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Pulmonary embolism

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Pulmonary embolism
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Pulmonary embolism

  1. 1. PULMONARY EMBOLISM Mr. ANILKUMAR B R , LECTURER , MEDICAL-SURGICAL NURSING
  2. 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. 3. Pulmonary embolism
  4. 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. 5. PULMONARY EMBOLISM
  6. 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. 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. 8. Venous endothelial disease 1) Thrombophlebitis 2) vascular diseases 3) foreign bodies (iv/central venous catheters)
  9. 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. 10. Other predisposing factors 1) Advanced age 2) Obesity 3) Pregnancy 4) Oral contraceptive use 5) Constrictive clothing 6) History of previous PE
  11. 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. 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. 13. Other symptoms include  Anxiety  Fever, Tachycardia, apprehension, cough, diaphoresis, hemoptysis and syncope.
  14. 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. 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. 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. 17. Treatment may include a variety of modalities  General measures to improve respiratory and vascular status.  Anticoagulation therapy  Thrombolytic therapy  Surgical intervention
  18. 18. Emergency management  Massive PE is a life – threatening emergency  The immediate objective is to stabilize the cardiopulmonary system.
  19. 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. 20. Continue  Hypotension is treated by a slow infusions of dobutamine.  Continue monitoring ECG  Blood is drawn for serum electrolytes, CBC etc
  21. 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. 22. Continue  Small doses of IV Morphine or sedative are administered to relive patient anxiety.
  23. 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. 24. Elastic compression stocking
  25. 25. Intermittent pneumatic leg compression devices
  26. 26. Pharmacologic therapy  Anticoagulation therapy: (heparin, warfarin Sodium) has traditionally been the primary method for managing acute deep venous thrombosis and PE.
  27. 27. Thrombolytic therapy  Thrombolytic therapy: (urokinase, streptokinase, alteplase and reteplase)
  28. 28.  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.
  29. 29. 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.
  30. 30. 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.
  31. 31. 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.
  32. 32. 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)
  33. 33. 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.
  34. 34. 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
  35. 35. Management of pain  Adequate management of chest pain is essential  A semi – fowler‘s Postion  Administer opioid analgesic as prescribed for severe chest pain
  36. 36. Managing oxygen therapy  Pulseoximetry  Deep breathing and incentive spirometry  nebulizer therapy, percussion and Postral drainage may be used for management of secretions.
  37. 37. Reliving anxiety
  38. 38. Monitoring for complications  Bleeding as a result of thrombolytic therapy  Cardiogenic shock  Pulmonary hypertension, cur pulmonale  Respiratory failure
  39. 39. Providing post operative care  Pulmonary artery pressure  Urinary output
  40. 40. 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.
  41. 41.  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)

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