Pulmonary embolism - nurse's actions

[Nuieve]

I have NCLEX test questions that contradict each other. Which is the initial action:

1. Elevate head of bed
or
2. Give oxygen.

I would assume elevate bed, since physician's order required for oxygen.

Also, I'm confused about positioning with embolism in general. Some books say "elevate the head of bed", some say put the patient in left Trandelenburg position to trap the clot in right atrium/ventricle.

Which is the correct nursing action?

[PamelaSRNV]

I've been taught to place the patient in Left Trans to try and guide the embolus into the left atrium. Also, you don't need an order to administer 2L oxygen---anything higher yes but until then at least you can get something flowing.

[psu_213, BSN, RN]

I'm a bit confused here. The title of the post mentions PE, and the first post includes the phrase 'trap the clot.' The discussion then turned to air embolism, which does not involve a clot. If it's air embolism, lying on the left side can trap the air in the right heart, preventing it from causing an infarction of the lung (that is the bigger issue than it getting into the arterial circulation from the venous circulation...stroke is one of the last things on my mind when it comes to an air embolism in the venous circulation.

If it is a confirmed PE, I would want an order for a heparin gtt.

[psu_213, BSN, RN]

Sorry, didn't realize this discussion was almost 5 yrs old!

[nurseprnRN, BSN, RN]

(I know this is an old thread, but it's a common question, so i'm gonna answer it anyway.)

I am loath to criticize the late daytonite for anything. However, if one had an air embolus originating in a vein, there is no anatomical way for it to travel to the left heart at all (given normal anatomy). Likewise any venous-originating clot. Can't happen. Why not?

Follow the blood stream:

body > veins > vena cava > right atrium > tricuspid valve > right ventricle > pulmonic valve > pulmonary artery > lungs> pulmonary vein > left atrium > mitral valve > left ventricle > aortic valve > arteries > body

Given normal anatomy, i.e., no intracardiac malformations, there is simply no way for a floating object to get to the left heart at all; it gets strained out in the pulmonary capillary bed. As a matter of fact, that's why you have a pulmonary capillary bed, to act as a strainer for all the microemboli you have in the course of an active life.

The only way a venous dvt or venous air embolus can get to the cerebral arterial circulation is if there is a direct connection between the venous side and the arterial side in the heart and the venous pressure is higher than the arterial pressure.

Anyone with an atrial or ventricular septal defect and a right-to-left shunt, who would be at risk for arterial embolus of venous origin, and this would be bad. However, since in most people, the left heart pressures are significantly higher than right heart pressures (by a factor of five to ten, more or less), any air or clot in the right heart keeps going right on out the pulmonary artery to the capillary bed.

Unsuspected asds are a known cause of stroke in younger people who lack other risk factors-- think of the much-beloved erstwhile heart and soul of the patriots' line, tedy bruschi, whose stroke fortunately resolved and whose asd was repaired endoscopically; he went back to football for the rest of that season and the next one (although he has since retired). As a matter of fact, most asds are found by accident or on post for unrelated issues, since the left-to-right shunt doesn't do much harm unless it's so huge that you get bad pulmonary hypertension and capillary bed damage (seen in single ventricle, for example).

A pulmonary embolus is dangerous for two reasons, and they depend on its size. We're going to worry about bigger ones. They close off a portion of the lung, so that part of the lung is no longer able to participate in gas exchange. If there's enough lung taken off the job that way, your person will die of hypoxia.

Another problem a large clot or shower of a lot of clot causes is that it obstructs blood flow through the lung tissue and makes the work load of the right ventricle a lot higher. Rvs aren't as strong as lvs-- as a matter of fact, normal rv systolic pressure is in the 20s-30s; compare that to normal lv systolic pressure, which you read with a blood pressure cuff and stethoscope at around 120+.

So an rv that's suddenly trying to push against a lot of resistance is going to fail, and that is the third serious problem a lot of clot in the lungs can cause: it will kill you partly because the lv will now not be seeing very much blood to pump out to the body.

So, the answer to the question is to maximize respiratory function as fast as you can, which is to sit that person bolt upright. If he has a prn oxygen order, then you slap it on. The question does not tell you he has a prn order, so for purposes of this discussion, he doesn't. In that case, you stay with him and get someone else to call for an o2 order (and a lot of other stuff).