nursing nur 265 med surg 265 exam 2 galen college of nursing

SIGNS AND SYMPTOMS Care for a patient with PE (BOX):
PATHOPHYSIOLOGY
peep
PULMONARY EMBOLISM KEY FEATURES (BOX)
 Collection of particulate matter (solid, liquid or air) that Apply O2 by nasal cannula or mask
Classic symptoms enters venous circulation and lodge in the pulmonary Reassure patient that the correct measures are being taken
Dyspnea, sudden onset vessels. Place patient in high fowlers position
Sharp, stabbing chest pain (pleuritic chest pain)  Large emboli: Obstruct blood flow, reduce gas exchange,
Apply telemetry monitoring equipment
reduce oxygenation, pulmonary tissue hypoxia, decreased
Apprehension, restlessness perfusion and potential death. Obtain an adequate venous access
Feeling of impending doom  Most common substance is blood clot Assess oxygen saturation continuously
Cough  It is most common preventable death in hospital Assess respiratory status at least Q30 min
Hemoptysis (bloody sputum) but is often misdiagnosed listening to lung sounds (abnormal or crackles)
 PE most often occur due to a Venous measuring the rate, rhythm, and ease of respirations
Signs thromboembolism (VTE) aka Deep vein thrombosis checking skin color and capillary refill
Tachypnea DVT. checking position of trachea
Crackles WHO IS AT RISK? Assess cardiac status by:
Pleural friction rub Prolonged immobility comparing BP in rt and lt arms
Tachycardia CAUSE OF PE FOR PT ON BED REST Central venous catheters checking pulse for quality
Surgery checking cardiac monitor for dysrhythmias
S3 or S4 heart sounds
Obesity checking for JVD
Diaphoresis Advanced age
Fever (low grade) Ensure that prescribed chest imaging and laboratory tests are obtained
Conditions that increase blood clotting
immediately
Petechiae over the chest and axillae Hx of thromboembolism
Smoking, pregnancy, estrogen therapy, CBC with diff, platelet count, PT, PTT, D-dimer and ABG
Decreased arterial oxygen saturations
HF, stroke, cancer (lung & prostate) and trauma
Systemic hypotension Examine the thorax for presence of petechia
Administer prescribed anticoagulants
Enoxaparin (Lovenox) or Fondaparinux (Arixtra)

PULMONARY EMBOLISM
Monitor PTT levels with these drugs (1.5-2.5)
TREATMENT Assess for bleeding
Nonsurgical management of PE is most common. Handle patient gently
Fibrinolytic drugs (alteplase) is used if patient meets criteria Institute bleeding precautions
Shock, hemodynamic collapse, or instability COMPLICATIONS
Must be administered in ICU due to high risk for bleeding Deoxygenated blood moves into the arterial circulation causing HYPOXIA
Heparin therapy Pts w/ s/s of PE who have risk factors and present with JVD, hypotension and cyanosis
Started in hospital usually continues for 5-10 days call RAPID, elevate HOB and administer O2. CARDIOGENIC SHOCK LABS / DIAGNOSTICS
Oral anticoagulant WARFARIN started on day 1 or 2 of heparin therapy Initially pt will be Hyperventilation triggered by hypoxia leads to
Therapy continuous with both heparin and warfarin until INR reaches 2.0 to respiratory alkalosis
3.0. Heparin is D/C once INR is greater than 2. Measured by ABG PaCo2 levels decrease - initially
Other drugs used than warfarin Then later it starts to shunt (blood not getting oxygen) resulting in
PRIORITY NURSING INTERVENTIONS/ TEACHING
Low-molecular weight heparin (enoxaparin) Respiratory acidosis
Preventions of Pulmonary Embolism (BOX) Chart 32-1
Thrombin inhibitor (rivaroxaban) Measured by ABG PaCo2 levels increase
Passive and active ROM exercises for postop and immobilized patients
Ambulate soon after surgery
Then due to lactic acid build up (tissue hypoxia) resulting in
Oral anticoagulant usage continues for 3-6 weeks but others may take it for
Anti-embolism and pneumatic compression stockings after surgery Metabolic acidosis
longer periods
Evaluate the patient for the need of anticoagulants (heparin or Enoxaparin) Even if ABG studies and pulse oximetry show hypoxemia, the results are not enough
Avoid the use of tight garters, girdles and constricting clothing alone for diagnosing PE. A patient with a small embolus may not be hypoxemic.
Antidotes for Anticoagulants and fibrinolytics Heparin - Protamine sulfate
Prevent pressure under the popliteal space Other Lab values
Do not place a pillow under the knee; instead use alternating pressure mattress BMP, troponin, BNP
Fibrinolytic drugs - Clotting factors - Fresh froze plasma - Aminocaproic acid Perform a comprehensive assessment of peripheral circulation
D-dimer test rises with fibrinolysis
Elevate the affected limb 20 degrees or more above the level of the heart improve venous
Warfarin
Surgical - Vitamin K1 (phytonadione)
management When the value is normal or low it can rule out PE
return
Embolectomy - Removal of the embolus Change patient position Q2hrs or ambulate as tolerated If elevated other test are needed to determine a PE occurred
May be performed when fibrinolytic therapy cannot be used for a patient Prevent injury to the vessel lumen by prevention local pressure, trauma, infection or sepsis Pulmonary angiography Best indicator
who has massive or multiple emboli with shock or bleeding complications Refrain from massaging leg muscle Computed tomography pulmonary angiography (CT-PA)
Instruct patient not to cross legs Ventilation perfusion (V/Q) scans not used as much only for certain
Inferior vena cava filtration placement of filter - Prevents further emboli from
Administer prescribed prophylactic low dose anticoagulant and antiplatelet drugs circumstances. Used if pt has Allergies to contrast dye
reaching the lungs in patients with ongoing risk for PE. Less risky than drug Teach patient to avoid activities that result in the Valsalva maneuver
therapy. Considered for those with: Recurrent or major bleeding while Chest X-ray - May diagnose other conditions that mimic acute PE
Breath holding, bearing down for bowel movements, coughing
receiving anticoagulants. Septic PE. Pulmonary embolectomy Administer prescribed drugs, such as stool softeners Doppler ultrasound - Can verify the presence of DVT and support a diagnosis of
Prevent episodes of Valsalva maneuver PE
Teach the patient and family about precautions
Encourage smoking cessation

, Pulmonary embolism (PE) severity and management
Prevention of injury for patient on (anticoagulants, Fibrinolytic and
options (BOX)
Antiplatelets) BOX
Massive PE.- High mortality rate 65%
 Handle the patient gently  Possible symptoms
 Use and teach UAP to use a lift sheet when moving and positioning patient in bed - Severe hypotension SBP <90 for more than 15min
 Avoid IM injections and venipunctures - Cardiac arrest/cardiopulmonary collapse
 When injections or venipunctures are necessary, use small gauge needles - Severe bradycardia
 Apply firm pressure to the needle stick for 10 min or until the site no longer oozes blood
- Shock
 Apply ice to areas of trauma
- Severe dyspnea/respiratory distress
 Test all urine, vomit and stool for occult blood
 Assess IV sites at least every 4 hours for bleeding  Management options
 Notify nursing personnel immediately if any trauma occurs and if bleeding or bruising is
- Unfractionated heparin (initial treatment)
noted
- CPR
 Avoid trauma to rectal tissue
- Inotropic or vasopressor support; fluids (Hypotension)
 Do not administer enemas
- Dobutamine, norepinephrine/dopamine, crystalloid solution
 If suppositories are prescribed, lubricate and administer with caution
- Monitor closely for pulmonary hypertension
 Instruct the patient and UAP to use an electric shaver rather than a razor
- Fibrinolytic therapy
 When providing mouth care or supervising others in providing mouth care
 Use a soft-bristled toothbrush or tooth sponge - Tissue plasminogen activator (tPA)
 Do not use floss - Alteplase (activase)
 Check to make certain that dentures fit and do not rub Sub massive PE
 Instruct the patient not to blow the nose forcefully or insert objects into the nose  Possible symptoms
 Ensure that the patient wears shoes with firm soles whenever he or she is ambulating - Normotension
 Ensure that antidotes to anticoagulation therapy are on unit - RV dysfunction on Echo
- RV dilation on Echo or CT
- Right bundle branch block
Preventing injury and bleeding (BOX) - ST elevation or depression
- T-wave inversion
During the time you are taking anticoagulants - Elevated BNP or troponin
 Use an electric shaver
 Use a soft bristle toothbrush and do not floss  Management option
 Do not have dental health work without consulting with HCP - Low-molecular weight (preferred)
 Do not take aspirin or salicylate products
- Thrombolytic therapy if elevation in troponin levels or BNP
 Read the label
- Fondaparinux (Arixtra)
 Do not participate in contact sports or any activity that is likely to result in being bumped,
scratched and scraped
- Unfractionated heparin
 If you are bumped, apply ice to the site for at least 1 hour
Low-risk PE - Mortality rate is low 1%-8%
 Avoid hard foods that would scrape the inside of your mouth
 Eat warm, cool or cold foods to avoid burning your mouth
 Possible symptoms
 Check your skin and mouth daily for bruises, swelling or areas with small, reddish-purple
marks that may indicate bleeding - Normotension
 Notify your HCP if you: - No RV dysfunction
 Are injured and persistent bleeding results - No elevation in BNP or troponin
 Have excessive menstrual bleeding
 See blood in your urine or bowel movements  Management option
 Avoid anal intercourse - Low-molecular weight (preferred)
 Take a stool softener to prevent straining during a bowel movement - Rivaroxaban (Xarelto)
 Do not use enemas or rectal suppositories - Thrombolytics not used due to risk for bleeding
 Do not wear clothing or shoes that are tight or that rub
 Avoid blowing your nose forcefully or placing objects in your nose
 If you must blow your nose do so gently without blocking either nasal passage
 Avoid playing musical instruments that raise the pressure inside your head, such as
brass wind instruments and woodwinds or reed instruments.
 Keep all appointments for laboratory test
 Monitor for bleeding Q2hrs
 Measure abdominal girth Q8hrs
 Reassure the patient to decrease anxiety

, Home care assessment (patient after PE) (BOX)
- Assess respiratory status
o Observe rate and depth of ventilation
o Auscultate lungs
o Examine nail beds and mucous membranes for evidence of cyanosis,
indicating reduced gas exchange
o Take a pulse oximetry reading
o Ask the patient if chest pain or SOB is experienced in any position
o Ask the patient about the presence of sputum and its color and
character
- Assess cardiovascular status
o Take vital signs, including apical pulse, pulse pressure
o Note presence or absence of peripheral edema
o Examine hand vein filling in the dependent position
o Examine neck vein filling in the recumbent and sitting position
- Assess lower extremities for DVT
o Examine lower legs and compared with each other for
 General edema
 Calf swelling
 Surface temperature
 Presence of red streaks or cordlike, palpable structure
o Measure calf circumference
- Assess for evidence of bleeding
o Examine the mouth and gums for oozing or frank bleeding
o Examine all skin areas, especially old puncture sites and wounds, for
bleeding, bruising or petechiae
o If the patient voids during the visit, test the urine for occult blood
- Assess cognition and mental status
o Check LOC
o Check orientation to time, place and person
o Can the patient accurately read a seven-word sentence containing
Normal Lab Ranges (BOX) no words with more than 3 syllables
- Assess the patients understanding of illness and adherence to treatment
o Symptoms to report to HCP
- Partial thromboplastin time (PTT)
o Drug therapy plan (correct time and dose)
o Monitor for HEPARIN o Bleeding precautions
o Normal 30-40seconds o Prevention of venous thromboembolism AKA (DVT)
o Therapeutic 1.5-2.5 times the normal
- Prothrombin Time (PT)
o Monitor for WARFARIN
o Normal 11-12.5
o Therapeutic 1.5-2.0 times the normal
- International normalized ratio (INR)
o Monitor for WARFARIN
o Normal 0.8-1.1
o Therapeutic 2.5-3.0
Alert
o Recurrent PE therapeutic 3.0-4.5 - Heparin comes in variety of concentrations in vials that have differing amounts,
which contributed to possible medication errors.

Alert
- Monitor patients at risk to recognize signs and symptoms of PE (SOB, chest pain,
hypotension without any obvious cause). If such symptoms are present, respond
by notifying the rapid response team. If PE is strongly suspected, prompt
categorization and management strategies are started before diagnostic studies
have been completed.

, SIGNS AND SYMPTOMS
PATHOPHYSIOLOGY ASSESSMENT
Oxygenation Failure (hypoxemic) - O2 IS NOT ABLE TO ATTACH TO HEMOGLOBIN
o
Air movement (ventilation) is normal but blood flow Symptoms of ARF are related to the systemic effects of (Hypoxia, Hypercapnia
(perfusion) is decreased
 Mismatch with ventilation or
and acidosis.
Applying 100% O2 does not correct the problem perfusion in the lungs causing a Dyspnea is hallmark sign of respiratory failure
PaO2 <60 mm Hg
Normal is 80-100 mm Hg decrease in gas exchange Evaluate how breathless the patient becomes while performing common task
SaO2 <90%  Acute respiratory failure (ARF) can be More intense when dyspnea develops rapidly
Normal is 95-100% either: Slowly progressive respiratory failure may be noticed as dyspnea on exertion or
lying down (orthopnea) and may find it easier to breath in upright position
Common causes of Oxygenation Failure (BOX) blood decrease to the lungs - Ventilatory failure -Chronic respiratory problems an increase in dyspnea may represent severe gas
Low atmospheric oxygen concentration
- Oxygenation failure low - PaO2= exchange problems
High altitude, closed spaces, smoke inhalation, carbon monoxide poisoning,
arterial oxygen level less than 60 Assess for changes in respiratory rate/patterns and changes in lung sounds
pneumonia, CHF with pulmonary edema, pulmonary embolism, ARDS,
Monitor ABGs for hypoxia and hypercarbia
interstitial pneumonitis-fibrosis, abnormal hemoglobin, hypovolemic shock, - Combination of the two Hypoxia respiratory failure symptoms include:
hypoventilation
PT WILL BE Restlessness, irritability, agitation, confusion and tachycardia
Complications of nitroprusside (vasodilator) therapy -dyspnea, restlessness, irritability, confusion, tachycardia, decreased Oxygen will not fix the problem
Thiocyanate toxicity and methemoglobinemia Hypercapnic respiratory failure symptoms include:
LOC, lethargy
Decreased LOC, HA, drowsiness, lethargic and seizures
Respiratory Acidosis can occur leading to:
Ventilatory failure (Hypercapnic) – UNABLE TO TAKE DEEP BREATHS keep PaO2 >60mm Decreased LOC, drowsiness, confusion, hypotension, bradycardia and weak
Blood flow (perfusion) is normal but air movement (ventilation) is inadequate -treat the cause peripheral pulses.
PaCo2 >45 mm Hg
PaCo2 = arterial carbon dioxide more than 45 -oxygen therapy
 Normal is 35-45 mm Hg
opH < 7.35
 Normal 7.35-7.45
SaO2 <90%
 Normal is 95-100%
ACUTE RESPIRATORY FAILURE
Common causes of Ventilatory Failure (BOX) ventilation is compromised Extrapulmonary
causes:
Neuromuscular disorders: LABS / DIAGNOSTICS
Myasthenia gravis, Guillain-Barre syndrome, poliomyelitis, spinal cord injuries
affecting nerves to intercostal muscles
Central nervous system dysfunction:
Stroke, ICP, meningitis
COMPLICATIONS
Chemical depression:
Opioid analgesics, sedatives, anesthetics, kyphoscoliosis, massive obesity, sleep
apnea, external obstruction/constriction

Intrapulmonary causes:
Airway disease:
COPD and Asthma
Ventilation-perfusion mismatch:
Pulmonary embolism, pneumothorax, ARDS, amyloidosis, pulmonary edema,
interstitial fibrosis
PRIORITY NURSING INTERVENTIONS/ TEACHING
The patient in ACUTE RESPPIRATORY FAILURE is always hypoxemic caused by an underlying Oxygen therapy is appropriate for any patient with acute hypoxemia
problem Used in ARF to keep the PaO2 levels >60 mm Hg while treating the cause of
ARF.
If O2 does not maintain acceptable PaO2 levels, Mechanical ventilation may
be needed
TREATMENT
Help the patient find a position of comfort for easier breathing
DRUG THERAPY
Upright position (fowlers)
Nebulizer or Metered dose inhaler (MDI)
Decrease anxiety caused by dyspnea
Dilate the bronchioles and decrease inflammation to promote gas
Relaxation techniques, diversion and guided imagery
exchange
Encourage deep breathing exercises AND COUGHING
Corticosteroids may be used but benefits have not been demonstrated
conclusively
COPD PT DIE AT NIGHT AND ALONE
Analgesics for pain

If mechanical ventilation is required
Neuromuscular blockade drugs are prescribed for optimal ventilation
effect