Transcript Medical Management

Pulmonary Empolism
Definition
• PE refers to the obstruction of the pulmonary
artery or one of its branches by a thrombus (or
thrombi) with any substance (solid, gaseous, or
liquid) that originates somewhere
in the venous system or in the right side of the
heart.; gas exchange is impaired
• Massive PE is a life-threatening emergency;
death commonly occurs within 1 hour after the
onset of symptoms.
• Prevention, rapid recognition, and treatment of a
PE are essential for a positive outcome.
Risk Factors
• It is a common disorder associated with:
– trauma,
– surgery (orthopedic, major abdominal, pelvic,
gynecologic),
– Pregnancy,
– Oral contraceptive use, estrogen therapy
– Smoking
– HF,
– age more than 50 years,
– Obesity
– hypercoagulable states, and
– prolonged immobility.
– Long bone fracture
• Most thrombi originate in the deep veins of the legs
Assessment and Diagnostic Methods
Diagnostic workup is performed to rule out other
diseases.
The initial diagnostic workup may include:
Spiral CT scan of the lung,
chest x-ray,
ECG,
ABG analysis, and
ventilation–perfusion scan.
• Pulmonary angiography is considered the best
method to diagnose PE, BUT
• D-dimer assay , and
pulmonary arteriogram may be warranted.
Clinical Manifestations
• Symptoms depend on the size of the thrombus and the area of the
pulmonary artery occlusion.
- Dyspnea is the most common
– Chest pain is common (sudden, pleuritic, substernal and may mimic
AP/MI)
– Anxiety,
– fever,
– tachycardia,
– apprehension, anxiety
– cough,
– diaphoresis,
– hemoptysis,
– syncope,
– Petechiae, cyanosis
– Pleural effusion
– shock, and sudden death may occur.
Clinical picture may mimic that of bronchopneumonia or HF.
Assess/Monitor
• Client’s respiratory status (airway patency,
breath sounds, RR, use of accessory muscles,
oxygenation status) before and following
intervention
• Client’s history regarding risk factors for a PE
• General appearance
• Laboratory and diagnostic findings (arterial
blood gases, CT scan)
Medical Management
• Immediate objective is to stabilize the cardiopulmonary
system.
• Nasal oxygen is administered immediately to
relieve hypoxemia, respiratory distress, and
central cyanosis.
• IV infusion lines are inserted to establish routes
for needed medications or fluids.
• A perfusion scan, hemodynamic measurements,
and ABG determinations are performed.
Spiral (helical) CT or pulmonary angiography
Medical Management
• Hypotension is treated by a slow infusion of dobutamine /
dopamine (pulmonary vasodilator and bronchodilator
• ECG monitoring (dysrhythmias and Rt ventricular failure)
• Digitalis glycosides, IV diuretics, and antiarrhythmic agents
are administered when appropriate.
• CBC & electrolytes.
• Mechanical ventilation, If clinical assessment and ABG
analysis indicate
• An indwelling urinary catheter is inserted to monitor
urinary output.
• Small doses of IV morphine or sedatives are administered
to relieve patient anxiety, to alleviate chest discomfort, to
improve tolerance of the endotracheal tube, and to ease
adaptation to the mechanical ventilator.
Medical Management
Anticoagulation Therapy
• Anticoagulant therapy (heparin, warfarin sodium
[Coumadin] are the primary method for managing acute
DVT and PE
• Patients must continue to take some form of
anticoagulation for at least 3 to 6 months after the
embolic event.
• Major side effects are bleeding and anaphylactic reaction
(shock or death). Other SE include fever, abnormal
liver function, and allergic skin reaction.
Medical Management
• Thrombolytic Therapy
• Thrombolytic therapy (urokinase & streptokinase)
are reserved for PE affecting a significant area
and causing hemodynamic instability.
• Bleeding is a significant side effect; nonessential
invasive procedures are avoided.
• Surgical Management
• A surgical embolectomy is rarely performed but
may be indicated if the patient has a massive PE
or hemodynamic Instability.
NANDA Nursing Diagnoses
•
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Impaired gas exchange
Decreased cardiac output
Risk for injury
Anxiety
Nursing Management
• Minimizing the Risk of PE
• Assess and monitor respiratory status (breath
sounds, vital signs, SaO2).
• Administer oxygen therapy as prescribed (highFowler’s position, collect and interpret ABG
values).
• Assess and monitor cardiovascular status (heart
rate and rhythm).
• Assess and monitor pain.
• Initiate and maintain IV access.
Nursing Management
Monitoring Anticoagulant and Thrombolytic Therapy
• Advise bed rest, monitor vital signs every 2 hours, and
limit invasive procedures.
• Measure INR or PTT every 3 to 4 hours after
thrombolytic infusion is started to confirm activation
of fibrinolytic systems.
• Perform only essential ABG studies on upper
extremities, with manual pressure on the site for at
least 30 minutes.
• Assess for contraindications (active bleeding, peptic ulcer
disease, history of stroke, recent trauma).
Nursing Management
Minimizing Chest Pain, Pleuritic
• Place patient in semi-Fowler’s position; change
position frequently.
• Administer analgesics as prescribed for severe pain.
Managing Oxygen Therapy
• Assess the patient frequently for signs of hypoxemia
.Assist patient with deep breathing and incentive
spirometry.
Alleviating Anxiety
• Encourage patient to express feelings and concerns.
• Answer questions concisely and accurately.
• Explain therapy, and describe how to recognize untoward
effects early.
Nursing Management
• Preventing Thrombus Formation
• Encourage early ambulation and active and passive leg
exercises.
• Advise patient to avoid prolonged sitting, immobility, and
constrictive clothing.
• Do not permit dangling of legs and feet in a dependent
position.
• Instruct patient to place feet on floor or chair and to avoid
crossing legs.
• Do not leave IV catheters in veins for prolonged period
• Instruct patient to place feet on floor or chair and to avoid
crossing legs.
• Do not leave IV catheters in veins for prolonged periods.
Prevention
• Ambulation or leg exercises in patients on bed
rest
• Application of sequential compression devices
• Anticoagulant therapy for patients whose
hemostasis is adequate and who are
undergoing major abdominal orthoracic
surgery
Complications and Nursing
Implications
• Decreased Cardiac Output
• Monitor for hypotension, tachycardia, cyanosis, jugular venous
distention,
and syncope.
• Initiate and maintain IV access.
• Administer IV fluids (crystalloids) to replace vascular volume.
• Continuously monitor electrocardiogram (ECG).
• Monitor pulmonary pressures. IV fluids may contribute to
pulmonary
hypertension for clients with right-sided heart failure (cor
pulmonale).
• Administer inotropic agents, such as dobutamine to increase
myocardial contractility.
• Vasodilators may be needed if pulmonary artery (PA) pressure is
high enough that it interferes with cardiac contractility.
Complications and Nursing
Implications
• Hemorrhage
– Assess for oozing, bleeding, or bruising from
injection and surgical sites.
– Monitor cardiovascular status (blood pressure,
heart rate and rhythm).
– Monitor CBC (hemoglobin, hematocrit, platelets)
and bleeding times (PT, aPTT, INR).
Complications and Nursing
Implications
• Administer IV fluids and blood products as
required.
• Test stools, urine, nasogastric drainage, and vomit
for occult blood.
• Monitor for internal bleeding (measure
abdominal girth, abdominal or flank pain).
• Avoid IM injections when possible. Use small
gauge needles for necessary injections.
• Avoid rectal temperatures and enemas; utilize
electric shavers and soft bristled toothbrushes.
international normalized ratio (INR) or activated
partial thromboplastin time (PTT) every 3
to 4 hours after
thrombolytic infusion is started to confirm
activation of fibrinolytic
• systems.