Acute Pulmonary Embolism

NAME: PUJA GUPTA

ROLL NO. 12
B.SC. NURSING 4TH YEAR
 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.
 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.
 Note: Although pulmonary embolism can arise from anywhere in the
body, most commonly it arises from the calf veins.
 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)
 Embolus

 An embolus is a detached intravascular solid, liquid,

or gaseous mass that is carried by the blood from its
point of origin to a distant site, where it often causes
tissue dysfunction or infarction.
 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)
 Epidemiology

 Observational Study of Pulmonary Embolism Patients in Shahid Gangalal

National Heart Centre: Among eleven consecutive patients PE, 8 male and 3
female patients(the age range was between 31- 68years) who were diagnosed
based on CT report, three were diagnosed as high risk pulmonary embolism,
others were intermediate risk, about the predisposing factors two have facture
bone; cancer in one, recent surgery in one, remaining three patient don’t have
any predisposing factor. Predisposing factors were same as the other
international study. Diagnosis of PE is tricky because of non-specific sign and
symptom. Shortness of breath and chest discomfort is the common symptoms.
 Etiology

 Deep Vein Thrombosis (DVT).

 Prolong bed rest.
 Surgery and trauma
 Heart disease.
 Chronic kidney disease.
 Etiology

 Liver disease.
 Cancer

 Hypercoagulable state.
 Risk Factors

 Smoking & Obesity

 Oral contraceptives and estrogen replacement
 Supplemental estrogen
 Pregnancy

 Advancing age
 Careless intravenous drug or fluid administration
 Pathophysiology

 Pathophysiological consequences of embolism

depend on:

The size of an embolus

Their number and

Size of the vessel/vessels involved

 Pathophysiology

 Emboli have two deleterious pathophysiologic

consequences:

 Respiratory compromise (due to the non-perfused,

although ventilated, segment); and

 Hemodynamic compromise (due to increased resistance to

pulmonary blood flow caused by the embolic obstruction)
Pathophysiology
 Clinical Features

 Most common s/s includes:

1. Dyspnea (most frequent)

2. Pleuritic or Substernal chest pain (common)

3. Cough (may produce bloody or blood-

streaked sputum)
 Symptoms

1. Acute dyspnea
2. Chest pain
3. Sweating
4. Cough
5. Hemoptysis
6. Chest tightness
 Signs

1. Tachypnea(most frequent sign) 1. Gallop rhythm

2. Tachycardia 2. Oedema

3. Hypotension 3. Crackles

4. Fever >38.8°C 4. Systolic ejection murmur

5. Cyanosis

6. Raised JVP
 Diagnostic Investigation

1. History and physical examination

2. Blood examination: May be leukocytosis and raised ESR

3. Chest X-ray (May look normal)

4. Continuous ECG monitoring

5. Pulse oximetry

6. Arterial blood gas analysis: Hypoxemia (PaO2), Hypocapnia

(PaCo2 ).
ECG
 Diagnostic Investigation

6. CBC count with WBC differential

7. Venous ultrasound

8. D-Dimers elevated (<500ng/L exclude PE)– Helps

ruling out PE

9. Troponin level, BNP level.

 Diagnostic Investigation

10. V/Q lung scan

11. Multidetector-row computed tomography

angiography (MDCTA) scan

12. Pulmonary Angiography (Gold Standard)

 Complications

• Death of part of the lung, called pulmonary infarction.

• Pulmonary hypertension

• Cardiac arrest and sudden death.

• Shock.
How to prevent
Pulmonary
Embolism?
 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)
 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.
 General preventive measures

1. Application of graduated compression stockings.

2. Use of intermittent pneumatic compression

devices.

3. Active leg exercises and early ambulation

 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
Compression stocking
Intermittent Pleuritic Compression(IPC)
devices
 Differential Diagnosis

• Acute Coronary Syndrome

• Pneumothorax

• Cardiac tamponade

• Pneumonia

• COPD
 Management

1. Emergency and General Management

2. Medical Management

3. Surgical Management

4. Nursing Management
 Emergency Management

 Acute PE is life-threatening emergency.

 Immediate objectives is to stabilize the cardio-
pulmonary system
 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.
 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.
 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.

 General Management

• 100% oxygen sitting up (patients may need

intubation)

• Fluids

• Opiates
 General Management

• Anticoagulants

• Unfractioned heparin IV continuous infusion (check

APTT regularly 4-6 hours)  OR

• Subcutaneous low-molecular-weight heparin – rapid

onset (no monitoring generally required)

• Warfarin (Oral) after patient is stable (check INR)

 General Management

 Look for cause of PE

 Remember Normal INR is 1. Therapeutic range for
people on warfarin INR 2-3
 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

 Medical Management

2. Pharmacological therapy

 Anticoagulation therapy

 Thrombolytic/ Fibrinolytic Therapy

 Pharmacological therapy

 Anticoagulation therapy
o Immediate full anticoagulation is mandatory for all patients
suspected of having DVT or PE. 
o Long-term anticoagulation is critical to the prevention of
recurrence of DVT or pulmonary embolism, because even in
patients who are fully anticoagulated, DVT and pulmonary
embolism can and often do recur.
 Pharmacological therapy

Anticoagulation medications include the following:

1. Unfractionated heparin (e.g. dabigatran)
2. Low-molecular-weight heparin (e.g. Enoxaparin)
3. Factor Xa inhibitors (e.g. fondaparinux,
rivaroxaban, apixaban, or edoxaban)
4. Warfarin (Coumadin)
 Pharmacological therapy

 Thrombolytic/ Fibrinolytic Therapy:

- Thrombolytic therapy should be used in patients with

acute pulmonary embolism;

a. who have hypotension (systolic blood pressure< 90

mm Hg)

b. who do not have a high bleeding risk and

 Pharmacological therapy

c. In selected patients with acute pulmonary

embolism not associated with hypotension who
have a low bleeding risk and whose initial
clinical presentation or clinical course suggests a
high risk of developing hypotension. 
 Pharmacological therapy

Thrombolytic agents used in managing acute pulmonary

embolism include the following:

1. Streptokinase and Urokinase

2. Alteplase

3. Reteplase
 Surgical Management

Surgical management options include the following:

1. Catheter embolectomy and fragmentation or

surgical embolectomy

2. Placement of vena cava filters

 Catheter 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.
 Catheter Embolectomy

 Typically this is done by inserting

a catheter with an inflatable
balloon attached to its tip into an
artery, passing the catheter tip
beyond the clot, inflating the
balloon, and removing the clot by
withdrawing the catheter.
 Surgical Embolectomy

A catheter is inserted into the affected vessel and is

used to remove the clot. 
 This involves traditional open heart surgery to remove
the blood clot from the affected artery or vein.
 After dividing the breastbone (sternotomy), surgeon
will open the affected blood vessel and remove the clot.
Surgical
Embolectomy
Venacava filter
 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. 

 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.
 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.
 Nursing Management

6. Risk for shock related to increased workload of

the right ventricle

7. Risk for Bleeding related to Anticoagulant or

thrombolytic therapy
 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.
 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 
 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.
 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.
 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
 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.
Summary
 Mcqs

1.The nurse assesses a patient for a possible pulmonary

embolism. The nurse looks for the most frequent sign of:

a) Cough
Note: d. Tachypnea is the
b) Hemoptysis most common sign to be
found among patients with
c) Syncope pulmonary embolism. Cough,
hemoptysis and Syncope is
d) Tachypnea.
not a sign of PE.
 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. Mcqs
 D: Elastic stockings could prevent venous stasis.

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.
 Mcqs

3.Which of the following is a type of embolism?

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

4. The following are diagnostic tests for a patient with

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

5.Whatare the possible complications in a patient with

pulmonary embolism?  D: Both right ventricular failure and
cardiogenic shock are possible
a) Right ventricular failure complications in a patient with
pulmonary embolism.
b) Cardiogenic shock  A: Right ventricular failure is a
possible complication in a patient
c) Septic shock with pulmonary embolism.
 B: Cardiogenic shock is a possible
d) Both A and B. complication in a patient with
pulmonary embolism.
 C: Septic shock is not a complication
in pulmonary embolism.
 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
 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.
 Robbins & Cotran. Pathologic Basis of Disease. Volume-I
& II South Asia Edition. Elsevier Publication. Page no. 127
and 697-699.
 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.
 References

 https://utswmed.org/conditions-treatments/acute-pul

monary-embolism/#:~:text=An%20acute%20pulmo
nary%20embolism%2C%20or,and%20travels%20to
%20the%20lungs
(Retrieved on June 1, 2021)
 https://www.slideshare.net/RahulGupta1687/pulmon

ary-embolism-135429348
 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
 References

 https://armandoh.org/disease/pulmonary-embolism/

(Retrieved on June 7, 2021)

 https://www.slideshare.net/EstherMaryMathew/pul

monary-embolism-esther
( Retrieved on June 27, 2021)
 https://www.researchgate.net/publication/264715065

_Observational_Study_of_Pulmonary_Embolism_P
atients_in_Shahid_Gangalal_National_Heart_Centre
(Retrieved on July-4, 2021)
 Assignment

Q. Write nursing considerations of

 Anticoagulation Therapy (2 marks)

 Thrombolytic/ Fibrinolytic Therapy (2marks)