A pulmonary embolism is a blockage in the lungs caused by a blood clot that forms elsewhere in the body and travels through the bloodstream. Symptoms include shortness of breath, chest pain, and anxiety. Diagnosis involves tests like CT scans, ventilation-perfusion scans, and pulmonary angiograms. Treatment focuses on anticoagulant medications like heparin to prevent further clotting and reduce the risk of additional embolisms. Nursing care monitors the patient's oxygenation status and educates them on preventing future clots.

1. Pulmonary Embolism
Henok Oncho BSN, RN,

2. Introduction
The incidence of Pulmonary emboli (PE) in the North
America is 100 persons in 100,000 population. This
means currently one person is experiencing PE in
every 1000 individuals.
Death from PE is usually confirmed after autopsy
results because PE is one of the most misdiagnosed
or under diagnosed diseases.

3. What is pulmonary
embolism?
PE is an obstruction of blood vessels in the lungs,
most often caused by a blood clot. However, PE also
can also be caused by air, fat, or amniotic fluid.
Obstruction of the lung arteries air , fat or amniotic
fluid are rare when compared to blood emboli.
The most common blood clot is formed in the lower
extremities veins and travels to the heart through
the vena cava that occludes the pulmonary arteries
resulting decreased perfusion or dead zone.

4. Animation of PE Formation
click on below

5. Pathophysiology of
Pulmonary Embolism
• Under normal conditions:-
There is a balance between activation of clotting
factors and fibrinolysis
• Clotting = fibrinolysis
• Hypercoagulability can be resulted from
+ trauma + malignancy + pregnancy
+ surgery + use oral contraceptive

6. What does Pulmonary
Embolism effect?
The lung’s ventilation is not affected; however, it’s
perfusion is reduced. This is also called mismatched V/Q
(ventilation-perfusion) ratio.
The occluded part of the perfusion is commonly called
dead zone.
PE can be symptomatic or asymptomatic often depending
on the size of the emboli and occluded or non perfused
areas of the lung.
The heart tries to compensate resulting in
= tachycardia
The lungs try to compensate for the shortage of oxygen in
the cells resulting in
= tachypnea

7. Pulmonary Embolism
effect chain
Pulmonary embolism obstructs blood flow to lung 
increased pressure on pulmonary artery and reflex
constriction of pulmonary blood vessels  poor
pulmonary circulation  pulmonary infraction

8. Question 1
Which physiologic effect of a pulmonary embolism
would initially affect oxygenation?
A. A blood clot blocks ventilation; perfusion is
unaffected
B. A blood clot blocks ventilation, producing hypoxia
despite normal perfusion
C.A blood clot blocks perfusion and ventilation,
producing profound hypoxia
D. A blood clot blocks perfusion, producing hypoxia
despite normal or supernormal ventilation

9. ANSWER
Answer D
The clot blocks blood flow to a region of the lung
tissue. That are remains ventilated but because blood
flow is blocked, no gas exchange can occur in that
region and a ventilation-perfusion mismatch is
present. Ventilation isn’t initially affected by a blood
clot because air can still move normally through the
bronchial tree.

10. Question 2
A client with a massive pulmonary embolism is
scheduled to have arterial blood gas analysis
performed. The nurse expects the analysis will
identify:
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

11. ANSWER
Answer D
A client with massive pulmonary embolism will have
a large region or lung tissue unavailable for
perfusion. This causes the client to hyperventilate
and blow off large amounts of carbon dioxide, which
crosses the unaffected alveolar-capillary membrane
more readily than does oxygen and results in
respiratory alkalosis

12. Symptoms of a Pulmonary
Embolism
Symptoms of a pulmonary embolism depend on the
size of the clot and the location in the lungs where it
becomes lodged.
The most common symptom of a pulmonary
embolism is shortness of breath. This may be gradual
or sudden.

13. Other symptoms of a
pulmonary embolism
include:anxiety
clammy or bluish skin
coughing
chest pain that may extend
into your arm, jaw, neck,
and shoulder
fainting
irregular heartbeat
lightheadedness
rapid breathing
rapid heartbeat
restlessness
spitting up blood
weak pulse

14. Risk Factors
Thrombophlebitis
Recent surgery
Invasive procedures
Immobility
Obesity
Myocardial infarction, heart
failure
Smoking
Varicose veins
Hormone replacement
therapy

15. Question 3
A nurse calls a physician with the concern that a patient has
developed a pulmonary embolism. Which of the following
symptoms has the nurse most likely observed?
A. The patient is somnolent with decreased response to the
family.
B. The patient suddenly complains of chest pain and
shortness of breath.
C. The patient has developed a wet cough and the nurse
hears crackles on auscultation of the lungs.
D. The patient has a fever, chills, and loss of appetite.

16. ANSWER
Answer: B
Typical symptoms of pulmonary embolism include
chest pain, shortness of breath, and severe anxiety.
The physician should be notified immediately. A
patient with pulmonary embolism will not be sleepy
or have a cough with crackles on exam. A patient
with fever, chills and loss of appetite may be
developing pneumonia.

17. Question 4
A male adult client is suspected of having a pulmonary
embolus. A nurse assesses the client, knowing that
which of the following is a common clinical
manifestation of pulmonary embolism?
a. Dyspnea
b. Bradypnea
c. Bradycardia
d. Decreased respirations

18. ANSWER
Answer A.
The common clinical manifestations of pulmonary
embolism are tachypnea, tachycardia, dyspnea, and
chest pain.

19. Question 5
The nurse would identify which of the following clients as
being at the highest risk for developing a pulmonary
embolus?
1. A 19-year-old four days postpartum with an obstetrical
history of placenta previa.
2. An obese 40-year-old man with multiple pelvic fractures
from an auto accident two days ago.
3. A 65-year-old woman who had a fractured hip repaired 10
days ago and who is in physical therapy daily.
4. A 22-year-old leukemic client with a platelet count of
120,000/mm3 and a hemoglobin level of 9.0g.

20. ANSWER
Strategy: Determine how each answer choice relates to
pulmonary embolism.
(1) at high risk for shock and bleeding complications
(2) correct–obesity, immobility, and pooling of blood in
the pelvic cavity contribute to development of pulmonary
emboli
(3) client does not have a high risk for pulmonary emboli
(4) at high risk for shock and bleeding complications

21. Picture of Pulmonary
Embolism

22. Assessment
Pulmonary Embolism is very difficult to diagnose due to its
nonspecific signs and symptoms. Pulmonary embolism should be
suspected with patients with new worsening dyspnea or
sustained hypotension without other explanation. However, it is
also common that a DVT or embolus produces no significant
symptoms and may be an incidental finding when the patient
undergoes imaging for other reasons (Morton & Fontaine, 2013,
p.563).
Because pulmonary embolism almost always occurs in
conjunction with deep vein thrombosis, some doctors refer to the
two conditions together as venous thromboembolism (VTE).

23. Assessment (subjective)
Chest Pain: sub sternal, localized; type- crushing,
sharp, stabbing with respirations
Sudden onset of profound dyspnea.
Restless, irritable, anxious
Sense of impending doom

24. Assessment (Objective)
Respirations: either rapid,
shallow or deep gasping.
Elevated temperature.
Auscultation: friction rub,
crackles; diminished breath
sounds
Cough; hemoptysis
ECG changes that reflect
right sided heart failure
Echocardiogram shows
increased pulmonary
dynamics
Shock
Tachycardia
Hypotension
Skin, cold, clammy

25. Assessment findings
Apprehension and
restlessness
Blood-tinged sputum
Chest pain
Cough
Crackles and wheezes on
auscultation
Cyanosis
Distended neck veins
Dyspnea
Feeling of impending doom
Hypotension
Petechiae over the chest and
axilla
Shallow respirations
Tachypnea and tachycardia

26. Question 6
A client with a pulmonary embolism tells the nurse
that he feels a sense of “impending doom.” The
nurse recognizes that this manifestation is caused by
what?
A. Inflammatory reaction in the lung parenchyma
B Loss of chest expansion
C. Loss of lung tissue
D. Sudden reduction in adequate oxygenation

27. ANSWER
Answer D
The client with a pulmonary embolism has a portion
of the lung not involved in oxygenation, causing the
client to feel apprehensive. If the area involved is
large, the apprehension can be great, giving the
client the feeling of “impending doom.”

28. How Is a Pulmonary
Embolism Diagnosed?
Diagnosing pulmonary embolism can be difficult, because there
are many other medical conditions, such as a heart attack or an
anxiety attack, that can cause similar symptoms.
To diagnosis PE, diagnosis depends on an accurate and thorough
medical history and ruling out other conditions. The doctor will
need to know about the patient’s symptoms and risk factors for
pulmonary embolism. This information, combined with a careful
physical exam, will point to the initial tests that are best suited
to diagnose a deep vein thrombosis or pulmonary embolism.

29. Diagnosis Tests
pulmonary angiography: this test involves making a small
incision so the doctor can guide specialized tools through
the veins. A special dye is injected so that the vessels of
the lung can be seen. This is the determining test for the
diagnosis of Pulmonary Embolism.
duplex venous ultrasound: this test uses radio waves to
visualize the flow of blood and to check for blood clots in
the legs.
venography: this is a specialized X-ray of the veins of the
legs.

30. One or more of the following
tests is done in order to
diagnose PE
chest X-ray: this standard, noninvasive test allows doctors to see the heart
and lungs in detail, as well as any problems with the bones around the
lungs.
electrocardiography (ECG): this test measures the heart’s electrical activity.
magnetic resonance imaging (MRI): this scan uses radio waves and
magnetic field to produce detailed images.
computed tomography (CT) scan: this scan gives the doctor the ability to
see cross-sectional images of the lungs.

31. Question 7
A client is suspected of having a pulmonary embolism
and asks the nurse how the doctor will definitively
determine the diagnosis. The nurse anticipates that
the physician will order.
A. Arterial blood gas (ABG) analysis
B. Chest X-Ray
C. Pulmonary Angiogram
D. Ventilation-perfusion scan

32. ANSWER
Answer C
A pulmonary angiogram is used to definitively
diagnose a pulmonary embolism. A catheter is passed
through the circulation to the region of the
occlusion; the region can be outlined with an
injection of contrast medium and viewed by
fluoroscopy. This shows the location of the clot as
well as the extent of the perfusion defect.

33. Overview of Management
Treat with medicines, procedures, and other
treatments
The main goals of treatment
Stop the blood clot from getting bigger
Prevent new clots from forming

34. Medications
Anticoagulants are prescribed when pulmonary
embolism is diagnosed or suspected
Heparin
Warfarin
Rivaroxaban
Fondaparinux
Most commonly the patient will take an anticoagulant
for at least 3 months after pulmonary embolism to
reduce the risk of having another blood clot.

35. Medications cont..
Thrombolytics or clot- dissolving medicines are not
commonly used to treat pulmonary embolism unless
in a life threatening situation.
These drugs can greatly increase the risk of serious
bleeding.
Reteplase (Retavase)
Alteplase (Activase, Cathoflo Activase)

36. Embolectomy
The removal of a clot
May be surgical or may be done with a minimal
invasive procedure that uses a catheter.
This treatment is used only in rare cases.

37. Other types of treatment
If medicines don’t work your doctor may suggest a
vena cava filter.
This keeps blood clots from traveling to your lungs.
Used when anticoagulants are not an option, when
clots form despite anticoagulant use, or when there is
an increased risk of death or severely restricted
lifestyle if another pulmonary embolism occurs.

38. Question 8
A definitive diagnosis of pulmonary embolism has
been made for a client. The nurse anticipates which
medication will be ordered?
A. Warfarin (Coumadin)
B. Heparin
C. Streptokinase (Streptase)
Acyclovir (Zovirax)

39. ANSWER
Answer B
Heparin is started I.V. once a pulmonary embolism is
diagnosed to reduce further clot formation. When a
therapeutic level of heparin is established, warfarin is
started. It can take up to 3 days before a therapeutic
level of warfarin is achieved.

40. Question 9
The nurse is teaching a client diagnosed with a
pulmonary embolism about the prescribed heparin
therapy. The nurse determines that teaching has
been effective when the client states that heparin is
given to:
A. Dissolve the clot
B. Break up the pulmonary embolism
C. Slow the development of other clots
D. Prevent clots from breaking off and embolizing to
the lung

41. ANSWER
Answer C
Heparin slows the development of other clots.

42. Priority Nursing Actions
1. Notify the Rapid Response
Team
2. Reassure the client and
elevate the head of the
bed
3. Prepare to administer
oxygen
4. Obtain vital signs and
check lung sounds
5. Prepare to obtain an arterial
blood gas.
6. Prepare for the
administration of heparin
therapy or other therapies.
7. Document the event,
interventions taken, and the
client’s response to treatment.

43. Nursing care goals
Monitor for signs of respiratory distress
Health teaching
Prevent from further occurrence
Need to continue medication
Follow-up care

44. Question 10
Nursing management of a client with a pulmonary
embolism will primarily focus on which action?
A. Assessing oxygenation status
B. Monitoring the oxygen delivery device
C. Monitoring for other sources of clots
D. Determining whether the client requires another
ventilation-perfusion scan

45. ANSWER
Answer A
Nursing management of a client with a pulmonary
embolism focuses on assessing oxygenation status
and ensuring that treatment is adequate. If the
client’s status begins to deteriorate, it’s the nurse’s
responsibility to contact the physician and attempt to
improve oxygenation.

46. How Can Pulmonary
Embolism Be Prevented?
Preventing pulmonary embolism (PE) begins with preventing deep
vein thrombosis (DVT). Knowing whether you're at risk for DVT and
taking steps to lower your risk are important.
Daily use of anticoagulant medicines may help prevent recurring
pulmonary embolism by stopping new blood clots from forming and
stopping existing clots from growing.
If you've already had DVT or PE, you can take more steps to prevent
new blood clots from forming. Visit your doctor for regular checkups.
Also, use compression stockings to prevent chronic (ongoing)
swelling in your legs from DVT (as your doctor advises).

47. Important steps to lower
your risk of PE
Exercise your lower leg muscles if you're sitting for a
long time while traveling.
Get out of bed and move around as soon as you're
able after having surgery or being ill. The sooner you
move around, the better your chance is of avoiding a
blood clot.
Take medicines to prevent clots after some types of
surgery (as your doctor prescribes).
Follow up with your doctor.

48. References
Pulmonary Embolism-Medications. (2013, February 5). Retrieved
September 15, 2014, from
http://www.webmd.com/lung/tc/pulmonary-embolism
Lisko, S. (2014). Respiratory Disorders. In NCLEX-RN questions &
answers made incredibly easy (Sixth ed., pp. 112-114).
Philadelphia, PA: Lippincott Williams & Wilkins.
Morton, P. (2013). Common Respiratory Disorders. In Critical
care nursing: A holistic approach (10th ed., pp. 561-565).
Philadelphia, PA: Lippincott Williams & Wilkins.
Silvestri, L. (2011). Respiratory System. In Saunders
comprehensive review for the NCLEX-RN examination (5th ed., p.
743). St. Louis, Mo.: Elsevier/Saunders.