l OM oAR cP SD | 89 45 4 69
l OM oAR cP SD | 89 45 4 69 NUR 265 EXAM 2 Study Guide
● Pulmonary embolism: clot that travels to the lungs
○ Risk factors ■ Prolonged immobility ■ Central venous catheter surgery ■ Obesity ■ Advancing age ■ Conditions that increase blood clotting (DIC) ■ Distort of thromboembolism ■ Smoking ■ Pregnancy ■ Hormonal birth control (estrogen therapy) ■ Heart failure ■ Stroke ■ Cancer ■ Trauma ■ Afib
○ S/s:
■ Dyspnea - SUDDEN ONSET ■ Pleuritic chest pain (sharp, stabbing type pain on inspiration) ■ Crackles ■ Wheezes ■ Apprehension ■ Anxiety ● Give O2 ■ Restlessness ■ Impending doom ■ Cough (productive or dry) ■ Tachypnea ■ Pleural friction rub ■ S3 or s4 heart sound ■ Diaphoresis ■ Low grade fever ■ Petechiae (fat embolism , does not impede blood flow, causes actual damage to the blood vessels) over chest and a axillae ■ If really big you can see EKG changes ■ hemoptysis - bloody sputum ■ Decreased Sao2 ■ Sudden dyspnea and chest pain= immediately notify rapid response team
○ Labs:
■ Hyperventilation (caused from pain and hypoxia) = respiratory alkalosis (low paco2 <35, high PH >7.45) = blood shunting from right side to left 1 / 3
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○ Dx:
side without picking up O2 from the = respiratory acidosis (high paco2 >45, low PH <7.35)= build up of lactic acid = metabolic acidosis (low HCO3 <22, low PH <7.35) ■ D-dimer rises (positive)
■ Pulmonary angiography = gold standard ● Only if stable ● Inject dye, use imaging
■ CT
■ Chest X-ray ■ Doppler ultrasound
○ Nursing intervention:
■ Call rapid ■ O2 - use pulse ox ● Nasal cannula ● Mask ● Mechanical ventilation ■ Tele ■ IV access ■ Monitor VS. lung sounds and cardiac/ respiratory status Q1-2hrs ● Assess for and document increasing dyspnea, dysrhythmias, JVD, pedal or sacral edema, crackles, cyanosis ■ CTPA, pulmonary angiography ■ Bleeding precautions ● Monitor and record amount of bleeding ● Asses Q2 hours ■ Measure abdominal girth Q8 Hours ■ Monitor labs daily ● Monitor CBC to watch for blood loss ○ Blood loss= RBC, plasma ○ Monitor platelet count = decreased platelet count = HIIT ■ Drug therapy ■ Make sure antidote is on the floor ● Anticoagulants - keep clots from getting bigger ○ Unfractionated heparin ■ Check PTT (normal 20-30) before administering (range between 1.5-2.5 times the control) (therapeutic 46-70) (>75 = complication) ■ 5-10 days (for 24 hours) ■ Protamine sulfate = antidote ○ Then transferred to oral warfarin ■ Monitor INR (2.0-3.0) ■ Vitamin K = antidote 2 / 3
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○ Heparin 5-10 days, most patients started on warfarin on day 1-2, both are continued together until the INR reaches 2-3, heparin will be continued for 24 hours after INR is >2 ● ○ Heparin induced thrombocytopenia ■ Body creates antibodies to the heparin = increased thrombin - prothrombin = increased clotting
■ Risk factors include:
● Duration of heparin use longer than 1 week ● Exposure to unfractionated heparin ● Post surgical prothrombin prophylaxis ● Being female
■ S/s:
● DVT
● PE
● Thrombocytopenia (hallmark sign) = platelets <150,000 ● Can through thrombus
■ Treatment:
● Argatroban and lepirudin (direct thrombin inhibitors) ● Inferior vena cava filtration - bedside procedure ○ Filter that catches things before it gets to the lungs ● Mechanical ventilation for respiratory acidosis + pao2 <60 = respiratory failure ●
● TPA
○ Antidote = clotting factors, frozen plasma, aminocaproic acid ● Mechanical ventilation
○ Mode:
■ A/C : assistive control ventilation
● Most restrictive - vent takes control of breathing completely
● Complications:
○ Hyperventilation ○ Respiratory alkalosis ( paco2 <35, ph >7.45)
● Resting mode: to try to allow patient to breath on their own, if not
working then the vent takes over and breathing pattern is established
■ SIMV: synchronized intermittent mandatory ventilation
● Can be used as a main ventilator or as a weaning method ● Allows for spontaneous breathing at patients own rate
■ CPAP: continuous positive airway pressure
○ Rate
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