Pulmonary Embolism Nursing Care and Management: Study Guide

Pulmonary embolism is a time-sensitive vascular emergency, and the nurse is often the one who catches it first. Death commonly comes within the first hour of symptoms, so early recognition drives everything. Know who is at risk, prevent the clot, and move fast when dyspnea, pleuritic chest pain, tachycardia, and tachypnea show up together.

What is Pulmonary Embolism?

Pulmonary embolism (PE) is a common disorder tied to deep vein thrombosis (DVT). PE is the obstruction of the pulmonary artery or one of its branches by a thrombus that originates in the venous system or the right side of the heart. DVT, the related condition, is thrombus formation in the deep veins, usually in the calf or thigh, sometimes in the arm, especially in patients with peripherally inserted central catheters.

Classification

Most PE is caused by a blood clot or thrombus, but other emboli occur. Fat emboli are cholesterol or fatty substances that can clog the arteries. Air emboli usually come from intravenous devices. Amniotic fluid emboli come from amniotic fluid that has leaked into the arteries. Septic emboli originate from a bacterial invasion of the thrombus.

Pathophysiology

When a thrombus completely or partially obstructs the pulmonary artery or its branches, the alveolar dead space increases. The area gets little to no blood flow and gas exchange is impaired. Substances released from the clot and surrounding area constrict the blood vessels and raise pulmonary resistance. That increased pulmonary vascular resistance raises pulmonary arterial pressure and the right ventricle's workload. When the workload exceeds the limit, right ventricular failure follows.

Statistics and Epidemiology

PE can occur even in healthy people. There are 237,000 nonfatal cases of pulmonary embolism in the United States every year, and 294,000 cases are considered fatal each year.

Causes

The most common causes are trauma anywhere in the body that releases a clot from the venous system, certain surgical procedures (orthopedic, major abdominal, pelvic, and gynecologic), hypercoagulable states, and prolonged immobility.

Clinical Manifestations

Symptoms depend on the size of the thrombus and the area of the pulmonary artery occluded. Dyspnea is the most frequent symptom, and its duration and intensity depend on the extent of embolization. Chest pain occurs suddenly and is pleuritic in origin. Tachycardia develops as the right ventricle works to keep up. Tachypnea is the most frequent sign.

Prevention

For patients at risk, the most effective approach is to prevent DVT. Avoid venous stasis with active leg exercises, early ambulation, and anti-embolism stockings. Sequential compression devices are plastic sleeves inflated with air to compress and relax the calf muscles. Mechanical prophylaxis can be static or dynamic. Graduated compression stockings move air sequentially up the leg followed by relaxation of the sleeve. Anticoagulant therapy may be prescribed for patients whose hemostasis is adequate and who are undergoing major elective abdominal or thoracic surgery.

Complications

Stay alert for cardiogenic shock, since the cardiopulmonary system is endangered in a massive PE, and right ventricular failure from the sudden increase in pulmonary resistance.

Assessment and Diagnostic Findings

Death from PE commonly occurs within one (1) hour after the onset of symptoms, so early recognition and diagnosis are priorities. The chest x-ray is usually normal but may show infiltrates, atelectasis, elevation of the diaphragm on the affected side, or pleural effusion. The ECG usually shows sinus tachycardia, PR-interval depression, and nonspecific T-wave changes. ABG analysis may show hypoxemia and hypocapnia, though ABG measurements may be normal even with PE present. Pulmonary angiogram allows direct visualization under fluoroscopy of the arterial obstruction and accurate assessment of the perfusion deficit. The V/Q scan evaluates the different regions of the lung and compares the percentage of ventilation and perfusion in each area.

Medical Management

PE is often a medical emergency, so emergency management comes first. Anticoagulation therapy with heparin and warfarin sodium has traditionally been the primary method for managing acute DVT and PE. Thrombolytic therapy with urokinase, streptokinase, or alteplase is used for PE, particularly in patients who are severely compromised.

Surgical Management

Removal of the emboli may require surgery. Surgical embolectomy removes the actual clot and must be performed by a cardiovascular surgical team with the patient on cardiopulmonary bypass. Transvenous catheter embolectomy introduces a vacuum-cupped catheter transvenously into the affected pulmonary artery. Interrupting the vena cava prevents dislodged thrombi from being swept into the lungs while allowing adequate blood flow.

Nursing Management

A key role of the nurse is to identify the patient at high risk for PE and minimize the risk in all patients.

Nursing Assessment

Evaluate all patients for risk factors for thrombus formation and pulmonary embolus. Assess the health history for previous cardiovascular disease, the family history for cardiovascular disease that may predispose the patient, and the medication record for drugs that increase PE risk. On physical exam, evaluate the extremities for warmth, redness, and inflammation.

Diagnosis

Based on the assessment data, nursing diagnoses include ineffective peripheral tissue perfusion related to obstructed pulmonary artery, risk for shock related to increased workload of the right ventricle, and acute pain related to pleuritic origin.

Nursing Care Planning and Goals

Planning and goals are to increase perfusion, have the patient verbalize understanding of the condition, therapy regimen, and medication side effects, display hemodynamic stability, report that pain is relieved or controlled, and follow the prescribed pharmacologic regimen.

Nursing Interventions

Prevent venous stasis by encouraging ambulation and active and passive leg exercises. Monitor thrombolytic and anticoagulant therapy through INR or PTT. Turn and reposition the patient frequently to improve the ventilation-perfusion ratio and manage pain. Manage oxygen therapy by assessing for signs of hypoxemia and monitoring pulse oximetry values. Relieve anxiety by encouraging the patient to talk about fears or concerns related to this frightening episode.

Evaluation

Success of the treatment plan is confirmed when perfusion is increased, the patient verbalizes understanding of the condition, therapy regimen, and medication side effects, hemodynamic stability is displayed, pain is relieved or controlled, and the prescribed pharmacologic regimen is followed.

Discharge and Home Care Guidelines

Teach the patient to prevent recurrence and to report signs and symptoms. Monitor adherence to the prescribed management plan and reinforce previous instructions. Monitor for residual effects of the PE and recovery. Remind the patient to keep followup appointments for coagulation tests and visits with the primary care provider.

Documentation Guidelines

Document individual findings, noting the nature, extent, and duration of the problem and effects on independence and lifestyle; characteristics of pain, precipitators, and what relieves it; pulses and BP; the plan of care; the teaching plan; response to interventions, teaching, and actions performed; attainment or progress toward desired outcomes; and modifications to the plan of care.