Massive PE is a medical emergency. Make sure that the patient's airway, breathing, and circulation (ABCs) are maintained. Administer oxygen immediately to support gas exchange and prepare for the possibility of intubation and mechanical ventilation. Obtain intravenous (IV) access for administration of fluids and pharmacologic agents. Before administration of thrombolytic agents, draw a coagulation profile and complete blood count to obtain a baseline.
Although it is rare, severe cases of PE that are unresponsive to anticoagulant or thrombolytic therapy may require surgery. The least invasive technique is the insertion of a transvenous catheter into the pulmonary vasculature. If the procedure is unsuccessful, however, a thoracotomy may be required to remove the obstructing embolism. Patients prone to PE seeded from deep vein thrombi may have a prosthetic umbrella inserted into the inferior vena cava to trap the emboli.
|Medication or Drug Class||Dosage||Description||Rationale|
|Thrombolytic agents||Varies with drug||Recombinant tissue plasminogen activator, reteplase, alteplase, urokinase, streptokinase||Break down clots previously formed and hasten resolution of clots, but have not been shown to reduce mortality|
|Anticoagulants||Varies with drug and patient weight; standard heparin dosage is 80 U/kg bolus IV followed by an infusion of 18 U/kg per hr titrated according to coagulation studies; starting dosage of warfarin is 5 mg per day for 2 days PO with changes depending on prothrombin time; enoxaparin: treatment of DVT and pPE: 1 mg/kg SC q 12 hr or 1.5 mg/kg SC q day||Sodium heparin; sodium warfarin (Coumadin); enoxaparin (Lovenox); dalteparin (Fragmin)||Standard treatment is to initiate intravenous heparin with clinical suspicion of PE to reduce further formation of clots|
Morphine sulfate to manage pain and anxiety, diuretics to reduce edema, inotropic agents for heart failure.INDEPENDENT
The primary concern for the nurse who is caring for a patient with PE includes the maintenance of ABCs by support of the cardiopulmonary system. The most important independent measure before PE formation is prevention of thrombus formation. To prevent PE in high-risk patients, encourage early chair rest and ambulation as the patient's condition allows. Even patients who are intubated and mechanically ventilated with multiple catheters can be gotten out of bed without physiological risk for periods of chair rest. Provide active and passive range-of-motion at least every 8 hours for all patients on bedrest. Teach the family and significant others of an immobile patient how to perform passive range-of-motion exercises. If the patient is not on fluid restriction, encourage drinking at least 2 L of fluids a day to decrease blood viscosity. Use compression boots for patients who are on bedrest to increase venous return.
During anticoagulant therapy, protect patients from injury. Report any signs of increased bleeding, such as ecchymosis, epistaxis, hematuria, mucous membrane bleeding, decreasing hemoglobin or hematocrit, and bleeding from puncture sites. Restrict parenteral injections and venipunctures to essential procedures only. If the patient is ambulatory, provide a safe environment.
Provide information about the diagnosis and prognosis of PE, and explain all procedures and diagnostic tests. Set aside time each day to talk with the patient and family to allow for expression of their feelings. If the patient is a child, monitor the patterns of growth and development using age-appropriate milestones and developmental tasks. Provide age-appropriate play activities for children.
Pulmonary Embolism has been found in Diseases and Disorders
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