NCLEX - Pulmonary Embolism and Deep Vein Thrombosis

Here are key facts for NCLEX (National Council Licensure Examination) from the Pulmonary Embolism & Deep Vein Thrombosis tutorial, focusing on the nursing process, patient care, and clinical judgment essential for licensure. See the tutorial notes for further details and relevant links.

• --

1. Definition & Relationship: Pulmonary embolism (PE) occurs when pulmonary arteries are obstructed, most commonly by emboli from deep veins of thighs/pelvis; deep vein thrombosis (DVT) and PE together are called venous thromboembolism. 2. Pathophysiology: Clot forms in deep vein → fragment breaks off → travels through IVC → right heart → pulmonary arteries → obstructs blood flow → impaired gas exchange. 3. Nonthrombotic Sources: PE can also result from air, fat, amniotic fluid, bacterial (septic), foreign bodies, and tumors. 4. Complications: Pulmonary hypertension, right heart failure, and pulmonary infarction. 5. Mortality Significance: PE is a leading cause of cardiovascular-related death. 1. Virchow's Triad: Three factors predisposing to thrombosis:

• Endothelial injury: Fracture, surgery, trauma, previous DVT; triggers clotting cascade
• Venous stasis: Immobility, elevated central venous pressure, heart failure, obesity
• Hypercoagulable states: Pregnancy, postpartum period, smoking, cancer, hormonal contraceptives/therapies, coagulation disorders (Factor V Leiden)

2. Combined Risk Factors: Patients with multiple predisposing factors (e.g., pregnant women on bed rest) have higher risk. 3. Preventable Factors: Many risk factors are modifiable through nursing interventions. 4. Prophylaxis Candidates: Recognition of high-risk patients who need preventive measures. 5. Assessment Focus: Comprehensive history and physical exam targeted at identifying risk factors. 1. DVT Presentation: When symptomatic, presents with unilateral leg swelling, tenderness, and signs of venous dilation; can also occur in upper body (less common). 2. PE Symptoms & Signs:

• Dyspnea and tachypnea (rapid breathing)
• Chest pain
• Hypoxemia and ventilation-perfusion mismatch
• Tachycardia and potential right heart failure
• Altered mental state, especially in elderly patients

3. Post-thrombotic Syndrome: Long-term complication of DVT due to venous valve damage. 4. Assessment Techniques: Focused cardiovascular and respiratory assessment. 5. Documentation: Thorough documentation of symptoms, vital signs, and physical findings. 1. Clinical Probability Tools:

• Wells Score for DVT: Based on swelling, edema, alternative diagnosis likelihood
• Wells Score for PE: Score ≥4 indicates PE likely; <2 low probability, 2-6 moderate, >6 high probability

2. Laboratory Tests:

• D-dimer: >500 ng/mL suggests possible PE or DVT, requiring further testing
• Arterial blood gases: May show hypoxemia and respiratory alkalosis

3. Imaging Studies:

• For PE: CT angiography, ventilation-perfusion scan, chest X-ray
• For DVT: Venous ultrasonography with compression, contrast venography

4. ECG Findings: Sinus tachycardia; S1Q3T3 pattern (S wave in lead I, inverted Q and T waves in lead III). 5. Nursing Role: Patient preparation, education, and monitoring during diagnostic procedures. 1. Supportive Care:

• Oxygen administration when saturation is less than 90%
• IV fluid management with saline
• Monitoring for and managing hemodynamic instability

2. Medication Administration:

• Anticoagulants: Heparin/enoxaparin or fondaparinux (short-term); warfarin (long-term)
• Monitoring for side effects, especially bleeding and heparin-induced thrombocytopenia

3. Advanced Treatments: Patient preparation and monitoring for embolectomy or clot dissolution procedures. 4. DVT Prophylaxis:

• Application and monitoring of sequential compression devices (SCDs)
• Administration of prophylactic anticoagulants (low-dose enoxaparin or heparin)

5. Patient Positioning & Mobility: Promoting appropriate activity while managing symptoms. 1. Risk Factor Modification: Teaching about modifiable risk factors and prevention strategies. 2. Medication Teaching: Anticoagulant purpose, administration, side effects, and monitoring. 3. Symptom Recognition: Signs of recurrent DVT, PE, or bleeding complications. 4. Activity Guidelines: Appropriate exercise and mobility recommendations. 5. Follow-up Care: Importance of continued medical monitoring and adherence to treatment plan.

• --

1. Respiratory Status: Monitor for dyspnea, tachypnea, oxygen saturation, and respiratory effort. 2. Cardiovascular Status: Assess for tachycardia, hypotension, and signs of right heart failure. 3. Pain Assessment: Evaluate chest pain (PE) or extremity pain (DVT) using appropriate pain scales. 4. Neurovascular Assessment: For DVT, assess affected extremity for pulses, color, temperature, sensation. 5. Mental Status: Especially important in elderly patients who may present with altered mental state. 1. D-dimer Testing: Proper specimen collection and patient education about purpose. 2. CT Angiography: Assessment for contrast allergies, renal function; hydration before and after procedure. 3. Ventilation-Perfusion Scan: Patient preparation and positioning during procedure. 4. Ultrasonography: Proper positioning and support of extremity during examination. 5. ECG Monitoring: Recognition of tachycardia and S1Q3T3 pattern relevant to PE. 1. Heparin Administration: Proper subcutaneous injection technique, site rotation, monitoring for bleeding. 2. Enoxaparin Considerations: Weight-based dosing, renal function assessment, injection technique. 3. Warfarin Management: Food and drug interactions, INR monitoring, bleeding precautions. 4. Bleeding Precautions: Minimizing fall risk, using soft toothbrush, electric razor, avoiding IM injections. 5. Monitoring Parameters: Signs of bleeding, platelet counts (for heparin-induced thrombocytopenia), therapeutic levels. 1. Sequential Compression Devices (SCDs): Proper application, assessment of skin integrity, ensuring appropriate use. 2. Early Mobilization: Safe ambulation techniques for hospitalized patients. 3. Hydration Maintenance: Encouraging adequate fluid intake unless contraindicated. 4. Position Changes: For immobile patients, frequent repositioning to prevent stasis. 5. Patient Education: Teaching about leg exercises, avoiding prolonged sitting, and recognizing symptoms. 1. Pulmonary Infarction: Monitoring for Hampton Hump on chest X-ray, indicating tissue ischemia typically in lower lobes. 2. Right Heart Failure: Assessing for jugular vein distention, peripheral edema, liver congestion. 3. Bleeding Complications: Monitoring for overt bleeding and signs of occult bleeding (tachycardia, hypotension, decreasing hemoglobin). 4. Heparin-Induced Thrombocytopenia: Regular platelet count monitoring, awareness of paradoxical clotting risk. 5. Post-thrombotic Syndrome: Long-term complication of DVT causing chronic venous insufficiency due to valve damage.

• --

Below is information not explicitly contained within the tutorial but important for NCLEX preparation. 1. Assessment: Focused assessment techniques for DVT and PE risk factors and symptoms. 2. Nursing Diagnoses: Impaired Gas Exchange, Ineffective Tissue Perfusion, Acute Pain, Activity Intolerance, Risk for Bleeding. 3. Planning: Prioritizing interventions based on patient status and risk level. 4. Implementation: Evidence-based nursing interventions for prevention and management. 5. Evaluation: Expected outcomes and reassessment criteria. 1. Unfractionated Heparin: Mechanism, administration routes, monitoring (aPTT), protamine reversal. 2. Low Molecular Weight Heparins: Dosing considerations, reduced monitoring requirements, longer half-life. 3. Direct Oral Anticoagulants: Administration considerations, lack of routine monitoring, reversal agents. 4. Thrombolytics: Administration protocols, absolute and relative contraindications, monitoring during therapy. 5. Analgesics: Appropriate pain management strategies that minimize bleeding risk. 1. Oxygen Therapy Management: Appropriate delivery methods and flow rates based on oxygen saturation. 2. Position to Promote Oxygenation: Semi-Fowler's or high Fowler's position to reduce work of breathing. 3. Emergency Response to Massive PE: Recognition and initial management of shock or respiratory failure. 4. Psychosocial Support: Addressing anxiety related to diagnosis and treatment. 5. Activity Progression: Gradual resumption of activities following established protocols. 1. Signs and Symptoms Requiring Medical Attention: Increased shortness of breath, chest pain, increased extremity swelling. 2. Anticoagulant Safety: Medication adherence, bleeding precautions, food and drug interactions. 3. Long-Term Prevention Strategies: Travel precautions, compression stockings, hydration, mobility. 4. Pregnancy Considerations: Special precautions for pregnant women with history of VTE. 5. Self-Monitoring Skills: Teaching pulse and respiratory self-assessment, weight monitoring. 1. Geriatric Patients: Recognition of atypical presentations, fall precautions with anticoagulation. 2. Pregnant Women: Modifications in assessment and treatment approaches. 3. Post-Surgical Patients: Enhanced monitoring and prophylaxis protocols. 4. Oncology Patients: Increased vigilance due to hypercoagulable state associated with cancer. 5. Chronically Immobile Patients: Intensified preventive strategies and routine assessment.