3emboli paru = Pulmonary emboli (PE) Sumbatan arteri pulmoner atau salah satu cabangnya oleh trombus atau benda asingPenyebab sumbatan gumpalan darah/trombus, droplet-droplet lemak, gelembung udara, tumorBerpotensi menimbulkan infark paru
4FAKTOR PREDISPOSISI Imobilitas Bedah mayor Stroke Keganasan, kemoterapiFraktur tungkai atau pelvisObesitasKateterisasi vena sentralKontrasepsi oralLuka bakarTriad virchow: hiperkoagulasi, perubahan hemodinamik, cedera /disfungsi endotel trombosisPredisposisi genetik untuk trombosis venaPerokokTerapi HormonSedang hamilHipertensiPenyakit cardiovaskulerResistensi terhadap protein C (inability of protein C to cleave Factor Va and/or Factor VIIIa, which allows for longer duration of thrombin generation and may lead to a hypercoagulable state)Faktor V leiden penyakit turunan hiperkoagulasiStres
6TANDA DAN GEJALA Dispneu Nyeri dada Batuk Hemoptisis Ansietas Sinkope HipotensiSianosisDenyut nadi lemahKulit dingin dan berkeringatMengi
7pathophysiologyThree primary influences predispose a patient to thrombus formation Virchow triad (Endothelial injury, Stasis or turbulence of blood flow, Blood hypercoagulability)Pulmonary emboli (PE) usually arise from thrombi originating in the deep venous system of the lower extremities; however, they may rarely originate in the pelvic, renal, or upper extremity veins or the right heart chambers.After traveling to the lung, large thrombi can lodge at the bifurcation of the main pulmonary artery or the lobar branches and cause hemodynamic compromise.Smaller thrombi typically travel more distally, occluding smaller vessels in the lung periphery. These are more likely to produce pleuritic chest pain by initiating an inflammatory response adjacent to the parietal pleura.Most pulmonary emboli are multiple, and the lower lobes are involved more commonly than the upper lobes.
11The risk of developing a pulmonary embolism is increased in these individuals: Hypercoagulable states Concomitant hypercoagulability may be present in disease states where prolonged venous stasis or injury to veins occurs. Factor V Leiden mutation causing resistance to activated protein C is the most common risk factor. Primary or acquired deficiencies in protein C, protein S, and antithrombin III are other risk factors.Venous stasis increased viscosity may occur due to polycythemia and dehydration, immobility, raised venous pressure in cardiac failure, or compression of a vein by a tumorImmobilization Immobilization leads to local venous stasis by accumulation of clotting factors and fibrin, resulting in thrombus formation. The risk of pulmonary embolism increases with prolonged bed rest or immobilization of a limb in a cast. Immobilization (usually because of surgery) was the risk factor most commonly found in patients with pulmonary embolism.
12Surgery and trauma Surgical and accidental traumas predispose patients to venous thromboembolism by activating clotting factors and causing immobility.Malignancy Pulmonary emboli have been reported to occur in association with solid tumors, leukemias, and lymphomas.PregnancyOral contraceptives and estrogen replacementHereditary factors antithrombin III deficiency, protein C deficiency, Protein S deficiency, Factor V Leiden, Plasminogen abnormality, Plasminogen activator abnormality, Fibrinogen abnormality, Resistance to activated protein CAcute medical illness AIDS (lupus anticoagulant), Congestive heart failure (CHF), Myocardial infarction
13Hemodynamic consequences Respiratory consequencesAcute respiratory consequences of pulmonary embolism include: increased alveolar dead space, hypoxemia, hyperventilationAdditional consequences that may occur include regional loss of surfactant and pulmonary infarction.Arterial hypoxemia is a frequent, but not universal, finding in patients with acute embolism.Pulmonary infarction is an uncommon consequence because of the bronchial arterial collateral circulation.Hemodynamic consequencesPulmonary embolism reduces the cross-sectional area (luas penampang) of the pulmonary vascular bed, resulting in an increment (kenaikan) in pulmonary vascular resistance, which, in turn, increases the right ventricular afterload.If the afterload is increased severely, right ventricular failure may ensue.
14PVR: pulmonary vascular resistance, RV: right ventricle, LV: left ventricle
17PEMERIKSAAN PENUNJANG Gas darah arteri menurunnya kadar pO2 akibat ventilasi yang berkurang.Plasma D dimer (uji sampel darah utk diagnosa penyakit terkait hiperkoagulabilitas) meningkat (>500ng/ml) pada 97% pasien emboli pulmonalD dimer fragmen D-dimer/ fibrin degradation fragmentEKG biasanya minor, tidak spesifik, sifat sementaraFoto thorax dpt memberi kesan normal atau minimal, bisa ditemukan pembesaran arteri pulmonal yang semakin bertambahScan ventilasi/perfusi paruAngiografi pulmonar dapat menunjukan diagnosa definitif bahkan pada emboli berukuran kecil (1-2 mm)CT scan angiografi sensitivitas dan spesifitas tinggi untuk emboli paru di arteri besar dan arteri lobarisUSG dopler non invasif, trombosis vena dalam
19PROGNOSISBerhubungan dengan penyakit yang mendasari
20DIAGNOSA KEPERAWATANImpaired gas exchange related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolusIneffective tissue perfusion related to impaired transport of oxygen across alveolar and/or capillary membraneDeficient knowledge (treatment regimen) related to complex disorder and therapyRisk for injury related to thrombolytic or anticoagulant therapyOther potential nursing diagnoses: Anxiety related to change in health status
21impaired gas exchange related to decrease pulmonary perfusion associated with obstruction of pulmonary arterial blood flow by the embolusExpected OutcomePatient maintains optimal gas exchange as evidenced by: Normal arterial blood gases (ABGs), Pulse oximetry results within normal range, Usual mental status, Normal respiration rate.Suggested NOC OutcomesElectrolyte & acid-base balance; Respiratory status: Gas exchange; Respiratory status: Ventilation; Tissue perfusion: Pulmonary; Vital signsSuggested NIC LabelsAirway ManagementOxygen TherapyRespiratory MonitoringAcid-Base Management
22interventionsAssess respirations: note quality, rate, pattern, depth, and breathing effort.Assess lung sounds, noting areas of decreased ventilation and the presence of adventitious sounds.Assess for signs and symptoms of hypoxemia: tachycardia, restlessness, diaphoresis, headache, lethargy, and confusion.Assess for signs or symptoms of pulmonary infarction: cough, hemoptysis, pleuritic pain, consolidation, pleural effusion, bronchial breathing, pleural friction rub, fever.Monitor vital signs.Assess for changes in orientation and behavior.Monitor arterial blood gases (ABGs) and note changes.Use pulse oximetry to monitor O2 saturation and pulse rate continuouslyAssess skin color for development of cyanosis
23Maintain oxygen administration device as ordered, attempting to maintain O2 saturation at 90% or greater.Position with proper body alignment for optimal respiratory excursionPosition patient to facilitate ventilation/perfusion matching. Use upright, high Fowler's position whenever possible.Pace activities and schedule rest periods to prevent fatigueEncourage deep breathing, using incentive spirometer as indicated.Administer medications as prescribed.
24Ineffective tissue perfusion DESIRED OUTCOMESThe client will maintain adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and the absence of respiratory distressNOC OUTCOMESCirculation status; tissue perfusion: abdominal organs; tissue perfusion: cardiac; tissue perfusion: cerebral; tissue perfusion: peripheral; tissue perfusion: pulmonaryNIC INTERVENTIONSCirculatory care: arterial insufficiency; circulatory care: venous insufficiency; cerebral perfusion promotion; cardiac care: acute, Hemodynamic Regulation, Embolus care, Neurological Monitoring
25interventions Monitior signs of tissue perfusion adequacy. Note skin color and feel temperature of the skinMonitor peripheral pulses. Note the decrease in pulseCheck capillary refill.Monitor neurological status
26Risk for injury related to thrombolytic or anticoagulant therapy EXPECTED OUTCOMEThe patient will remain free of unusual bleedingThe patient will display no signs of recurrent embolySuggested NOC OutcomesMedication response; Risk control
27InterventionsMonitor for bleeding. Check color of urine, occult blood in stool, and/or changes in vital signs. (Patients with history of peptic ulcer disease, alcoholism, kidney or liver disease, and the elderly are at greatest risk for bleeding)Monitor vital signs. (Increase in heart rate accompanied by low blood pressure or subnormal temperature may signal bleeding.Monitor laboratory values: aPTT and PTT for therapeutic values.Monitor CBC in female patients who are menstruating. (Anticoagulation may cause excessive blood loss during menses.)EvaluationEvaluate effectiveness of drug therapy by confirming that the patient goals and expected outcomes have been met.The client’s laboratory values exhibit a decrease in blood coagulation.
28Deficient knowledge (treatment regimen) related to complex disorder and therapy EXPECTED OUTCOMEThe patient and family will describe the action, dosage, frequency, and adverse effects of the prescribed anticoagulant; activities that can cause or prevent clot formation; and safety considerations while the patient is on anticoagulant therapy.Suggested NOC OutcomesKnowledge: Treatment regimen
30EDEMA PULMONAL Peningkatan jumlah cairan yang berlebihan di alveoli Pulmonary edema an accumulation of fluid in the alveoli and interstitial spaces of the lungsMengganggu difusi oksigenBisa menyebabkan gagal nafasEdema paru kardiogenik disebabkan oleh peningkatan tekanan di dalam pembuluh darah paru akibat buruknya fungsi jantung pada gagal jantung kongestif, infark miokard, kelainan katup.Edema paru non-kardiogenik disebabkan oleh faktor-faktor lain, seperti gagal ginjal, latihan fisik di ketinggian, trauma dada, kerusakan jaringan paruTekanan darah pulmonal > 15 mmHg edema pulmonal
31Cardiogenic :Congestive heart failurePericardial effusion with tamponadeSevere arrhythmias (tachycardia/fast heartbeat or bradycardia/slow heartbeat)Severe heart attack with left ventricular failure
36TANDA DAN GEJALACoughing and restlessness during sleep (premonitory symptoms).Sudden onset of dyspnea.Severe anxiety, restlessness, irritability.Cool, moist skin.TachycardiaOrthopneaParoxysmal nocturnal dyspneaDistended Jugular veinsWheezingNoisy, wet respirations that do not clear with coughing.Cough with Frothy, blood-tinged sputum.
37DiagnosticOxymetry or ABG ValuesChest X-ray (may reveal fluid in/around lung space or enlarged heart)Echocardiogram to detect valvular diseaseMeasurement of pulmonary artery wedge pressure by swan ganz catheterBlood culture in suspected infectionCardiac markers in suspected MI
38PENATALAKSANAAN Meningkatkan fungsi respirasi Mengatasi penyebab OksigenasiMedikasi
39EDEMA PULMO - CONGESTIVE HEART FAILURE therapy Diuretics, which remove excess fluids from the bodyMedicines to strengthen the heart muscle, control the heartbeat, or relieve pressure on the heartContractility enhancement therapy (digoxin [Lanoxin], dopamine [Intropin], dobutamine [Dobutrex] improves the ability of the heart muscle to pump more effectively, allowing for complete emptying of blood from the ventricle and a subsequent decrease in fluid backing up into the lungs.
40complications of pulmonary edema DysrhythmiaRespiratory failure
41DIAGNOSA KEPERAWATANIneffective breathing pattern related to pulmonary edema.Impaired gas exchange related to excess fluid in the lungs.Ineffective tissue perfusion related to decreased cardiac muscle contractility.Anxiety related to sensation of suffocation and fear.
42Ineffective breathing pattern related to pulmonary edema Desired OutcomePatient's breathing pattern is maintained as evidenced by: eupnea, normal skin color, and regular respiratory rate/patternSuggested NOC OutcomesRespiratory Status: Airway PatencyRespiratory Status: VentilationRespiratory Status: Gas ExchangeVital Sign StatusSuggested NIC InterventionsAirway Management;Oxygen therapy;Respiratory MonitoringProgressive Muscle Relaxation;Anxiety Reduction;
43Intervention Assess respiratory rate and depth Assess for dyspnea and quantifyMonitor breathing patternsNote muscles used for breathingMonitor for diaphragmatic muscle fatigueAssess position patient assumes for normal or easy breathingUse pulse oximetry to monitor O2 saturation and pulse rateMonitor ABGs as appropriate; note changesMonitor for changes in orientation, increased restlessness, anxiety, and air hunger
44Position patient with proper body alignment for optimal breathing pattern Encourage sustained deep breathsAdminister oxygen, as ordered, to maintain an acceptable level of oxygen at the tissue level.Suction airway as needed to maintain patent airways.Assist patient to Fowler’s position, which will promote expansion of lungs and provide comfort.Assist patient with ADLs as needed to conserve energy and avoid overexertion.
46COR PULMONALCor Pulmonal (CP): hipertrofi dan atau dilatasi dari ventrikel kanan akibat hipertensi (arteri) pulmonal yang disebabkan oleh penyakit intrinsik dari parenkim paru, dinding thoraks, maupun vaskuler paru.Dikenal juga sebagai Pulmonary Heart Disease (PHD) pelebaran ventrikel kanan sebagai respon terhadap peningkatan resistensi atau hipertensi pulmonalHarus dibedakan dengan penyebab lain dari hipertropi ventrikel kanan seperti stenosis mitral, kelainan jantung bawaan, gagal jantung kiri.Cor pulmonal dapat bersifat akut akibat emboli paru yang pasif, dapat juga kronis
51PATOFISIOLOGI Vasokontriksi pulmonal Perubahan anatomi vaskuler paru Peningkatan viskositas darahIdiopatik atau hipertensi pulmonal primer
52pathophysiologyLung disorders cause pulmonary hypertension by several mechanisms: *Loss of capillary beds (eg, due to bullous changes in COPD or thrombosis in pulmonary embolism *Vasoconstriction caused by hypoxia, hypercapnia, or both Pulmonary hypertension increases afterload on the RV (right ventricle) resulting elevated end-diastolic and central venous pressure and ventricular hypertrophy and dilation. Demands on the RV may be intensified by increased blood viscosity due to hypoxia-induced polycythemia. Rarely, RV failure affects the LV if a dysfunctional septum bulges into the LV, interfering with filling and thus causing diastolic dysfunction.
58DIAGNOSISRontgen dada Hipertropi ventrikel kanan, dilatasi atrium kanan, paru perifer menunjukan penurunan vaskuler.EKG bisa didapatkan gambaran hipertropi ventrikel kanan-deviasi aksis ke kanan, Gelombang R menonjol di V1 dan T inversi di lead precordial, S melebar di lead I II III, Q melebar di lead III, P pulmonal lead II, III, aVF, Q lebar di lead IIIEchocardiogram dilatasi ventrikel kanan, regurgitasi katup trikusidalis
60Cor pulmonale Gagal jantung kongestif edema pulmonal, edema perifer Inotropik Meningkatkan kontaktilitas jantungOksigenasiBronkodilatorAgen mukolitikMedikasi untuk mencegah penjendalan darah
61NURSING DIAGNOSISDecreased cardiac output related to an ineffective ventricular pumpDesired Outcome: patient demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest painSuggested NOC OUTCOMES. Cardiac pump: Effectiveness; Circulation status; Tissue perfusion: Abdominal organs and peripheral; Vital sign status; Energy conservation; Fluid balanceINTERVENTIONS. Cardiac care; Circulatory care: Mechanical assist device; Fluid/electrolyte management; Medication administration; Medication management; Oxygen therapy; Vital signs monitoring
62INTERVENTIONSAssess restlessnessAssess heart rate and blood pressure.Assess skin color and temperature.Assess peripheral pulses.Assess fluid balance and weight gain.Assess heart sounds, noting gallops, S3, S4. S3 denotes reduced left ventricular ejection and is a classic sign of left ventricular failure.Assess lung sounds.Determine any occurrence of paroxysmal nocturnal dyspnea (PND) or orthopnea.Monitor continuous ECG as appropriate.Assess response to increased activity.Assess urine output.Assess for chest pain.
63Administer medication as prescribed, noting response and watching for side effects and toxicity. Maintain optimal fluid balance.Maintain hemodynamic parameters at prescribed levels.Maintain adequate ventilation and perfusionPlace patient in semi- to high-Fowler’s position.Administer humidified oxygen as ordered.Maintain physical and emotional rest, as in the following: o Restrict activity. This reduces oxygen demands. o Provide quiet, relaxed environment. Emotional stress increases cardiac demands. o Organize nursing and medical care. This allows rest periods. o Monitor progressive activity within limits of cardiac function.
64Case 1A 65 year old female presents to your floor from the ER. The patient is admitted for dyspnea. You note that the patient presents with extreme dyspnea on activity, especially during ambulation. The patient’s O2 saturation drops during activity to 82% on room air. The patient oxygen saturation is 88-89% while resting. You place the patient on 2L nasal cannula. The patient states she does not wear any oxygen at home. She states she started feeling very short of breath and having “chest like pain” on inspiration ever since she got back from her trip from China which was 2 days ago. She said she thought it was pneumonia but she hasn’t been coughing up anything. Patient’s history includes: Breast Cancer 2000, double mastectomy 2001, Appendectomy 1983, Rhinoplasty VS: HR 105, BP 115/82, O2 Saturation 93% 2L nasal cannula, Temp. 98.6, RR 21, pain 2 on scale. D-Dimer 920, Troponin Pt had a CT scan with PE protocol performed before arrival to your floor and the results showed positive for Pulmonary Embolism. Pt is started on Lovenox 1mg/kg BID subq and Coumadin 5mg PO daily.