Valuable for nursing students..

1. PULMONARY
EMBOLISMPRESENTED BY: MR. RAMESH CHAUHAN
2nd
YEAR Bsc. NURSING,
ACHARYA COLLEGE OF
NURSING, BANGALORE

2. PULMONARY EMBOLISM

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.