Question

Pulmonary embolism-Diagnosis, pathophysiology related to client problem, health promotion and disease prevention, risk factors, expected findings, Lab tests, diagnostic procedures, nursing care, medications , client education,Therapeutic procedures , lnterprofessional care, safety considerations, complications.

Answer 1

#. Pulmonary embolism :-

Obstruction of the pulmonary arterial bed occurring when a mass (such as a dislodged thrombus) lodges in the main pulmonary artery or branch, partially or completely obstructing it

Most thrombi originating in deep veins of the leg

Possibly asymptomatic, but sometimes causing rapid death from pulmonary infarction

#. Pathophysiology :-

Thrombus formation results from vascular wall damage, venous stasis, or blood hypercoagulability. (See Pulmonary emboli.)

Trauma, clot dissolution, sudden muscle spasm, intravascular pressure changes, or peripheral blood flow changes can cause the thrombus to loosen or fragment.

The thrombus (now an embolus) floats to the heart's right side and enters the lung through the pulmonary artery. There, the embolus may dissolve, continue to fragment, or grow.

By occluding the pulmonary artery, the embolus prevents alveoli from producing enough surfactant to maintain alveolar integrity. Alveoli collapse and atelectasis develops.

Effects include increased pulmonary vascular resistance, impaired gas exchange, increased airway resistance, and decreased pulmonary compliance.

If the embolus enlarges, it may occlude most or all of the pulmonary vessels and cause death.

#. Causes :-

Deep vein thrombosis

Pelvic, renal, and hepatic vein thrombosis

Rarely, other types of emboli, such as bone, air, fat, amniotic fluid, tumor cells, or a foreign body

Right heart thrombus

Upper extremity thrombosis

Valvular heart disease

#. Risk Factors :-

Various disorders and treatments (see Who's at risk for pulmonary embolism?)

#. Incidence :-

Pulmonary embolism develops in 1 case per 1,000 persons each year.

It affects African-Americans more commonly than whites. It's more common with advancing age.

More men die of pulmonary embolism than women.

It's the third most common cause of death in hospitalized patients.

#. Complications :-

Respiratory failure

Pulmonary infarction

Pulmonary hypertension

Acute cor pulmonale

Embolic extension

Hepatic congestion and necrosis

Pulmonary abscess

Shock

Acute respiratory distress syndrome

Massive atelectasis

Ventilation-perfusion mismatch

Death

#. Assessment-History :-

Predisposing risk factor

Shortness of breath for no apparent reason

Pleuritic pain or angina

Anxiety and apprehension

#. Physical Findings :-

Tachycardia

Tachypnea (most common)

Low-grade fever

Weak, rapid pulse

Hypotension

Productive cough, possibly with blood-tinged sputum

Warmth, tenderness, and edema of the lower leg

Restlessness

Transient pleural friction rub

Crackles

S3 and S4 with increased intensity of the pulmonic component of S2

With a large embolus: cyanosis, syncope, distended neck veins

#. Diagnostic Test Results-Laboratory :-

Arterial blood gas (ABG) values show hypoxemia, hypocapnia, and respiratory alkalosis.

D-dimer level is elevated.

White blood cell count may be normal or elevated.

Serum troponin and brain natriuretic peptide levels may be elevated.

#. Diagnostic Test Results-Imaging :-

Chest radiography rules out other causes of chest pain and is normal in early stages. Westmark sign (pulmonary vessel dilation with a sharp cutoff), atelectasis, pleural effusion, and an elevated diaphragm may be seen in later stages.

Computed tomography angiography identifies the pulmonary embolism (test of choice for stable patients).

Lung ventilation perfusion scan shows a ventilation-perfusion mismatch (used only if computed tomography scanning is unavailable or contraindicated).

Pulmonary angiography shows a pulmonary vessel filling defect or an abrupt vessel ending and reveals the location and extent of pulmonary embolism (gold standard).

Spiral chest computed tomography scan may show central pulmonary emboli.

Echocardiography may reveal right ventricular strain and pulmonary hypertension, tricuspid regurgitation, or septal flattening.

Doppler flow imaging may reveal deep vein thrombosis.

Duplex ultrasonography identifies deep vein thrombosis as the cause.

#. Treatment :-

O2 therapy (possible intubation)

Treat shock (IV fluids, pressors)

TCDB, IS (prevent atelectasis)

Anticoagulant therapy (Heparin drip to bridge Warfarin-long term)

Fribrinolytic therapy (tPA, Atelplase)

Opioids (chest pain)

Limit activity

SVC filter (high risk)

Embolectomy (really sick), risk of mortality with procedure

#. Health promotion and maintenance :-

-prevent venous stasis

-passive ROM

-early ambulation

-compression stalkings

-avoid tight clothing

-no crossing legs

-no leg message

-avoid valsalva maneuver

-smoking cessation

#. Nursing interventions :-

raise head of the bed

O2 therapy

anticoagulants

vital signs

pulse ox

assess pailor or cyanosis

cognative status

suctioning

#. Prevent injury and bleeding

-know when to notify MD

-avoid anal intercourse

-take stool softner

-no enemas

-no tight clothing or shoes

-avoid playing wind instruments

-keep appointments for all lab tests