Risk Stratification of a Pulmonary Embolism: What You Need to Know and Why
- In this course we will learn how to risk stratify patients presenting with pulmonary embolisms (PE).
- You’ll also learn the basics of both modifiable and non-modifiable risk factors for patients developing PEs.
- You’ll leave this course with a broader understanding of PE, deep vein thrombosis (DVT), and venous thromboembolism (VTE).
Contact Hours Awarded: 1.5
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The following course content
What’s lurking behind those deep veins? Does knowing a patient’s risk for getting a pulmonary embolism (PE) after surgery save lives? Absolutely it does. But it is better than that. Risk stratification equips healthcare providers with the precise tools to target the kind of care a patient needs to reach a positive outcome. Now, while it is true that doctors are the ones who utilize the classification of risk for PE‘s among their patients most of the time, being aware of the patient‘s comorbidities is the nurse‘s job as well. One of the first things you do when receiving your patient assignment is to review the patient’s past medical history. This course will explain how important it is to gather as much information as possible, especially for the operative patient’s health and well-being.
While having the right tools to provide optimum care is at the top of the list in healthcare, utilizing the right resources is equally important to global health management. Before the COVID-19 pandemic, venous thromboembolism (VTE) was the global leading cause of death and disability (4). Just think about the burden that places on healthcare. If we, as nurses, will make even the smallest of impacts on our patient’s safety and well-being, then we must equip ourselves with knowledge; the kind of knowledge that contributes to positive patient outcomes.
You may be asking yourself, “how does all this information affect me, the nurse?” Nurses are the educators. Therefore, this course is designed to highlight necessary skills to re-educate and/or refresh those skills that help identify PEs after surgery. Most importantly, however, is educating our patients to manage their own health effectively.
Another main constant regarding risk stratification of a PE after surgery is the patient‘s personal risk factors. Some of the major dynamics include age, a healed tibia fracture, advanced cancers, and a C-section (2, 5).
Some of the minor undercurrents of getting a PE after surgery include sitting on a plane for eight hours, being overweight and taking birth control (2). With those kinds of patient-associated risks, who isn‘t at risk for getting a PE? We will discuss this idea more in-depth later.
What questions would you ask a pre-op patient?
Why is it important to get the complete history and physical of a pre-op patient?
Why is it important to get a complete list of current medications in a pre-op patient?
Can you name at least five people who live with or experienced any of these health-related issues?
If a family member were going in for an elective surgery, what would you tell them about what you know about the risks associated with PEs?
Global Implications: PE is One of the Leading Causes of Death
The study of the origins of a PE date back to the 19th century. Since then, scientists have been making correlations between trauma within the body, the body‘s fragile vasculature, and the obstacles within the vessels that carry blood (3,5).
There are dozens of worldwide cardiological societies that categorize risk for a PE. And they all use different methods, systems, and techniques to categorize the risks for developing a blood clot-related disease. Patients may present with a deep vein thrombosis (DVT) or PE. And while the United States does not have a current tracking system for DVTs and PEs, it is estimated that blood clots are the leading cause of death and disability for close to a million patients worldwide (1,5,6).
Do you think the global statistics about PEs have increased with the arrival of Coronavirus?
What are the commonalities between PEs and COVID-19?
Risk Factors for PEs
There are many variables for a patient developing a PE, including modifiable and non-modifiable risk factors.
Modifiable Risk Factors (5)
Non-modifiable Risk Factors (5)
Do you have one or more family members who have one or more of either the modifiable or non-modifiable factors for PE?
How do you think taking estrogen affects lung function?
What Does a DVT Look and Feel Like?
If you have ever cared for a post-operative patient, you know that most DVTs are found in the lower extremities. However, upper extremity DVTs also exist and hold the potential to be more fatal, especially if they camp out near major veins. Patients may also have complaints of minimal soreness or pain in their lower extremities, with or without redness.
Other signs and symptoms of a DVT/PE include increased swelling in one or more of the limbs, any unusual numbness or tingling in any one of the patient’s extremities, anxiety, pleuritic chest pain, palpitations, wheezing, and even coughing up blood (5).
As part of your practice, do you usually write down D-dimer results? If so, what are the normal levels?
What is the highest level of D-dimer you have seen?
What other body processes are D-dimers used to diagnose?
Why is home health and after care management so important in patients going home with a DVT?
PE/VTE Management & Treatment
Management of the patient with a DVT or PE will depend on where the blood clot is and its size.
It is typically assumed that the larger the clot, the more dangerous. Without getting too technical, different screening tools are utilized, and what is great about them is that they are effective in streamlining therapy (5,8). Currently, the best practices for a PE/VTE are based on what phase of treatment is needed.
Typically, newly diagnosed patients are started on Coumadin (otherwise known as, Warfarin). Once therapy has begun, doctors will place patients on low molecular weight heparin given subcutaneously. If D-dimer levels are high, patients are placed on a heparin drip.
Anticoagulants are an additional form of therapy that is commonly utilized; Xarelto and Eliquis have been shown to significantly reduce the risk of developing a DVT/PE (5, 10).
Diagnosis and treatment forms:
- D-dimer: May be used to determine the presence of a blood clot. * This test is mostly used to rule out the presence of a blood clot and not to definitively diagnose.
- Ultrasound and CT scan is the preferred and most accurate way to determine the presence of a VTE/PE.
*Typically, when the Ultrasound or CT is positive for PE, healthcare providers would begin patients on anticoagulation therapy if it not contraindicated (1,5,7).
What are three examples of anticoagulation therapy in your hospital or doctor‘s office?
Why is it important to get coagulation labs on patients?
How might an issue like mental illness, let‘s say depression, for example, affect a patient with a DVT?
So, what can we teach our patients about managing a DVT or PE? One of the most important, underestimated feats we can teach them is to stay hydrated.
Next is the importance of medication compliance. Being consistent with medication intake is so important across all aspects of healthcare management.
Additionally, we need to teach the importance of staying active and monitoring for signs of bleeding while on anticoagulation therapy, such as being short of breath, feeling dizzy, and any unusual bruising (5).
What are five signs of bleeding while on blood thinners?
What role does a tele-health nurse play in medication compliance?
How important are social workers and home health nurses in the care management team of patients with DVT’s/PE’s?
References + Disclaimer
- Atallah, J., Shah, S., Toy, D., Dodelzon, K., & Schweitzer, A. D. (2021). The importance of imaging – Perspectives from redeployment. Clinical imaging, 69, 380–383. https://www.clinicalimaging.org/article/S0899-7071(20)30386-7/fulltext
- Bĕlohlávek, J., Dytrych, V., & Linhart, A. (2013). Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism. Experimental and clinical cardiology, 18(2), 129–138.
- Jancin, B. (2020). Risk stratification key in acute pulmonary embolism. The Hospitalist presented by shm. Retrieved from https://www.the-hospitalist.org/hospitalist/article/227014/pulmonology/risk-stratification-key-acute-pulmonary-embolism
- Raja, A. S., Greenberg, J. O., Qaseem, A., Denberg, T. D., Fitterman, N., Schuur, J. D., & Clinical Guidelines Committee of the American College of Physicians (2015). Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Annals of internal medicine, 163(9), 701–711. https://doi.org/10.7326/M14-1772
- Risk stratification action guide (2019). Value transformation framework. National Association of Community Health Centers. https://www.nachc.org/wp-content/uploads/2019/03/Risk-Stratification-Action-Guide-Mar-2019.pdf
- Roberts, S.H., & Lawrence, S.M. (2017) Venous thromboembolism updated management guidelines. American Journal of Nursing, 117, 38-47. doi:10.1097/01.NAJ.0000516249.54064.53
- Shashank, A. (2017). The Importance of Risk Stratification in Population Health Management. https://hitconsultant.net/2017/03/13/risk-stratification-population-health-management/#.YCmQTGhKjIU
- Sista, A. K., Kuo, W. T., Schiebler, M., & Madoff, D. C. (2017). Stratification, Imaging, and Management of Acute Massive and Submassive Pulmonary Embolism. Radiology, 284(1), 5–24. https://doi.org/10.1148/radiol.2017151978
- Tak, T., Karturi, S., Sharma, U., Eckstein, L., Poterucha, J. T., & Sandoval, Y. (2019). Acute Pulmonary Embolism: Contemporary Approach to Diagnosis, Risk-Stratification, and Management. The International journal of angiology : official publication of the International College of Angiology, Inc, 28(2), 100–111. https://doi.org/10.1055/s-0039-1692636
- Wilbur, J., & Shian, B. (2017). Deep Venous Thrombosis and Pulmonary Embolism: Current Therapy. Am Fam Physician. 2017 Mar 1;95(5):295-302.
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