massive pulmonary embolism case pres

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Presented By:

Del Rosario, Pamela Janine T.De Vera, Gazzel M.

Fuentes, Mary Dominica Guballa, Guianne Mishael R.

Magpayo, Allen Jerome R.Padilla, Ma. Patricia T.

Pagcu, Ronald I.Yamon, Abigail Faye A.

Presented to:Michelle Suguitan RN, MSN

August 14, 2013

Massive Pulmonary EmbolismCase Presentation

St. Jude College

School of Nursing Don Quijote Street, Sampaloc, Manila



HISTORY:

55-year-old female nursing home resident with past medical histo

dilated cardiomyopathy (estimated left ventricular ejection fractio

previous transthoracic echocardiogram), and prior deep venous th

was found to be hypotensive and in respiratory distress while at hnursing facility.

She was brought to the emergency department, where vital signs

for temperature of 100.9ºF, HR=142/min, BP=90/60 mmHg after in

fluids, with oxygen saturation of 99% while breathing 100% oxyge

rebreather mask. Computed tomography of the chest with pulmoprotocol revealed large, thrombi in the right main and left main p

arteries with incomplete occlusion, in addition to multiple segmen

right upper, middle and lower lobes. No lower extremity deep vei

were noted on venogram. Anticoagulation was initiated and the p

transferred to the intensive care unit (ICU) for further managemen



OBJECTIVES

• To be able to describe and explain massive pulmonary emtogether with the risk factors contributing to the occurrencondition.

• Review the anatomy and physiology of the organ involved

• Correlate the results in the laboratory and diagnostic prodone

with the patient including their purposes and specific nuresponsibilities before, during and after the procedure.

• Enumerate the different medications for the disease condtheir indications and specific nursing responsibilities befoand after medication administration.

INTRODUCTION



BIOGRAPHICAL DATA • Name: GM

• Age: 55 years old

• Gender: Female

• Address: Pampanga

• Civil Status: Married

• Nationality: Filipino

•

Insurance Coverage: N/A• Admitting Medical Diagnosis: Massive Pulmonary Embolism

• Reason for seeking health care/chief complaint during admissiDifficulty breathing

• Past Medical History: AIDS, Dilated Cardiomyopathy, Deep VeinThrombosis



PHYSICAL ASSESSMENT



BODY PARTS FINDINGS ANALYSIS

EYES Pupil 3mm reactive,

Eye deviated

Pupils normal in size; eye deviation may indic

ORAL CAVITY Lips and mucous

membrane pale

May indicate decreased hemoglobin

SPEECH Expressive aphasia Damage to the broca’s area

THORAX Chest pain Due to the presence of pulmonary embolism

LUNGS Presence of Bilateral

crackles

Due to pulmonary embolism

Tachypnea Indicates hypoxemia

HEART S3 and S4 gallop S3, murmurs; Indicates CHF

Tachycardia Cardiac compensation

ABDOMEN Soft and nontender normal

LOWER

EXTREMITIES

Presence of grade 1+

edema

Accumulation of fluid in the interstitial compa

Cold to touch Accumulation of fluid due to venous system c

to pulmonary embolism and dilated cardiomy

Right sided weakness Due to neurological involvement of the right s



Diagnostic Tests

E i i N l l Fi di A l i



Examination Normal values Findings Analysis

Na (sodium) 133-145

mmol/L

134mmol/L Normal

K (potassium) 3.5-5.0 mmol/L 4.6 mmol/L Normal

HCO3 (bicarbonate) 22-26 mEq/L 13 mEq/L Low, indicates metabolic alkalos

BUN 10-20 mg/dL 45 mg/dL High, decreased cardiac output

perfusion & reduction in glomer

leading to inadequate eliminatio

nitrogenous wastes

Creatinine 0.5-1.5 mg/dL 2.8 mg/dL Slightly elevated, may indicate c

s. glucose 60-110 mg/dL 102 mg/dL Normal

troponin 0.08mg/ml 2.7mg/ml High, indicates MIABG:

pH 7.35-7.45 7.32 Slightly low, indicates acidosis

PaCo2 35-45 25 mmHg Low, indicate compensatory resp

PaO2 85-95 mmHg 250 mmHg High, may , indicate compensato

or may also Indicate polycythem



ABG’S(ICU) prior to

intubation

Actual findings Normal findings Interpre

pH 7.32 7.35-7.45 A decrea

and PaCO2metabolic

(p. 297)

and sudda

edit

PaCO2 25 mmHg 35-45 mm HgPaO2 71 mmHg 70-100 mm Hg

Laboratory findings:

Actual findings Normal findings Interpretation

Negative Negative Normal

Guaiac test ( Fecal Occult Blood Test)



Actual findings Interpretation

-Dilated left ventricular with

depressed systolic function

-Moderate tricuspid regurgitation anddilated inferior vena cava noted

Stretching distorts the valve an

supporting structures, prevent

valve closure due to hercardiomyopathy (p.906) Lemo

Burke 3rd edition

ECG(echocardiogram)

Actual findings InterpretationPulmonary emboli in bilateral pulmonary

artery

Thrombus that completely or partia

obstruct the pulmonary artery or it

causes increased dead space and e

impairment of gas exchange (p.582

and suddarths 12th edition

CT scan (Chest)



ANATOMY

AND

PHYSIOLOGY



PATHOPHYSIOLOGY

RF: Dilated cardiomyopathy, Deep vein thrombosis, hypertension



blood stasis, vessel injury, hypercoagulability

Thrombus formation

Dislodgement of thrombus or portion of thrombus

Migration of thrombus to pulmonary circulation

Occlusion of the pulmonary artery Substances released from the clot & surrounding area (ex.thrombox

prostaglandin & endothelin) causes blood vessel and bronchioles con

Area in the lungs that is continued to

be ventilated but little/no blood flow

occurs ( increased dead space)

Decreased oxygen levels inthe blood

Detection of respiratory center of

this hypoxemic state

Compensatory tachypnea and

tachycardia

Increased pulmonary vascular resistance and pulmonary arterial pres

Increased workload on the right ventricle

(when ventricular workload exceeds its capacity )

Decreased COCHFsystemic hypotension

Renal hypoperfusion destruction of renal parenchyma

Inability of the body to eliminate nitrogenous and other wastes

Increased BUN,Creatinine levels, oliguria

(over time)

Chronic kidney disease

Dyspnea, chest pa

hypoxemia



Nursing Care Plans

A t Di i Pl i I t ti R ti l



Assessment Diagnosis Planning Intervention Rationale

Skin warm to touch

Flushed skin

Presence of foley catheter

Vital signs as follow:

T-39oC

RR-30cpmPR-140bpm

BP-80-60mmHg

Hyperthermia

related to infectious

process secondary

to Foley catheter

insertion

Analysis:Pyrogens cause a

rise in body

temperature; it also

acts as an antigen

triggering immune

system responses.

The hypothalamus

reacts to raise the

set point and body

respond by

producing heat.

Reference :

Fundamentals of

Nursing pg 488

Within 2 hours of

nursing intervention

the patient temperature

will lower down to

normal level:

T-36.5-37.5 C

Independent:

Assess the causative

factor(site of foley

catheter)

Monitor vital signs

Provided tepidsponge bath

Provide cool

circulating

environment

Dependent :

Administered

antipyretic such as

ASA

Maintain IV fluid as

ordered

Swelling and

discharge of t

indicates infe

Notes progre

changes of condition

Enhances hea

by evaporatio

conduction

Dissipates he

convection

Antipyretic re

fever by its ce

action on the

hypothalamu

Prevents

dehydration





OBJECTIVE

T-39

Pr-140

Rr-30

Bp-80/60-Presence of S3 and

S4 upon auscultation

-Presence of grade 1

bilateral edma on

lower extremities

-Cold clammy skin

Subjective:-chest pain

-dyspnea

-abdominal pain

Ineffective tissue

perfussion

Analysis:

Decrease in

oxygen resultingin the failure to

nourish the

tissues at the

capillary level.

(Nurses pocket

guide p.705)

Within 2

hours of

nursing

intervention

s patient’svital signs

will be at

normal

range.

Independent:

-Monitor Bp, ABG’s, and

laboratory values

-Evaluate vital signs,

noting changes in Bp,heart rate and

respiratory rate.

-Monitor the condition

of the skin (lower

extremities)

for edema and skin

temp.-Auscultate heart and

lung sounds frequently.

-Elevate head of the bed

Administer fursemide as

ordered

-Provides

comparison with

current findings.

(Nurses pocketguide p.705)

-to promote

circulation and

venous drainage

-used to decrease

edema



Drug Study

NAME OF MECHANISM DOSAGE INDICATIONS CONTRAINDICATION SIDE



DRUG OF ACTION EFFECTS

Heparin

Drug Class:

Anticoagulant

Prevents

conversion of

fibrinogen to

fibrin and

prothrombin

to thrombin by

enhancing

inhibitory

effects of

antithrombin

III

1000 units

in 20ml

D5W

-prevention of

DVT

-pulmonary

emboli

-MI

Hypersensitivity

Leukemia with

bleeding

Severe

thrombocytopenic

purpura

Fever, chills,

hematuria,

hemorrhage

anemia,

rash,

dermatitis,

anaphylaxis

NAME OF MECHANISM OF DOSAGE INDICATIONS CONTRAINDICATION SIDE



DRUG ACTION EFFECTS

Abacavir

Drug

Class:

Antiviral

A synthetic

nucleoside analog

with inhibitory

action against HIV.

Inhibits replication

of the virus by

incorporating into

cellular DNA by

viral reverse

transcriptase,

therebyterminating the

cellular DNA chain.

500 mg IV

q6hrs

(ANST)

In combination

with other

antiretroviral

agents for HIV-1

infection

Hypersensitivity

Lactic acidosis

Fever,

headache,

malaise,

insomnia,

nausea,

vomiting,

diarrhea,

cramps, ras

dyspnea,

lactic

acidosis

NAME OF MECHANISM DOSAGE INDICATIONS CONTRAINDICATION SIDE



NAME OF

DRUG

MECHANISM

OF ACTION

DOSAGE INDICATIONS CONTRAINDICATION SIDE

EFFECTS

Clopidogrel Inhibits first

and second

phases of

ADP-

induced

effects in

platelet

aggregation

50mg/

tab 1tab

PO OD

-reducing the

risk of stroke

-MI

-peripheral

arterial

disease in

high risk pts.

-acute

coronarysyndrome

-transient

ischemic

attack

Hypersensitivity

Active bleeding

Headache

dizziness,

GI

bleeding,

epistaxis,

bleeding,

cough,

bronchitis

NAME OF MECHANISM OF DOSAGE INDICATIONS CONTRAINDICATION SIDE EFFECT



DRUG ACTION

Enalapril Selectively

suppresses

renin-

angiotensin-

aldosterone

system; inhibits

ACE; prevents

conversion of

angiotensin I to

angiotensin II,

dilation orarterial, venous

vessels

10mg/tab

1tab OD PO

Hypertension

CHF

Left ventricular

dysfunction

-hypertension

-angioedema

Dysrhythmia

MI,

Orthostatic

hypotension,

proteinuria,

renal failure,

neutropenia.

NAME OF MECHANISM DOSAGE INDICATIONS CONTRAINDICATION SIDE EFFECTS



DRUG OF ACTION

Levetiracetam Unknown,

may inhibit

nerve impulse

by limiting

influx of sodium ions

across cell

membrane in

minor cortex

5mg/tab

2tabs

q12hrs PO

Adjunctive

therapy in

partial onset

seizure

Hypersensitivity Dizziness,

somnolence,

asthenia,

abdominal

pain,pharyngitis.

DRUG NAME MECHANISM OF DOSAGE INDICATION CONTRAINDICATI ADVERSE EFFEC



ACTION ON

furosemide

Drug class: loop

diuretics

Inhibits reabsorption

of sodium and chloride

from the proximal and

distal tubules and

ascending limb of the

loop of Henle, leading

to a sodium-richdiuresis.

-40 mg/tab 1tab OD,

PO

-20 mg TIV

-Treatment of

hypertension

-Acute pulmonary

edema

-Contraindicated with

hypersensitivity to

furosemide,

sulphonamides

-Use cautiously with

Diabetes mellitus

CNS: headache,

dizziness, insomnia

CV: Hypotension

Derma: rash, pruritus

urticaria, dry skin

GI: diarrhea, abdomi

pain, nausea,constipation, dry mo

GU: Polyuria, nocturi

glycosuria

DRUG NAME MECHANISM OFACTION

DOSAGE INDICATION CONTRAINDI-CATION

ADVERSE EFFECTS



ACTION CATION

aspirin (ASA)

Drug class:

Antiplatelet,

Antipyretic

-Inhibition of

platelet

aggregation is

attributable to

the inhibition of

platelet synthesis

of thromboxane

A2

-Antipyretic

effects are not

fully understood,

but it acts in the

thermoregulatory

center of thehypothalamus to

block the effects

of endogenous

pyrogen by

inhibiting

synthesis of

prostaglandin

intermediary

80 mg/tab-1

tab OD, PO

-for fever

-reduction of risk of

recurrent TIA’s and

CVA in patients with

history of TIA

-reduction of risk of

death or nonfatal MI

in patients with

history infarction or

unstable angina

pectoris or

suspected acute MI

-Contraindicated

with allergy to

salicylates or

NSAID’s, Aspirin,

bleeding defects,

blood coagulation

defects

Acute aspirin

toxicity: respiratory

alkalosis,

tachypnea,

hemorrhage,

confusion,

pulmonary edema,

fever, metabolic

acidosis, seizures

GI: nausea,

epigastric

discomfort,

anorexia

Salicylism:dizziness, tinnitus,

vomiting, diarrhea,

confusion,

lassitude

-A

a

-

t

-

in

c

-

s

w

o

-

t

um

-

m

a

-

im

c

DRUG NAME MECHANISM OF DOSAGE INDICATION CONTRAINDI- ADVERSE



ACTION CATION EFFECTS

epinephrine

(adrenaline)

Drug class:

-Alpha-adrenergic

agonist

-Beta1 and Beta 2-adrenergic agonist

-Bronchodilator

-Cardiac stimulant

-Mydriatic

-Sympathomimetic

Naturally occurring

neurotransmitter, the

effects of which are

mediated by alpha or

beta receptors target

organs. Effects of alphareceptors include

vasoconstriction,

contraction of dilator

muscles of iris. Effects

on beta-receptors

include positive

chronotropic and

inotropic effects on the

heart; bronchodilation,

vasodilation.

5 mcg/min TIV -Relief from

respiratory

distress

-Prophylaxis of

cardiac arrest

and attacks of transitory AV

heart block

-Contraindicated

with hypersensitivity

to epinephrine or

components of

preparation,

tachyarrhythmias,hypertension, renal

impairment,

ischemic heart

disease, cardiac

dilation

-use cautiously with

CAD, elderly

CNS: dizziness,

light headedne

headache,

fatigue, letharg

GI: nausea,

abdominaldiscomfort,

Derma: Allergi

reactions (rash

pruritus)

CV: arrhythmia

tachycardia,

palpitaitons

GU: decrease

urine formatio

dysuria,



Nurse’s Progress Notes

DATE TIME NURSING NURSING INTERVENTION



PROBLEMS

8-13-13 10:15 >Respiratory

distress

>difficulty of

breathing

>position the patient at semi fowlers po

>administer oxygen via non-rebreather m

>vital signs taken: BP-80-90mmHg, RR-3

140BPM, Temp-39

10:30 >ABG obtained results: pH-7.04, CO2-38

>ECG obtained results: sinus tachycardia

beats.

>administered heparin drip 5000unit in

units/hour

>prepare patient for chest CT scan and o

consent

10:40 >assisted ET tube insertion performed by

10:45 >echocardiogram obtained, results: left

depressed systolic function moderate tr

regurgitation and dilated inferior vena ca

DATE TIME NURSING NURSING INTERVENTION



PROBLEMS8-13-13 1:00 >Hyperthermia

>Hypotension

>administered PNSS 1L to run for 12h

>administered PNSS 1L to run for 12h

2:00 >Progressive DOB >assisted in endotracheal intubation; ET changed

hooked patient to mechanical ventilator

>requested radiologic department for chest xray tplacement

>assessed chest expansion; symmetrical

>auscultated chest fields, crackles heard bilaterall

>repositioned patient and suctioned secretions as

3:00 >Oliguria >weighed underpads soaked with urine, initial out

catheterization 150g in 3h>inserted foley catheter, urine output on the 1st h

20cc,3rd hour-0

>administered furosemide 20mg IV, after 30 min.

4:00 >Hyperthermia >checked proper regulation of PNSS

>performed tepid sponge bath

>administered antipyretics as ordered



DISCHARGE PLAN

MEDICATIONS Take the medications as prescribed and avoid skipping. Contact physician if adnoticed such as itching and difficulty of breathing



noticed such as itching and difficulty of breathing.

Always check with health care provider before taking any medicine, including

medications.

Wear an identification bracelet or carry a medicine card stating that taking an

EXERCISE Walk occasionally and do active exercise of moving legs and ankles while sittin

TREATMENT Avoid stressful and exhausting moments for this also can aggravate symptomperiods every day is very beneficial and effective.

HEALTH

EDUCATION

Report the occurrence of dark, tarry stools to the health care provider immed

Continue to wear antiembolism stockings as long as directed.

Avoid sitting with legs crossed or sitting prolonged periods of time.

Look for bruising and bleeding when taking anticoagulants and to avoid bump

Avoid laxatives because they may affect vitamin K absorption (Vitamin K prom

Use toothbrush with soft bristles to prevent gum injury/gingival bleeding

OUTPATIENT

FOLLOWUP

Attend to physician’s follow up check-up (Two weeks after discharge) at the o

Be sure to ask the physician about modifications with regards to medications,

examinations to be done.

DIET Instruct adequate fluid intake.

Instruct client to increase intake of nutritious food such as vegetables and fru

SPIRITUALEncourage client to have positive outlook in life, pray for continuous recovery

massive pulmonary embolism case pres

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