Learning Outcomes
At the end of this lecture, students will be able to: Describe PE, its pathophysiological changes, and discuss its clinical manifestations. Identify the diagnostic test that may be used to diagnose PE. Discuss the medical and nursing management of PE.
Introduction
Pulmonary embolism (PE) is an obstruction of the pulmonary artery (next slide) or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system. The types of emboli could be a blood clot (most common), air, fat, amniotic, fluid, and septic (from bacterial invasion of the thrombus). PE is often associated with trauma, surgery (orthopedic), pregnancy, heart failure, age > 50 years, hypercoagulable states, and prolonged immobility. Most thrombi originate in the deep veins of the legs; other sites include the pelvic veins and the hearts right atrium. An enlarged right atrium in fibrillation causes blood to stagnate[ ]and form clots that may travel into the pulmonary circulation causing PE.
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Pathophysiology
When there is a complete or partial obstruction of a pulmonary artery or its branches by a thrombus, the alveolar dead space (next slide) is increased. The area, although continuing to be ventilated, receives little or no blood flow, resulting in impaired or absent gas exchange. In addition, various substances are released from the clot and surrounding area, causing regional blood vessels and bronchioles to constrict. This causes an increase in pulmonary vascular resistance. This results in an increase in pulmonary arterial pressure and, in turn, an increase in right ventricular work to maintain pulmonary blood flow. When the work requirements of the right ventricle exceed its capacity, right ventricular failure occurs, leading to a decrease in cardiac output followed by a decrease in systemic blood pressure and the development of shock.
Alveolar dead space: A well-ventilated part of the lung is not receiving blood flow. The air reaching that region of the lung is therefore wasted since it cannot participate in gas exchange, thus the 6 alveoli are considered dead.
Clinical Manifestations
The symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus. Dyspnea is the most frequent symptom; while tachypnea is the most frequent sign. Chest pain is common and is usually sudden and pleuritic. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. Deep venous thrombosis is closely associated with the development of PE. Typically, patients report sudden onset of pain and/or swelling and warmth of the proximal or distal extremity, skin discoloration, and superficial vein distention.
Medical Management
Emergency management.
Nasal oxygen to relieve hypoxemia, respiratory distress, and central cyanosis. Intravenous infusion lines to administer medications or fluids. A perfusion scan, arterial blood gas determinations are performed. Pulmonary angiography may be performed. Hypotension is treated by a slow infusion of dobutamine (Dobutrex). The ECG is monitored continuously for dysrhythmias which may occur suddenly. Digitalis glycosides, intravenous diuretics, and antiarrhythmic agents may be indicated. Blood is drawn for serum electrolytes and complete blood count. Intubation and mechanical ventilation may be performed based 10 on clinical assessment and arterial blood gas analysis.
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Nursing Management
Minimizing The Risk of Pulmonary Embolism
A major responsibility of the nurse is to identify patients at high risk for PE and to minimize the risk of PE in all patients. Therefore, the nurse must give attention to conditions predisposing to a slowing of venous return (i.e. prolonged immobilization, prolonged periods of sitting/traveling, varicose veins, spinal cord injury), hypercoagulability due to release of tissue thromboplastin after injury/surgery (i.e. pancreatic, GI, GU, breast, or lung tumor, increased platelet count in polycythemia), venous endothelial disease (i.e. thrombophlebitis, foreign bodies such as IV/central venous catheters)
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