Description

Create a response to the discussion bellow by Sheimeka in NU623 APA style 

Pulmonary Embolism

Presenting/associated symptoms

The classic presentation of pulmonary embolism (PE) is the sudden onset of shortness of breath, pleuritic chest pain, and hypoxia. Nevertheless, most patients don’t have apparent symptoms initially. Symptoms can fluctuate from sudden hemodynamic collapse to progressive dyspnea (Quellette, 2019).

Signs of pulmonary embolism include the following:

• Tachypnea (respiratory rate >16/min)
• Rales
• Accentuated second heart sound
• Tachycardia (heart rate >100/min)
• Fever (temperature >37.8°C [100.04°F])
• Diaphoresis
• S₃or S₄ gallop (Ouellette, 2019)

Specific diagnostic tests used in the workup

Wells clinical prediction rule was created to decrease the use of venography which is an invasive test for DVT. The criteria consist of 8 components with a probability score between 0 and 8. This test is useful in predicting pretest probability based on assessing risk factors and physical findings before any diagnostic testing (Uphold, & Graham, 2013).

Diagnostic testing should be implemented on symptomatic patients with probable pulmonary embolism to confirm the diagnosis. The provider should complete a hypercoagulation workup if no distinct origin for an embolic disease is apparent.

Laboratory tests that should be done include:

• D-dimer testing
• Ischemia-modified albumin level
• White blood cell count
• Arterial blood gases:
• Serum troponin levels
• Brain natriuretic peptide (Ouellette, 2019)

Imaging studies that assist in the diagnosis of pulmonary embolism include:

• Computed tomography angiography (CTA):
• Pulmonary angiography:
• Chest radiography:
• V/Q scanning (Quellette, 2019)

Treatment plan using 1st line therapeutic interventions, patient education and follow up expectations

The majority of patients with acute PE should receive LMWH or fondaparinux instead of IV Unfractionated heparin therapy (UFH).   IV UFH is recommended as the initial type of anticoagulation, if the patient has severe renal failure, or if thrombolytic therapy is a possibility.  LMWH given once-daily is endorsed over twice-daily regimens. Instead of giving warfarin, Apixaban, dabigatran, rivaroxaban, and edoxaban are alternatives for prophylaxis and treatment of PE. 

A vitamin K antagonist should be started on the same day as an anticoagulant. A patient with only one thromboembolic event should receive warfarin therapy for at least 3 months. Other interventions include early ambulation, utilizing graduated compression stockings. Long-term anticoagulation is critical to the prevention of recurrence DVT or pulmonary embolism. The patient should follow up with the vascular specialist.

Support whether or not you would refer the patient to another health care provider for treatment. Include the name of the specialty and your rationale for the referral.

A referral to a specialist in vascular medicine and coagulation disorders is recommended for pulmonary embolism (Uphold, & Graham, 2013). Vascular specialist are trained to manage vascular issues which include stroke, PAD, CAD, AAA, PE, DVD, and several other diseases. A hematologist is trained to diagnose and treat diseases of the blood. A Hematologist would recommend a workup for a procoagulant defect and can suggest a pertinent anticoagulation regimen (Uphold, & Graham, 2013).

Uphold, C. R., & Graham, M. V. (2013). Clinical guidelines in family practice (5th ed.). Gainesville, FL: Barmarrae Books.