Embolism: Types, Symptoms, Risk factor, Diagnosis, and Nursing care

• A thrombus is a blood clot that forms in a vein
• An embolus is anything that travels through the blood vessels until it reaches a vessel that is too small to let it pass. When this happens, the blood flow is stopped by the embolus.
• An embolism refers to the lodging of an embolus, which may be a blood clot, a fat globule or a gas bubble in the bloodstream, which can cause a blockage. Such a blockage (vascular occlusion) may affect a part of the body distanced from the actual site of the embolism.

Classification

There are different types of embolism, some of which are listed below:

1. Arterial: Arterial embolisms are those that follow and, if not dissolved on the way, lodge in a more distal part of the system circulation.

• An arterial embolus might originate in the heart (from a thrombus in the left atrium following atrial fibrillation or be a septic embolus resulting from endocarditis). Thrombus formation within the atrium occurs mainly in patients with mitral valve disease, and especially in those with mitral valve stenosis (narrowing) with atrial fibrillation (AF)
• Patients with prosthetic valves also carry a significant increase in the risk of thromboembolism.
• Emboli often have more serious consequences when they occur in the so-called “end circulation”: areas of the body that have no redundant blood supply, such as the brain and heart

2. Venous:

• Assuming a normal circulation, an embolus formed in a systemic vein will always impact the lungs, after passing through the right side of the heart. This will form a pulmonary embolism that will result in a blockage of the main artery o the lung and can be a complication deep-vein thrombosis
• The most common sites of origin of pulmonary emboli are the femoral veins. The deep veins of the calf are the most common sites of actual thrombi.

3. Paradoxical (venous to arterial):

• In paradoxical embolism, also known as crossed embolism, an embolus from the veins crosses to the arterial blood system. This is generally found only with heart problems such as septal defects (holes in the cardiac septum) between the atria or ventricles. The most common such abnormality is patent foramen ovale, occurring in about 25 % of the adult population, but here the defect functions as a valve which is normally closed, because the pressure is slightly higher in the left side of the heart. Sometimes, for example, if a patient coughs just when an embolus is passing it might cross to the arterial system

Direction

The direction of the embolus can be one of two types:

• Anterograde
• Retrograde

In Anterograde embolism, the movement of emboli is in the direction of blood flow.

In Retrograde embolism, however, the emboli move in opposition to the blood flow direction; this is usually significant only in blood vessels with low pressure (veins) or with emboli of high weight.

Regardless of its source, an embolus does its damage by getting stuck in a large artery or branch and blocking blood flow beyond that point.

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Embolism by Wikipedia

Risk Factors

Following are the major risk factors of Embolism:

• Previous DVT or family history of DVT
• Immobility, such as bed rest or sitting for long periods
• Recent surgery
• Above the age of 40
• Hormone therapy or oral contraceptives
• Pregnancy or post-partum
• Previous or current cancer
• Limb trauma and/or orthopedic procedures
• Coagulation abnormalities
• Obesity

Symptoms

Some major symptoms of Embolism:

• Discoloration of the legs
• Calf or leg pain or tenderness
• Swelling of the leg or lower limb
• Warm skin
• Surface veins become more visible
• Leg fatigue

Pulmonary Embolism:

Introduction

Pulmonary Embolism is a condition in which the pulmonary vasculature is blocked by foreign matter such as blood clots, air tumor tissue, bone, or by needle or catheter. Usually, the result of peripheral venous thrombosis may lead to pulmonary infarction and pulmonary hypertension. This plan, which includes intervention specific to this condition, may be used in association with thrombophlebitis /thrombosis.

The embolus travels from the venous circulation to the right side of the heart and pulmonary artery obstructing blood flow and resulting in increased pulmonary arterial pressure and increase right ventricular work to maintain blood flow.

When the work requirement of the right ventricular exceeds its capacity, right ventricular failure, and a decrease in cardiac output followed by decrease BP and development of shock and pulmonary infarction

 Etiology

1. Prolonged immobilization
2. Central venous catheters
3. Abdominal, pelvic or thoracic surgery
4. Obesity
5. Advancing age
6. Hyper-coagulability
7. History of thrombo-embolism
8. Cancer diagnosis
9. Venous stasis
10. Thrombophlebitis
11. Pregnancy and use of contraceptives.

Clinical Manifestations

1. Respiratory manifestations: dyspnea, tachypnea, tachycardia, pleuritic chest pain, dry cough, hemoptysis.
2. Cardiac manifestations: distended neck veins, hypotension, abnormal heart sounds, abnormal electrocardiogram findings, and cyanosis
3. Low-grade fever, petechiae
4. Presence of venous thrombosis in lower limbs.
5. Sudden death (massive pulmonary embolism)

Diagnostic Test Results

1. ABGs levels show respiratory alkalosis and hypoxemia.
2. Pulmonary angiography shows the location of embolism and the filling defect of the pulmonary artery.
3. Physical findings: clinical signs and symptoms
4. Chest X-ray shows dilated pulmonary arteries, penumoconstriction, and diaphragm elevation on the affected side.
5. Radioisotope lung scan.

Nursing Diagnosis

1. Ineffective breathing pattern related to chest pain decreased lung expansion caused by emboli with severity depending on size and number of vessels occluded.
2. Impaired gas exchange related to altered blood flow caused by obstruction of circulation to the pulmonary vascular bed

Nursing Intervention

Assess for:

1. Respiratory status including history and physical examination especially thrombus/ thrombophlebitis of both peripheral and deep veins

Rationale: Provides database and baselines

1. Respiratory rate, depth, ease, dyspnea tachypnea, tachycardia, cough, chest pain hemoptysis; crackles, and accentuated pulmonic heart sound on auscultation.

Rationale: Changes indicate whether emboli are small, medium, or massive-sized.

Treatment and Nursing Intervention

1. Bed rest with active and passive range of motion
2. Keep the patient with fowler position to enhance ventilation
3. Assist with turning, coughing, and deep breathing to mobilize secretions and clear airway.
4. Assess respiratory status to detect respiratory distress.
5. Assess cardiovascular status. An irregular pulse may signal arrhythmia caused by hypoxemia. If the cause of PE by thrombophlebitis, the temperature may be elevated.
6. Administer 02 to enhance oxygenation.
7. Establish an IV line for fluids and drugs.
8. Monitor and record intake and output to detect fluid volume overload and renal perfusion.
9. ABGs monitoring to evaluate the need for mechanical ventilation.
10. Monitor laboratory studies because a patient on heparin and need to evaluate electrolyte, CBC and Hct.
11. Anticoagulant drugs:

• Heparin (IV): stop further thrombus formation and extended the clotting time need adjustment for the dosage to maintain the activated partial thromboplastin time (PTT).
• Warfarin sodium (coumadin): may give simultaneously at the beginning or after 5-6 days of heparin therapy, the dosage is controlled by monitoring of prothrombin time (PT) or after 5 of heparin therapy

1. Thrombolytic agents

• Streptokinase- lyses thrombi in deep venous system and emboli in pulmonary circulation, causing more rapid resolution of the thrombi/emboli and restoring pulmonary circulation to normal, improve circulatory and hemodynamic status.
• Thrombolytic therapy usually followed with heparin and warfarin treatment to prevent additional thrombus formation

1. Morphine is given to reduce chest pain and anxiety.
2. Diuretics: Lasix if right ventricular failure develops.

Surgical intervention: embolectomy, inferior vena cava interruption.

Some frequently asked Questions:

a) What are the types of embolism?
Ans: There are three types of embolism, they are:
i. Arterial
ii. Venous
iii. Paradoxical (venous to arterial), etc.

b) What is pulmonary embolism diagnosis pulmonary embolism treatment?
Ans: Following are the diagnosis of pulmonary embolism:

1. Bed rest with active and passive range of motion
2. Keep the patient with fowler position to enhance ventilation
3. Assist with turning, coughing, and deep breathing to mobilize secretions and clear airway.
4. Assess respiratory status to detect respiratory distress.

c) what is the first sign of pulmonary embolism?
Ans: The first sign of pulmonary embolism is a rapid change in heart rate and shortness of breath.

d) What is pulmonary embolism definition?
Ans: Pulmonary Embolism is a condition in which the pulmonary vasculature is blocked by foreign matter such as blood clots, air tumor tissue, bone, or by needle or catheter.

e) What is arterial embolism?
Ans:  Arterial embolisms are those that follow and, if not dissolved on the way, lodge in a more distal part of the system circulation.