Case Study: Pathophysiology, Diagnosis, and Management of PE

This case study focuses on a 60-year-old female patient admitted to the medical-surgical unit with altered consciousness, shortness of breath, and tachycardia, diagnosed with a deep vein thrombosis (DVT) leading to pulmonary embolism (PE) and obstructive shock. The document details the pathophysiology of PE, which involves a blood clot blocking a pulmonary artery, leading to impaired blood circulation, ventilation-perfusion mismatch, and potential right ventricle failure. The patient's presentation, including signs and symptoms of shock (shortness of breath, altered mental status, tachycardia, low blood pressure, and abnormal lab values) are examined. The diagnostic procedure, echocardiography, and anticipated medical interventions like surgery, fluid administration, and vasopressor administration (epinephrine, dopamine) are outlined. The case study also highlights nursing interventions, including fluid administration, vital sign monitoring, medication administration, and patient preparation for surgery, providing a comprehensive overview of the patient's condition and management.

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1. Pathophysiology of pulmonary embolism
Pulmonary embolism is a condition which occurs when a blood clot or emboli especially
originating from lower extremities or the pelvic region mainly due to VTE, block an artery in the
lung especially at the bifurcation or where arteries branch, therefore, blocking the blood supply
to that area. The clot can also originate from the upper extremities but rarely. Pulmonary
embolism occurs when a clot or emboli detach and enters the pulmonary circulation (Giordano et
al. 2017). This emboli cause vascular occlusion and therefore, impaired blood circulation.
Bilateral lung involvement is usually the most common type. The lower lung lobes are more
affected than the upper ones. Large emboli usually occlude the main pulmonary artery while
small ones occlude peripheral arteries causing pulmonary infarction. Once the arteries are
occluded, a dead ventilation space is created as the alveolar ventilation exceeds pulmonary
capillary blood flow. There is an increase in pulmonary vascular resistance with occlusion of the
arteries, therefore, causing ventilation-perfusion mismatch (Turetz et al. 2018).
In addition, vasoconstriction can occur in the unaffected areas of the lung triggered by
vasoconstriction mediators such as thromboxane and serotonin released from activated platelets.
This further impairs blood circulation in the lungs. An increase in pulmonary artery systolic
pressure causes right ventricle failure due to increased right ventricle afterload. This
consequently impairs left ventricular refill as time progresses. This can lead to hypoperfusion,
myocardial ischemia, shock and even death. Pulmonary embolism usually presents with dyspnea,
shock, hypoxemia and tachycardia (Simonneau et al., 2017). Pulmonary embolism causes an
obstructive type of shock. This is because the emboli block the arteries supplying blood, and
therefore blood does not reach the required places in the lungs or heart. Pressure increase also

affects circulation and end up causing ventricular failure hence decreased cardiac output which
eventually leads to shock (Prakash, Badheka and Allareddy 2018).
2. Signs and symptoms of shock
The signs and symptoms of shock from the case scenario include: shortness of breath and
increase or high respiratory rate of 21 breaths per minute (normal 12-16 breaths/min), low blood
pressure of 100/76 mmHg (normal 120/80mmHg- 140/90 mmHg), low pulse pressure of 36
mmHg (normal 40-60 mmHg) and increased heart rate (tachycardia) of 128 bpm (normal 60-100
bpm). The patient also has a high mean arterial pressure (MAP) of 118 mmHg (normal 70-100
mmHg) and decreased level of consciousness, the patient responds to a pain stimulus (de Souza
et al. 2018).
3. Diagnostic procedure/test.
The physician will order for echocardiography in order to identify the cause of shock
resulting from a pulmonary embolism. Echocardiography is a test which used sound waves to
produce live images of the heart. It is used to detect abnormalities in the heart like blood clots,
fluid in the air sacs or aortic abnormalities. The echocardiogram will enable the physician to
locate where the emboli are located in order for an appropriate intervention to be put in place,
such as surgery (Nagueh et al. 2016).
4. Medical interventions
According to Kim (2018), the main treatment of obstructive shock is eliminating the cause
of obstruction. Surgery is mainly done to remove emboli or a blood clot blocking the artery.
Emergency surgery has to be done in order to restore blood flow as soon as possible before organ

failure occurs. Open heart surgery can be done to remove the emboli. Therefore it is anticipated
that the physician will call for emergency surgery after diagnosis.
Another anticipated medical intervention is fluid administration to restore normal blood
pressure. Fluid given should be monitored to avoid cardiac overload. Fluid commonly used is
normal saline or ringers lactate. This will help raise blood pressure as other tests are being
performed (Marik and Weinmann 219). Another intervention is the administration of epinephrine
or non-epinephrine and dopamine. These drugs help to increase blood pressure increases blood
flow to body organs in order to prevent organ failure (Sadleir, Clarke, Lim and Platt 2018).
It is also anticipated that drugs such as nifedipine will be stopped or the dosage and
frequency reviewed to prevent further decrease in blood pressure as nifedipine is an
antihypertensive drug (Botta et al. 2018).
5. Nursing intervention
The nurse will administer fluids to the patient, preferably normal saline or ringers lactate, to
increase blood pressure. Increase in fluid volume increases blood pressure and thus increased
blood flow to body organs, especially body organs such as the brain and this prevents organ
failure.
The nurse will monitor fluid administration using a fluid chart and monitoring vital signs to
ensure that the normal range is achieved and any changes in the patient's state are identified early
and appropriate interventions implemented (Truong et al. 2019).

The nurse will also administer the drugs prescribed and monitor the patient for any potential
effects or changes in condition. The nurse will also continue monitoring the patient's mental
status using a glass cow coma scale (GCS) to detect any changes.
The nurse will also prepare the patient for surgery, making sure all parameters required
before surgery are available.

Reference
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