Medical-Surgical Nursing
A 69-year-old obese women with a pelvic fracture has been immobile for four days.
The patient is now anxious, dyspneic, and domaining of substernal pain. The patient's capillary refill is greater than seconds. Heart rate 122 /min Respiratory rate 26 /min Temperature 38.2 C Which of the following the nurse suspects for this patient?
Explanation
Core Concept: A pulmonary embolism (PE) occurs when a deep vein thrombosis (DVT), often originating in the lower extremities or pelvis due to venous stasis (immobility, pelvic fracture), hypercoagulability, and endothelial injury (Virchow's triad), dislodges and travels to the pulmonary arteries. This causes a massive ventilation-perfusion (V/Q) mismatch, right heart strain, and profound hypoxia.
Clinical Presentation:
- Sudden onset dyspnea, pleuritic chest pain, tachycardia, tachypnea, and hypoxia.
- Anxiety, sense of impending doom, and occasionally a low-grade fever or hemoptysis.
- Complications include right ventricular failure (cor pulmonale), cardiogenic shock, and sudden cardiac death.
Diagnosis:
- First-line diagnostic tool: Clinical probability scoring (Wells Criteria), D-dimer assay (if low probability), and ECG (looking for the S1Q3T3 pattern or signs of right heart strain).
- Gold standard diagnostic test: CT Pulmonary Angiography (CTPA) to directly visualize the thrombus in the pulmonary vasculature. A V/Q scan is the alternative gold standard if CTPA is contraindicated (e.g., severe renal failure).
Management:
- Acute management: Hemodynamic support, supplemental oxygen, and immediate therapeutic anticoagulation (e.g., IV unfractionated heparin, LMWH, or DOACs). Massive PE with hypotension requires thrombolytics (e.g., tPA) or surgical embolectomy.
- Gold standard long-term/definitive management: Long-term anticoagulation (3-6 months or lifelong) and the placement of an Inferior Vena Cava (IVC) filter if anticoagulation is strictly contraindicated.