Webinar about Medical Surgical Nursing.

2. Acute Pulmonary Embolism
NAME: PUJA
B.SC. NURSING
NMCTH, NEPAL

3. Introduction
 Pulmonary embolism is an obstruction or occlusion
of the pulmonary artery or one of its branches by a
thrombus, fat or air embolus, or tumor tissue that
originates somewhere in the venous system or in the
right side of heart and has been brought to its site by
the current of pulmonary circulation.

4. Introduction
 The occlusion material is mostly blood clot, but may be
a fat globule, air bubble, amniotic fluid, piece of tissue
or a clump of bacteria.
 Most often, the condition results from a blood clot that
forms in the legs or another part of the body (deep vein
thrombosis, or DVT) and travels to the lungs.

5. Introduction
 Clinically, it is defined as an acute hemodynamic
disturbance due to occlusion of pulmonary
vasculature due to an embolus or emboli.
 It is considered as the third most common
cardiovascular disorder after Acute Coronary
Syndromes (ACS) and Stroke. (NHJ)

6. Embolus
 An embolus is a clot or other plug (thrombus) that is
carried by the bloodstream from its point of origin to
a smaller blood vessel, where it obstructs
circulation.

7. Epidemiology
 The incidence of PE is estimated to be
approximately 60 to 70 per 100,000 (Globally)
 In spite of rapid advances in the diagnosis and
management of PE, the exact epidemiology of PE in
Nepal is largely unknown. (The Egyptian Heart
Journal)

8. Etiology
 Thrombotic
 Non-thrombotic

9. Thrombotic cause
a) Deep vein thrombosis (DVT) (>90%)
b) Congestive heart failure (CHF)
c) Right-sided endocarditis
d) Atrial fibrillation (AF)

10. Non-thrombotic cause
a) Fat embolism, following bone trauma or a
fracture
b) Amniotic fluid embolism
 Spontaneous delivery
 Caesarean section

11. Non-thrombotic cause
c) Tumour embolism
 Choriocarcinoma
d) Parasitic embolism
 Schistosomiasis
e) Air embolism
Pulmonary barotrauma in divers

13. Clinical Risk Factors
1. Prolonged immobilization
2. Varicose veins of legs
3. Postpartum period
4. Oral contraceptives
5. Congestive heart failure
6. Hypercoagulable state
7. ‘In-plaster’ injuries or
fracture of lower limb
bones
8. Antiphospholipids
syndrome
9. Thrombophlebitis (rare)

14. Risk Factors
Careless intravenous drug or fluid administration.
Obesity
Age>50 years

15. Risk factors

16. Pathophysiology
 Pathophysiological consequences of embolism
depend on:
The size of an embolus
Their number and
Size of the vessel/vessels involved

17. Pathophysiology

20. Pathophysiology

21. Clinical Features
 Most common:
1. Tachypnea
2. Dyspnea (most frequent)
3. Pleuritic or Substernal chest pain (common)
4. Anxiety

22. Symptoms
1. Acute dyspnea
2. Chest pain (Pleuritic and non-pleuritic)
3. Sweating
4. Cough
5. Hemoptysis
6. Chest tightness
7. Syncope

23. Signs
1. Tachypnea
2. Tachycardia
3. Hypotension
4. Fever >38.8°C
5. Cyanosis
6. Raised JVP
7. Gallop rhythm
8. Oedema
9. Crackles
10. Systolic ejection murmur

26. Diagnostic Investigation
1. History and physical examination
2. Blood examination: May be leukocytosis and raised ESR
3. Chest X-ray
4. Continuous ECG monitoring
5. Pulse oximetry
6. Arterial blood gas analysis: Hypoxemia (PaO2),
Hypocapnia (PaCo2 ).

27. ECG

28. Diagnostic Investigation
6. CBC count with WBC differential
7. Venous ultrasound
8. D-Dimers elevated (<500ng/L exclude PE)
9. Troponin level, BNP level.

29. Diagnostic Investigation
10. V/Q lung scan
11. Multidetector-row computed tomography
angiography (MDCTA) scan
12. Pulmonary angiography

30. Complications
• Death of part of the lung, called pulmonary infarction.
• Pulmonary hypertension
• Cardiac arrest and sudden death.
• Shock.
• Abnormal heart rhythms.

31. Complications
• A buildup of fluid (pleural effusion) between the
outside lining of the lungs and the inner lining of the
chest cavity.
• Paradoxical embolism.

32. Prevention
 For patients at risk for PE, the most effective approach is
prevention.
 Prevention of injury and accidents.
 Careful administration of IV drugs and IV fluids. No flushing
of blocked IVs.
 Active and passive exercise according to the condition (body
movement)

33. Prevention
 Regular checkup of BP and maintain normal level.
 Regular checkup of blood count, Hbs, PCV levels.
 Adjustment of diet as per need.
 Prevention and early detection of rheumatic fever and
rheumatic heart disease.
 Early detection and treatment pulmonary conditions.

34. General preventive measures
1. Application of graduated compression
stockings.
2. Use of intermittent pneumatic compression
devices.
3. Active leg exercises and early ambulation

35. Prevention
 An additional method to prevent venous thrombosis in
surgical patients is administration of subcutaneous
unfractionated or low-molecular-weight heparin (LMWH).
 Lifestyle modification such as;
o Weight loss
o Smoking cessation
o Regular exercise

36. Compression stocking

37. Intermittent Pleuritic Compression(IPC)
devices

38. Management
1. Emergency Management
2. Medical Management
3. Surgical Management
4. Nursing Management

39. Emergency Management
 Acute PE is life-threatening emergency.
 Immediate objectives is to stabilize the cardio-
pulmonary system

40. Emergency mgmt. consists of the following
actions
1. Supplemental oxygen (nasal O2), intubation if
necessary.
2. Establish routes for medications or fluids.
3. For hypotension that does not resolve with IV fluids,
prompt initiation of vasopressor therapy (Dobutamine,
dopamine, or norepinephrine) is recommended.

41. Emergency mgmt. consists of the following
actions
4. Hemodynamic measurements and evaluation for
hypoxemia are performed. If available, MDCTA will
be performed.
5. ECG is monitored continuously for dysrhythmias and
right ventricular failure, which may occur suddenly.
6. Blood is drawn for serum electrolytes, CBC, and
coagulation studies.

42. Emergency mgmt. consists of the following
actions
7. Insert indwelling urinary catheter to monitor urinary
output.
8. Small doses of IV morphine or sedatives are given to
relieve patient anxiety, to alleviate chest discomfort, to
improve tolerance of the ET tube, and to ease
adaptation to the mechanical ventilator, if necessary.
9. Pulmonary embolectomy in life threatening situation.

44. Medical Management
1. Non-pharmacological therapy
 Oxygen therapy
 Anti-embolism stockings or intermittent
pneumatic leg compression devices
 Elevate leg above the level of the heart

45. Medical Management
2. Pharmacological therapy
 Anticoagulation therapy
 Thrombolytic/ Fibrinolytic Therapy

46. Anticoagulation therapy
1. Low-molecular-weight heparin (e.g. Enoxaparin
[Lovenox])
2. Unfractionated heparin, or one of the new oral
anticoagulants (NOACs), such as a direct thrombin
inhibitor (e.g., dabigatran [Pradaxal]) or a Factor Xa
inhibitor (e.g., fondaparinux [Arixtral], rivaroxaban
[Xarelto], apixaban [Eliquis], or edoxaban [Savaysa]
3. Warfarin (Coumadin)

47. Thrombolytic/ Fibrinolytic Therapy
 Used in patients with an acute PE who have hypotension
and do not have a contraindication or potential bleeding
risk.
 Thrombolytic therapy with recombinant tissue
plasminogen activator tPA (Activase) or other
thrombolytic agents like kabikinase (Streptase).

48. Surgical Management
1. Surgical embolectomy
2. Venacava interruption with the insertion of Vena
cava filter.

49. Embolectomy
 Embolectomy is the
emergency surgical removal
of emboli which are blocking
blood circulation.
 It usually involves removal
of thrombi (blood clots), and
is then referred to as
thrombectomy.

50. Venacava filter

52. Nursing Management
Nursing Goal:
1. Prevent venous stasis and complication of PE.
2. Monitor thrombolytic therapy.
3. Manage pain.
4. Manage oxygen therapy.
5. Reduce fear and apprehension.

53. Nursing Management
Nursing diagnosis:
1. Ineffective tissue perfusion related to perfusion and
ventilation inequality or obstructed pulmonary artery by PE as
evidenced by desaturation (Oxygen saturation below 90%),
dyspnea.
2. Impaired gas exchange related to decreased lung perfusion
caused by the obstruction of pulmonary arterial blood flow by
the embolus as evidenced by decreased PaO2 and increased
PaCO2.

54. Nursing Management
3. Acute chest pain or recurrent chest pain related to PE.
4. Anxiety related to the pain due to PE.
5. Deficient Knowledge related to new medical condition
possibly evidenced by inaccurate follow-through of
instruction.

55. Nursing Management
6. Risk for shock related to increased workload of
the right ventricle
7. Risk for Bleeding related to Anticoagulant or
thrombolytic therapy

56. Maintaining tissue perfusion
 Keep the patient on bed rest. Provide a quite environment and
allow bedside commode.
 Administer O2 as ordered.
 Administer and monitor thrombolytics being given through INR or
PTT
 Provide comfortable semi-fowler’s position.
 Encourage ambulation and active and passive leg exercises to
prevent venous stasis.

57. Maintaining adequate gas exchange
 Assess the skin color, nail beds, and mucous membranes for color
changes. Monitor for any changes in vital signs.
 Auscultate lung sounds, noting areas of decreased ventilation and the
presence of adventitious sounds.
 Maintain client on bed rest. May resume activity gradually as tolerated.
 Position the client properly to facilitate ventilation-perfusion matching.
 Administer oxygen as indicated.
 Anticipate the need to start anticoagulant therapy

58. Relieving pain
 Assess level and severity of pain and monitor vital signs.
 Administer prescribed pain medications i.e. morphine.
 Keep patient in comfortable i.e., semi-fowler’s position.
 Encourage client to do deep breathing exercise and provide
music therapy.
 Turn patient frequently and reposition to improve ventilation-
perfusion ratio.

59. Relieved anxiety
 Providing comfortable and calm atmosphere.
 Limit visitors
 Provide sound sleep at night.
 Encourage the patient to talk about any fears or concerns
related to this frightening episode.
 Anxiolytic may be given as prescribed.

60. Providing knowledge
 Assess the client’s knowledge of pulmonary embolus: its severity, prognosis, risk
factors, and therapy.
 Provide information on the cause of the problem, common risk factors, and effects of PE
on body functioning.
 Instruct the client about medications, their actions, dosages, and side effects.
 Discuss with and provide the client with a list of what to avoid when
taking anticoagulants
 Discuss and give the client a list of signs and symptoms of excessive anticoagulation
 Discuss with and give the client a list of measures to minimize the recurrence of emboli

61. Postoperative Care After Embolectomy
 Monitor the patient’s pulmonary arterial pressure and urinary output.
 Assess the insertion site of the arterial catheter for hematoma formation and
infection.
 Maintain the blood pressure at a level that supports the perfusion of vital organs.
 Prevent peripheral venous stasis and edema of the lower extremities, elevates the
foot of the bed and encourage isometric exercises, use IPC devices and early
ambulation.
 Discouraged sitting for long period as hip flexion compresses the large veins in
the legs.

63. Summary

64. Mcqs
1. The nurse assesses a patient for a possible pulmonary
embolism. The nurse looks for the most frequent sign of:
a) Cough
b) Hemoptysis
c) Syncope
d) Tachypnea.
Note: d. Tachypnea is the
most common sign to be
found among patients with
pulmonary embolism. Cough,
hemoptysis and Syncope is
not a sign of PE.

65. Mcqs
2. The following are nursing interventions to assist in the prevention of
pulmonary embolism in a hospitalized patient include all except:
a) A liberal fluid intake.
b) Assisting the patient to do leg elevations above the level of the heart.
c) Encouraging the patient to dangle his or her legs over the side of the
bed for 30 minutes, four times a day.
d) The use of elastic stockings, especially when decreased mobility
would promote venous stasis.
 C: Dangling could get the emboli stuck and may
impede blood flow.
 A: A liberal fluid intake may help dissolve the clot.
 B: Leg elevations are done to avoid impeding blood
flow.
 D: Elastic stockings could prevent venous stasis.

66. Mcqs
3. Which of the following is a type of embolism?
a) Travelling emboli.
b) Fat emboli.
c) Burn emboli.
d) Diabetic emboli.
 B: Fat emboli are one of
the types of emboli.
 A: Travelling emboli is
not a type of emboli.
 C: Burn emboli are not a
type of emboli.
 D: Diabetic emboli are
not a type of emboli.

67. Mcqs
4. The following are diagnostic tests for a patient with
pulmonary embolism except:
a) Chest X-ray
b) ECG
c) ABG analysis
d) Pulmonary function tests
 D: Pulmonary function tests
are not performed in a patient
pulmonary embolism.
 A: Chest x-ray is a diagnostic
test for patients with
embolism.
 B: ECG is a diagnostic test for
patients with pulmonary
 C: ABG analysis is a diagnostic
test for patients with
embolism.

68. Mcqs
5. What are the possible complications in a patient with
pulmonary embolism?
a) Right ventricular failure
b) Cardiogenic shock
c) Septic shock
d) Both A and B.
 D: Both right ventricular failure
and cardiogenic shock are possible
complications in a patient with
embolism.
 A: Right ventricular failure is a
possible complication in a patient
pulmonary embolism.
 B: Cardiogenic shock is a possible
complication in a patient with
embolism.
 C: Septic shock is not a
complication in pulmonary

69. References
 Brunner and Suddarth’s. Textbook of Medical-Surgical
Nursing. South Asian Edition. Volume I. Wolters Kluwer
(India) Pvt. Ltd., New Delhi. Page no. 413-416 and 632.
 Chugh S N. Textbook of Medical Surgical Nursing Part-
1. 3rd edition. Avichal Publishing Company. Page no.
416-419

70. References
 Black Joyce M, and Jane H. Hawks. Medical
Surgical Nursing: Clinical Management for Positive
outcomes. Volume-1. 8th edition. Avichal Publishing
Company 8, Industrial Area, Trilokpur Road, Delhi.
Page no.1591-1594.

71. References
 Lewis’s. Medical Surgical Nursing. Second South
Asia Edition. Elsevier Publication. Volume-1 .Page
no. 577-579.
 Pandey Gita. Textbook of Adult Nursing. 3rd edition.
Health Learning Materials Centre TU, IOM
Maharajgunj, Kathmandu. Page no. 47-49.

72. References
 https://utswmed.org/conditions-treatments/acute-
pulmonary-
embolism/#:~:text=An%20acute%20pulmonary%20emb
olism%2C%20or,and%20travels%20to%20the%20lungs
(Retrieved on June 1, 2021)
 https://www.slideshare.net/RahulGupta1687/pulmonary-
embolism-135429348 (Retrieved on June 2, 2021)

73. References
 https://nurseslabs.com/pulmonary-embolism-
nursing-care-plans/3/ (Retrieved on June 2, 2021)
 https://en.wikipedia.org/wiki/Embolectomy#:~:text=
Embolectomy%20is%20the%20emergency%20surg
ical,then%20referred%20to%20as%20thrombectom
y (Retrieved on June 2, 2021)

74. Assignment
Q. Write nursing considerations of
 Anticoagulation Therapy (2 marks)
 Thrombolytic/ Fibrinolytic Therapy (2marks)