Question

Documentation for Rachael Heidebrink

• 1. Document your initial assessment data of Rachael Heidebrink, including signs and symptoms related to pulmonary embolism, heparin infusion, and vital signs.
• 2. Document the heparin infusion, including rate change.
• 3. Document the patient education you provided to Rachael Heidebrink during this scenario related to the heparin infusion.
• 4. Document the dose of warfarin you gave in this scenario.
• 5. Document the patient education you provided to Rachael Heidebrink during this scenario related to the warfarin.
• 6. Document any repeat assessments done during this scenario

Answer 1

1) Initial assessment of pulmonary embolism --

A. Assess the patency of the airway -- Patient should be fine

B. Assess the breathing -- Check respiratory rate, saturation, perform a respiratory examination.

• Patient with pulmonary embolism may be hypoxic, in this case, prescribe oxygen, the type of method and rate depends upon the extent of the condition.
• Palpate the chest, it can help exclude the other diagnosis.
• Percussion will tell the presence of pneumothorax or pleural effusion based on the consolidation.
• The presence of wheeze or crackles may imply acute heart failure which can be caused either by pulmonary embolus, asthma, infection.

C. Assess the hemodynamic stability via the pulse, BP, CRT.

Perform a full cardiovascular exam, looking for signs of pericarditis, an important differential diagnosis to exclude.

D. Check for disability --

• Check GCS
• Blood sugar level

E. Carry out the relevant exams --

• DVT in legs, calf tenderness
• The temperature of the body
•   ABG --

a) The result depends upon the size of the embolus.

b) The larger the PE, the lower PaO2.

c) A very large embolus may cause metabolic acidosis due to hypoxemia and anaerobic metabolism.

• Look out for infection signs, pneumonia.
• Blood test :

a) Clotting

b) FBC

c) CRP

• Chest X-ray --

a) Many times normal, but is great for excluding pleural effusions, consolidations, pneumothorax.

b) Fractures as it cause shortness of breath and chest pain

• ECG -- For looking out the heart condition, as PE causes dilation of the right atrium and right ventricle or right ventricular ischemia.
• CTPA -- Gold standard for checking PE.

Sign and Symptoms of PE --

1. Hemoptysis or regular cough
2. Pleuritic chest pain
3. Wheezing or whistling sound during auscultation
4. Leg swelling
5. Dyspnea
6. Orthopnea
7. Lightheadedness or low oxygen in the body
8. Palpitations

Heparin infusion -- As an anticoagulant therapy, to prevent the progression of DVT and to reduce the size and frequency of PE. It is rapid-acting because it stimulates antithrombin 3.

Prophylaxis of DVT -- 5000 units SC q8-12hr, or 7500 units SC q12hr

Treatment dose can vary, 1 example is here -- 80 units/kg IV bolus, then continuous infusion of 18 units/kg/hr.

There are 2 types of Heparin --

A) Unfractionated heparin

B) Low molecular weight heparin

• Enoxaparin
• Dalteparin

Vital signs --

Heart rate: Tachycardia: elevated heart rate

Respiratory rate: Tachypnea: elevated respiratory rate

Hypotension: decreased blood pressure / Hypotension can also be seen

Hypoxia: decreased SaO2

Dyspnoea: Difficulty breathing

Temperature: it can be seen as elevated as various changes are going on in the body.

Ans 2. Heparin infusion: It is done as an iv continuous infusion.

• 1st we have to set up their IV after it looks to the order, mostly the first part is to give bolus. The bolus is typically a large part of heparin, eg. 80 units/kg. We can calculate the amount of heparin by multiplying this 80 units times the patient's weight.
• After pooling the heparin into a syringe administer it through the patient's IV tubing, and it will get distributed throughout the patient's body.
• To offset the coagulation of blood as later sometimes heparin will be eliminated as it will be detected as a foreign thing by our body, the second part of IV heparin order will be given which is by a heparin drip. The value of this is 18units/kg/hour, it is in per hour meaning that it is an IV rate that we will set on the infusion pump. After calculating the correct rate of the infusion pump in mL/hr the infusion pump will add heparin to the patient's body. Mostly at the exact same rate as the body is eliminating heparin and once will restore the heparin level.
• To check if our calculation is correct and everything is right we will check the clotting time of the patient. So blood test for APTT will be done which is, activated partial thromboplastin time. Based on the result from this test we will change or keep the heparin dose.

Ans 3. Patient education to provide him during heparin infusion:

By providing him the background, the basics of what is heparin and how it works, and why it is being infused in his body needed. And to aware the patient that he should take care of himself and stay careful using sharp objects and let the medical staff know if any allergic reaction, pain, bleeding-like signs he sees.