contraceptives (contraceptives that contain both estrogen and progesterone), obesity, surgery, atrial fibrillation (AFIB), and pregnancy.
If the patient has a long bone fracture — for example, if they fractured their femur — that can lead to the formation of a fat emboli, embolized fat within the capillary beds that can cause direct tissue damage or induce a systemic inflammatory response, like PE. In this case, fat emboli travel to the lungs and lead to a pulmonary embolism.
Signs and symptoms
The signs and symptoms of pulmonary embolism include shortness of breath, anxiety, chest pain with inspiration (inhaling), tachycardia, tachypnea (abnormally rapid breathing), hypotension (low blood pressure), and diaphoresis (excessive sweating).
Fat emboli can cause the presence of petechiae, red dots that appear all over the skin. These red dots are indicative of a fat emboli.
A patient with an embolism will have an elevated D-dimer. This elevated reading could be caused by a DVT or a PE. Either way, it indicates the likelihood that the patient has a clot somewhere in their body.
To diagnose a pulmonary embolism, a computerized tomography (CT) scan is necessary.
Treatments for a pulmonary embolism can include medications and/or surgery.
Among the medications used to treat a PE are anticoagulants, such as warfarin (an oral anticoagulant) and heparin (an anticoagulant administered through an IV or through a subcutaneous injection), as well as thrombolytics, such as alteplase.
Thrombolytics help break up clots, while anticoagulants prevent clots from getting bigger. Anticoagulants also prevent the formation of new clots.
Surgical interventions include a thrombectomy — the removal of the blood clot — or the placement of a vena cava filter, a device that prevents new emboli from entering the lungs.
Nursing care for a patient with PE includes sitting them upright, to allow them to breathe more easily, as well as administering oxygen as ordered.
A patient who is discharged from hospital care usually continues their treatment for PE (or DVT) at home. This requires educating them on how to manage their ongoing therapy.
When a patient has a pulmonary embolism, they typically start on heparin right away because it's a fast-acting medication that gets the anticoagulation into the patient's system quickly. Concurrently, they start on warfarin, because warfarin takes several days to achieve a therapeutic level. To measure the therapeutic level of warfarin, check the patient's PT (prothrombin time) and INR (international normalized ratio) levels. An INR between 2 and 3 is considered therapeutic for warfarin therapy.
A patient who returns home on warfarin therapy will need periodic blood draws to ensure a therapeutic level of warfarin is being maintained. They should be instructed to maintain a consistent intake of vitamin K. If they dramatically increase their intake of vitamin K, that will decrease the effectiveness of their warfarin treatment, because vitamin K is an antidote to warfarin.
Conversely, a sudden decrease in their intake of vitamin K could put them at risk for bleeding.
Any therapy that includes an anticoagulant puts the patient at risk for bleeding. That means that the patient should be taught how to care for themselves.
They should avoid taking aspirin, because it can cause the patient to bleed more easily.
Patients and their families should do what they can to prevent falls, because falls can pose the risk of cuts and bruising, which can lead to excessive bleeding.
Even small cuts and wounds can be dangerous to a patient on warfarin therapy. They should brush their teeth with a soft-bristled brush, and use an electric razor to shave, rather than one with a blade or blades. Even blowing their nose holds the potential for bleeding, so encourage the patient to blow their nose gently.
Because deep vein thrombosis can be a key cause of a pulmonary embolism, encourage the patient to stop smoking if they do smoke, because smoking can lead to blood clotting and poor circulation. They should increase their mobility because immobility is a key risk factor for a PE. And they can wear compression stockings to help prevent the formation of DVTs.
Hi I'm Cathy with Level Up RN. In this video, we are going to talk about a pulmonary embolism or PE. And at the end of the video, I'll be giving you guys a little quiz to test your knowledge of the information I'll be covering, so definitely stay tuned for that.
So a pulmonary embolism is a life-threatening blockage in the pulmonary vasculature and it is caused by an emboli or blood clot that occludes one of the pulmonary arteries. The most common cause of a PE is a DVT, so deep vein thrombosis. So a patient will have a DVT in one of their legs, and then that DVT can travel up through the vascular system and lodge itself in the lungs, and this, of course, impairs circulation and impairs gas exchange.
So risk factors associated with a PE include immobility, smoking, combined oral contraceptives - so oral contraceptives that contain both estrogen and progesterone - obesity, surgery, atrial fibrillation. And then, pregnancy is another risk factor. And then, if the patient has a long bone fracture - for example, if they fractured their femur - that can cause a fat emboli which can also travel to the lungs and become a pulmonary embolism. So signs and symptoms of PE include shortness of breath, anxiety, chest pain with inspiration, tachycardia, tachypnea, hypotension, and then with a fat emboli that can cause the presence of petechiae which are like these red dots all over the skin. So if you see those, then that would be indicative of a fat emboli.
In terms of labs, the patient's D-dimer will be elevated in the presence of a clot. So this could be elevated due to a DVT or a PE. If it's elevated, then it is likely the patient has a clot somewhere in their body. And then, we can diagnose PE with a CT scan.
Medications used to treat a PE include anticoagulants such as warfarin and heparin, and thrombolytics such as alteplase. So the thrombolytics will help break up the clots, whereas the anticoagulants will prevent the clot from getting any bigger. And it will prevent formation of new clots. Surgical interventions include a thrombectomy - so that is removal of the blood clot - or the placement of a vena cava filter which the intent of that device is to catch the clot before it can reach the lungs.
So in terms of nursing care, we're going to want to sit the patient upright so that they can breathe more easily and administer oxygen as ordered. When the patient has a PE, we typically start them on heparin right away because that's very fast-acting to get that anticoagulation on board quickly. And then, concurrently, we also start them on warfarin because warfarin takes several days to get to a therapeutic level. So we measure that therapeutic level by checking the patient's PT and INR levels, and an INR between 2 and 3 is considered therapeutic for warfarin therapy. So the patient will go home with warfarin, and they will need periodic blood draws to make sure we are maintaining a therapeutic level of warfarin. So one thing we need to educate the patient on is that they need to maintain a consistent intake of vitamin K. Because if they're like eating this much vitamin K and they suddenly increase their intake, that's going to really decrease the effectiveness of warfarin because vitamin K is the antidote for warfarin. So we don't want that to happen, and then, we also don't want them to suddenly decrease their intake of vitamin K because then they're going to be at risk for bleeding. So we want them to just maintain their intake of vitamin K. We also want to caution them that bleeding is possible while being on an anticoagulant. So they need to make sure they don't take aspirin, that they prevent falls from happening because if they were to fall and hit something, then bleeding could be a real problem for them. We want to advise them to use a soft toothbrush and an electric razor instead of a straight razor, and they should also avoid blowing their nose forcefully. In terms of prevention of DVTs because, again, the DVTs are the key cause of a PE, we want to encourage the patient to stop smoking if they do smoke. They should increase their mobility because immobility is a key risk factor for a PE. And then, they can wear compression stockings to help prevent the formation of DVTs.
All right, time for a quiz. I have three questions for you. First question, what is the most common cause of a pulmonary embolism?
If you said a DVT or deep vein thrombosis, you are correct. Question number two, what lab will be elevated in the presence of a clot?
The answer is D-dimer. And then question number three, how should a patient modify their intake of vitamin K while on warfarin?
The answer is they should maintain a consistent intake of vitamin K.
All right. I hope this video and this quiz has been helpful for you. Good luck with studying, and I'll see you on another video soon.
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