Pulmonary Embolism Sp07

Front 1

Etiology and risk factors of PE

Back 1

 Deep calf, femoral, popliteal, or iliac veins
 Other sources: tumors, air, fat, bone marrow, amniotic fluid, sepsis, heart valve vegetation in endocarditis

 Major operations: hip, knee, abdominal, pelvic
 Inactivity
 Prophylaxis

Front 2

Pathophysiology of PE

Back 2

 Perfusion decreased
 Ventilation unaffected (VQ mismatch)
 Results in hypoxemia
 Large pulmonary vessel blocked
 Increases pulmonary vascular resistance causing right-sided CHF
 Causes atelectasis
 Bronchial constriction
 Reduces cardiac output or shock causing hypoxia and acidosis
 Smaller vessel
 Less severe clinical manifestations
 Altered perfusion

Front 3

Clinical manifestations of PE

Back 3

 Nonspecific and may appear late
 Most common
 Tachypnea
 Dyspnea
 Anxiety
 Chest pain (pleuritic, sudden)
 Other
 Apprehension, cough, diaphoresis, syncope, hemoptysis
 Crackles, accentuated S2, tachycardia, fever
 Less common: S3, S4, edema, murmur, cyanosis

Front 4

Pulse Oximetry

Back 4

 Low sats, may be unresponsive to increases in FIO2.
 Massive PE
 Low PaO2
 Low PaCO2
 Severe respiratory alkalosis
 Increased LDH 3 isoenzyme

Addn'l: VQ scan, Spiral CT, Pulmonary angiograpgy - for other /s others cannot confirm dx

Front 5

Medical management

Back 5

 Stabilizing the cardiopulmonary system
 Anticoagulant therapy to prevent more PE
 Fibrinolytic therapy

Front 6

Stabilizing the cardiopulmonary system

Back 6

 Oxygen to maintain a PaO2 of 60
 low flow per nasal cannula,
 ET
 Increase BP by raising preload (RV end diastolic pressure)
 IV fluids
 Inotropic drugs if needed
 NaBicarbonate if needed to reverse acidosis

Front 7

Heparin

Back 7

 Reduce further clots or extension of existing clots.
 Heparin (unfractionated) IV bolus and continuous infusion
 Therapeutic activated partial thromboplastin time (aPTT) level is more than 60 seconds or 1.5-2.5 times the baseline.
 Nomogram Protamine antagonist, hold ASA and other anticoagulants
 Low molecular weight Heparin SC
 If hemodynamically stable (not in shock)
 Requires no blood testing.

Front 8

Warfarin (Coumadin)

** fibronolytic thx - for unstable clients, lyse clots and resotre. R side hart fxn, may have high motality rate

Back 8

 Keep International Normalized Ratio (INR) at 2.5-3 (higher than DVT). The INR is based on the Prothrombin Time (PT).
 Takes 2-3 days to replace heparin anticoagulation effect.
 Avoid Vitamin K in diet, which is antagonist
 Hold other anticoagulants such as ASA.

Front 9

Complications of P.E. (SRD)

Back 9

 Shock
 Respiratory failure
 Dysrhythmias

Front 10

Nursing management

Back 10

 Assess vital signs and lung sounds
 Monitor for hypoxemia and distress
 Auscultate heart sounds
 Assess for edema, liver engorgement
 Elevate the head of the bed, without severe flexion of hips.
 Alleviate fears and anxiety
 Monitor labs
 Treat pain with drugs such as morphine
 Anticoagulant precautions
 Soft sponge tooth brushes, at least 10 minute pressure on punctures, observe for blood, flank pain
 Avoid or minimize trauma: toothbrush, bruising, injections
 Increased fiber, supervised ambulation to prevent falls

Front 11

Surgical mgt:

Back 11

vena cava filter (Greenfield filter)
Embolectomy catheter.