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.
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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.
The most common cause of a pulmonary embolism is deep vein thrombosis (DVT). You can learn about best practices for care of a patient with DVT in our Fundamentals of Nursing Flashcards
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.
Risk factors
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.
Labs
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.
Diagnostics
To diagnose a pulmonary embolism, a computerized tomography (CT) scan is necessary.
Treatments
Treatments for a pulmonary embolism can include medications and/or surgery.
Medications
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.
Surgery
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
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.
Patient teaching
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.
Warfarin 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.
Prevent DVTs
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.
1 comment
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