Question

Review the pathophysiology of PE( Pulmonary Embolism) , then answer and submit the following questions:

1. What places a patient at risk for PE?

2. What care interventions are needed to prevent PE development?

3. Identify PE manifestations that you might observe.

4. What diagnostic tests should be done immediately?

5. How would you prepare the patient for testing?

6. What would you tell the family? The patient?

7. Should you, as the nurse, contact the Rapid Response Team? Why? (If yes, when should you contact them?)

8. What would the patient look like if he/she were in respiratory acidosis?

Answer 1

1. What places a patient at risk for PE?

Your blood goes from your heart to your lungs through your pulmonary artery. In the lungs the blood is supplied with oxygen, then it goes back to the heart, which pumps the oxygen-rich blood to the rest of your body. When a blood clot gets caught in one of the arteries that go from the heart to the lungs, it’s called a pulmonary embolism (PE). The clot blocks the normal flow of blood. This blockage can cause serious problems, like damage to your lungs and low oxygen levels in your blood. The lack of oxygen can harm other organs in your body, too. If the clot is big or the artery is clogged by many smaller clots, a pulmonary embolism can be fatal.

Pulmonary embolisms usually travel to the lungs from a deep vein in the legs. Doctors call this “deep vein thrombosis” (DVT). These clots develop when the blood can’t flow freely through the legs because your body is still for a long time, say during a long flight or drive. It might also happen if you’re on bed rest after surgery or illness.

2. What care interventions are needed to prevent PE development?

Five things that may help lower your chances of developing these dangerous blood clots:

1. Blood Thinners
Doctors call these “anticoagulants.” They keep your blood from forming clots. Your doctor may prescribe them to you while you’re in the hospital for surgery. He might also suggest you keep taking them for some time after you go home.

Your doctor might also recommend blood thinners if you’ve been hospitalized after a stroke or heart attack, or have complications from cancer.

2. Compression Stockings
These are long socks that squeeze your legs. The extra pressure helps blood move through your veins and leg muscles. Your doctor may recommend you wear them for a while after surgery.

3. Exercise
Get out of bed and walk when you’re getting over a long stay in the hospital or an illness that’s kept you in bed for too long. It’ll keep the blood in your legs flowing so it doesn’t have a chance to pool.

4. Stretching During Trips
If you’re on a long flight, try to walk up and down the aisles every 30 minutes or so. If you can’t stand up, flex your ankles by pulling your toes toward you.

Here’s another stretch you can try to do while seated:

• Pull your leg up toward your chest with one hand.
• Hold the bottom of that leg with the other hand.
• Keep this pose for 15 seconds, then try it with the other leg.
• Do this up to 10 times.

If you’re driving a long distance, stop every hour and stretch your legs.

5. Lifestyle Changes
Along with exercise, there are a number of steps you can take going forward. Here are some important ones:

• Maintain a healthy weight.
• If you plan to take hormones, like birth control or replacement therapy, talk to your doctor about your risk for blood clots.
• If you have other health issues, like diabetes or heart failure, take your meds, watch what you eat, and talk to your doctor about any changes.
• If you smoke, quit.

3. Identify PE manifestations that you might observe.

When an artery in your lung gets blocked by a blood clot, you have a pulmonary embolism (PE).

Symptoms can vary. What you experience will likely depend on the size of the clot and how much of your lung it affects. If you have lung or heart disease, that can play a role, too.

PE Is a Medical Emergency
Symptoms of PE tend to come on suddenly. Call emergency if you have any of the following:

• Shortness of breath
• Chest pain
• Cough (it may be bloody, and there might be blood in the gunk you cough up)
• Pain in your back
• Much more sweating than usual
• A lightheaded feeling, or passing out
• Blue lips or nails

4. What diagnostic tests should be done immediately?

If you think you have a pulmonary embolism (PE), you should get medical help right away. Your doctor will likely start with a physical exam. He’ll look closely at your legs to see if they’re swollen, tender, discolored, or warm. These are signs that you may have a clot deep in one of your veins. Your doctor may order a number of tests, like a chest X-ray or ultrasound. You might also have blood tests. These can measure the amount of oxygen and carbon dioxide in your blood. They can also help your doctor detect a substance called D dimer. This is a small protein fragment that’s present in the blood after a clot is broken down by the body.

Other tests your doctor might order include:

• Computed tomographic angiography (CTPA). This is a special type of X-ray test. It’s also the main one doctors use to see if you have a PE. Your doctor will inject dye (“contrast”) into your veins. He’ll be able to see the blood vessels in your lungs on the X-ray.
• Ventilation/perfusion (V/Q) scan. This test is used if the CTPA isn’t available, or isn’t a good match for you. It uses a radioactive material to show which parts of your lungs are getting air flow (ventilation) and blood flow (perfusion). If there’s low blood flow to a certain area, but the air flow is normal, a clot may be present.
• Pulmonary angiography. This is the most accurate test to detect PE. It may be used if other tests haven’t shown clear results. A specialist inserts a long, thin tube (catheter) into a large vein in your groin and into the arteries within your lung. He then injects dye through the catheter. Images of the blood vessels inside the lung will pop up on an X-ray.
• MRI . This may be a good option if you’re pregnant or your doctor is concerned that other tests that use contrast might be harmful to you.
• Echocardiogram . This is an ultrasound of the heart. It can’t detect a PE, but it does show if you have strain on your heart caused by one.

5. How would you prepare the patient for testing?

A pulmonary embolism (PE) is a blood clot in the lung. It’s serious and can be life-threatening. But the good news is that if it’s caught early, doctors can treat it. Here’s a look at some of the most common ways they tackle this condition.

Blood Thinners
Also called “anticoagulants,” these are the most common treatment for a blood clot in the lung. They serve two key roles: First, they keep the clot from getting any bigger. Second, they keep new clots from forming.

They don’t dissolve blood clots. Your body normally does that on its own over time.

The most commonly prescribed blood thinners are warfarin (Coumadin, Jantoven) and heparin. Warfarin, in a pill, can treat and prevent clots. Heparin can lower the chances of another clot forming. You get it through a shot or an IV.

Treatment can begin while you’re in the hospital. How long you’ll stay and be treated depends on your condition.\

Low-molecular-weight heparins are also becoming widely used. These can be self-injected at home. They include:

• Dalteparin (Fragmin)
• Enoxaparin (Lovenox)
• Tinzaparin (Innohep)

6. What would you tell the family? The patient?

Pulmonary Embolism: Patient / Family Education

You have been diagnosed with a pulmonary embolism. Here is some basic information pulmonary embolism and how it is treated.

What is a pulmonary embolism?
Pulmonary embolism (or “PE”) is a blockage in one or more of the blood vessels that supply blood to the lungs. Most often these blockages are caused by blood clots that form elsewhere and then travel to the lungs.

Why are blood clots dangerous?
If a blood clot forms or gets stuck inside a blood vessel, it can clog the vessel and keep blood from getting where it needs to go. When that happens in the lungs, the lungs can get damaged and the heart can struggle to pump the blood through the lungs. Having blocked arteries in the lung can make it hard to breathe and can even lead to death. Most blood clots that end up in the lungs form in the legs or pelvic area (where the legs connect to the body) and then travel to the lungs.

How are blood clots in the lungs treated?
Most people being treated for a blood clot in the lung are treated first in the hospital. Blood clots in the lungs are treated with medicines that keep clots from getting bigger or dissolve clots. Some of these medicines are injected directly into a vein, while others come in shots or pills. Anti-clotting medicines do not dissolve existing blood clots, but they do keep them from getting bigger. They also help keep new blood clots from forming. The body is able to dissolve clots on its own over days to weeks. Most cases of pulmonary embolism are considered "low risk", that is the chance of dying from them is low and the treatment is relatively simple. In some cases, a person has a clot that is severe enough to cause low blood pressure and even shock. (Shock is when blood pressure gets too low, and not enough blood can get to the body’s organs and tissues.) This condition is called "massive pulmonary embolism" and when this happens it is not safe to wait for the body to dissolve clots on its own. With massive pulmonary embolism doctors can give a medicine to dissolve the clot. The medical term for this is "thrombolysis", while a more common term is “clot busting." This treatment is usually given through a vein. This treatment can help to break up clots and reduce the strain on the heart, but it can also cause bleeding elsewhere in the body. In some cases doctors may insert a catheter through the veins of the leg into the lungs and deliver the clot busting medicine directly into the lungs (this is called catheter directed therapy or CDT).
Some blood clots force the heart to work harder than normal but do not cause low pressure. This condition is called "submassive pulmonary embolism." Treatment for this condition must be determined on a case by case basis, weighing the benefits of various therapies against the risks of those therapies.
People who cannot take medicines to treat clots, or who fail to benefit from the medicines, can get a different treatment. This is called an “inferior vena cava filter” (also called an IVC filter). The inferior vena cava is the large vein that carries blood from your legs and the lower half of your body back up to
your heart. IVC filters go inside the inferior vena cava. They filter and trap any large clots that form below the location of the filter. Your doctor might suggest one of these filters for you if:

• You cannot safely take warfarin or another anti-clotting medicine
• You form clots even while on warfarin or another anti-clotting medicine
• You have a dangerous bleeding problem while on warfarin or another anti-clotting medicine
• You are so sick that another pulmonary embolism could kill you

Risk of dying from pulmonary embolism (ranges from different studies):

• Low risk pulmonary embolism: 1%
• Submassive pulmonary embolism: 4-30%, depending on the severity or right heart impairment.
• Massive pulmonary embolism: 15% with hypotension, 30% with cardiogenic shock, 70% when associated with cardiac arrest.

Risk of bleeding from blood thinning and clot dissolving therapies:

• Heparin blood thinning: less than 1% chance of serious bleeding.
• Clot dissolving medication given into a vein: 2-3% chance of bleeding in the head, 6% chance of bleeding elsewhere.

Clot dissolving medication given through a catheter into the lungs: less than 1% chance of serious bleeding (this therapy requires placement of a catheter through the groin veins into the lungs).

7. Should you, as the nurse, contact the Rapid Response Team? Why? (If yes, when should you contact them?)

Yes, as a nurse we should contact the referrring physician and the physician should contact the Rapid Response Team. Pulmonary embolism (PE) is a complex diagnosis that encompasses a wide range of clinical presentations. Often patients who present with PE have complicated medical histories which can make their management challenging. Pulmonary embolism response teams (PERTs) are developing at multiple centers to improve the decision making, efficiency and orchestration of these clinical strategies. Concordantly with development of PERT programs is the design and implementation of systems to allow for numerous specialists to convene and discuss complex PE patients in real time. The mechanisms to engage a multidisciplinary approach are proving to be an invaluable resource in the decision making processes and treatment of high risk PE patients. PERTs develop in many different forms to take advantage of locally available resources and suit local clinical demands. To activate PERT, referring physicians call a 24-hour telephone number. This activation phone call triggers a “rapid response” consultation by the PERT fellow who gathers pertinent clinical information and assesses the severity of the case. If appropriate, an online meeting of the entire multi-disciplinary team convenes to discuss the case, review clinical findings, lab tests and radiographic images and generate diagnostic and treatment recommendations. The team also assembles appropriate resources if advanced interventions are necessary. This system simultaneously gathers multiple experts to discuss cases and generate treatment plans in real-time. A key aspect of their PERT program is the inclusion of many clinicians such as (but not limited to) vascular medicine and intervention specialists, intensive care unit teams, emergency department teams, cardiologists, pulmonologists, hematologists, radiologists, and cardiothoracic surgeons.

8. What would the patient look like if he/she were in respiratory acidosis?

Respiratory acidosis is a condition that occurs when the lungs can’t remove enough of the carbon dioxide (CO2) produced by the body. Excess CO2 causes the pH of blood and other bodily fluids to decrease, making them too acidic. Normally, the body is able to balance the ions that control acidity. This balance is measured on a pH scale from 0 to 14. Acidosis occurs when the pH of the blood falls below 7.35 (normal blood pH is between 7.35 and 7.45).

Respiratory acidosis is typically caused by an underlying disease or condition. This is also called respiratory failure or ventilatory failure. Normally, the lungs take in oxygen and exhale CO2. Oxygen passes from the lungs into the blood. CO2 passes from the blood into the lungs. However, sometimes the lungs can’t remove enough CO2. This may be due to a decrease in respiratory rate or decrease in air movement due to an underlying condition such as:

• asthma
• COPD
• pneumonia
• sleep apnea

Symptoms of respiratory acidosis

Initial signs of acute respiratory acidosis include:

• headache
• anxiety
• blurred vision
• restlessness
• confusion

Without treatment, other symptoms may occur. These include:

• sleepiness or fatigue
• lethargy
• delirium or confusion
• shortness of breath
• coma

The chronic form of respiratory acidosis doesn’t typically cause any noticeable symptoms. Signs are subtle and nonspecific and may include:

• memory loss
• sleep disturbances
• personality changes