1. No category

1.
2.
3.
4.
5.
Interpret the pathophysiology of the topic into fundamental concepts.
Identify pertinent nursing assessments.
Discuss diagnostic testing associated with the case.
Illustrate case study topic with clinical examples.
Identify appropriate nursing diagnoses in priority order.
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
Sandra James is a 32 y. o. female with a history of varicose
veins. She is a 5'2" and 150 lbs. Ms. James has two
children ages 6 and 4. Her current method of birth control
is oral contraceptives.
She is currently hospitalized following excision of internal
and external hemorrhoids. All other history is
insignificant.
Ms. James’post operative course is uneventful until the
second day when she complains of pain in her left calf. On
examination you find the calf swollen and warm to the
touch
L R. Homans sign is positive

You inform the primary physician and a doppler
flow study is performed. The results reveal a left
popliteal deep vein thrombosis.


Ms. James is placed on bed rest and
anticoagulation therapy via a continuous heparin
infusion. She does well on heparin for 2 days
after which she begins to c/o shortness of breath
and left anteior chest pain that worsens with
deep inspiration. She is restless and afraid and
says, “Am I going to die?”
Physical assessment reveals the following:





BP
HR
Resp
Temp
160/88
120
34 and labored
99EF
A stat chest x-ray showed left lower lobe
atelectasis. Ms. James is started on O2 via
nasal cannula at 4 liters/min and an arterial
blood gas is drawn. The following results are
obtained:




PH
PaCO2
PaO2
SaO2
7.52 ↑
28 ↑
131
99%
A ventilation perfusion scan performed that afternoon
reveals perfusion defects of the anterior and
posterior segments of the left upper lobe. Ventilation
is normal, and a pulmonary embolus (PE) is
suspected. Ms. James is scheduled for a pulmonary
angiogram the next morning.



On the morning of the scheduled angiogram, Ms.
James PT and PTT are as follows:
PT
Control
INR
16.7 sec.
1.7 sec.
PTT 46.9 sec.
Control
25.3 sec.
The angiogram is postponed pending reversal of
the anticoagulation.
Several hours later, Ms. James exhibits
tachycardia, diaphoresis, and cyanosis. Her SaO2,
which is being monitored by pulse oximeter,
drops to 81%. She is placed on a
100%nonrebreathing mask. An ABG is drawn
after 30 min., and the results are as follows:




pH
PaCO
PaO2
SaO2
7.48
30
45
81%
Ms. James is intubated and placed on a volume
ventilator. A moderate amount of blood-tinged
secretions are suctioned from her endotracheal
tube. A pulmonary angiogram done that day
reveals emboli in the left upper lobe lingular and
right main pulmonary arteries. Bilateral iliac vein
Greenfield filters are placed under fluoroscopy
and anticoagulation therapy is resumed. Once
the prothrombin times are in the therapeutic
range. Coumadin is started. Ms. James is
extubated 24 hr after the filters are placed and
the heparin is discontinued after 72 hr. She
makes steady progress and is discharged on
Coumadin therapy several days later.
1.
2.
3.
4.
Fat Emboli
Air Emboli
Amniotic Fluid Emboli
Thrombus (Clot Emboli)

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

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


Long term immobility
Oral contraceptive use
Estrogen therapy
Smoking
Hypercoagulability
Obesity
Surgery
Heart failure
Chronic Atrial fibrillation
Autoimmune hemolytic anemia (sickle cell)
Long bone fractures
Advanced age
1.
Fat Embolism:
circulatory condition
characterized by a plug of fat blocking an artery.
The plug enters the circulatory system after the
fracture of a long bone or traumatic injury to
adipose tissue or to a fatty liver. Fat emboli are the
result of the release of free fatty acids, causing a
toxic vasculitis, followed by thrombosis, and
obstruction of small pulmonary arteries by fat.
Usually occurs within 12-36hrs after an injury.
 Risk Factors
o multiple fractures
o Males
o Patients 10 – 39 years old
o Trauma to adipose tissue or liver
o Burns
o Osteomyelitis
o Sickle cell crisis
2. Air Embolism:
the abnormal presence of air in
the CV system resulting in obstruction of blood flow.
May occur if large quantity of air is inadvertently
introduced by injection (as during IV therapy or
surgery) or by trauma (puncture wound)
 Risk Factors
o Any surgical procedures that can lead to infusion
of air
o Creation of a pressure gradient of air entry (ex.
Lumbar punctures, peripheral IVs, central venous
catheter, etc.)
o Positive pressure ventilation (during mechanical
ventilation or scuba diving)
o Blunt & penetrating trauma to the chest,
abdomen, neck, or face can lead to entry of air
Wittenberg, A.G. (2006). Venous air embolism. Retrieved February 6, 2008, from eMedicine
WebMD on the World Wide Web:http://emedicine.medscape.com/article/761367-
overview
3. Amniotic Fluid Emboli (AFE): occurs when
amniotic fluid is drawn into the maternal
circulation and carried to the woman’s lungs.
Fetal particulate matter (skin cells, vernix,
hair, and meconium) in the fluid obstructs
pulmonary vessels. Failure of the right
ventricle occurs early and can lead to
hypoxemia. Left ventricle failure follows

Risk Factors
o
o
o
o
o
o
medical induction of labor,
multiparity,
cesarean section or operative vaginal delivery,
abruption,
placenta previa, and
cervical laceration or uterine rupture
4. Thrombus: a condition in which a blood vessel is
obstructed by a thrombus carried in the
bloodstream from its site of formation. The area
supplied by an obstructed artery may tingle &
become cold, numb, and cyanotic. Thrombi can
result from blood stasis, alterations in clotting
factors, and injury to vessel walls.
 Risk Factors









Immobility
A-fib, heart failure/MI, rheumatic heart disease
Prolonged surgery (longer than 30min)
Pregnancy
Postpartum period
Trauma
Mechanical ventilation
Obesity
Age > 55y/o
Resources


http://www.mayoclinic.com/health/pulmonary-embolism/DS00429/DSECTION=symptoms
http://www.apsfa.org/pesymptoms.htm (NIH Publication No. 05-5684 March 2005)
Lung
Involvement,
Clot Size,
Degree of:
Heart Disease
Lung Disease
http://improvedbreathing.com/
http://dvt-livingwithdvt.blogspot.com/2008/03/dvtand-pulmonary-embolism.html
http://www.libsearthwatch.com/?p=178
When Active
or
At Rest
Varies from sharp to dull, and no set location, however will
increase with exertion but will NOT subside with rest
http://www.flickr.com/photos/partymonstrrrr/2868149940/
http://www.mcglinch.com/blog/2007/10/beware-all-ye-who-enter.html
http://www.healthopedia.com/pictures/electrocardiogram-of-ventriculartachycardia.html

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Wheezing
Leg swelling
Clammy or bluish-colored skin
Excessive diaphoresis (sweating )
Anxiety , Feelings of dread
Weak pulse
Lightheadedness or fainting (syncope)
Fever




The three classic signs of dyspnea, chest
pain, and bloody cough (hemoptysis) only
occur in 20% of patients
The most common manifestations are
anxiety and sudden onset of unexplained
dyspnea, tachypnea, or tachycardia
Another common finding is moderate
hypoxemia with a low PaCO2
Crackles (Rales) and a sudden change in
mental status as a result of hypoxemia are
other manifestations



Massive emboli may result in sudden collapse of patient
with shock, pallor, severe dyspnea, hypoxemia and
crushing chest pain, although some with massive PE do
not experience pain. The pulse is rapid and weak, low
BP, and ECG shows right ventricular strain. When there
is rapid obstruction of 50% or more of pulmonary
vascular beds, corpulmonale may result since the right
ventricle can't pump blood to the lungs.
Medium sized emboli often cause pleuritic chest pain,
dyspnea, slight fever, a productive cough with blood
streaked sputum, and tachycardia and a pleural friction
rub may be found upon examination.
Small emboli usually go undetected or produce vague,
transient symptoms. Repeated small emboli gradually
cause a reduction in the capillary bed and eventually
pulmonary hypertension.
•Immobilization
•Surgery
within the last 3 months
•Stroke
•History
of DVT
•Malignancy
•Obesity
•Smoking
•Hypertension
•Oral Contraceptives


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



Sudden onset of dyspnea or tachypnea
Tachycardia
Sharp chest pain
Restlessness and anxiety
Nonproductive cough or hemoptysis
Palpitations
Nausea
Syncope
Mild to moderate hypoexmia with a low
PaCO2






Crackles
Fever
Decreased chest wall excursion
Diaphoresis
Edema
Cyanosis

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
History: 32 y.o. female with a history of
varicose veins.
5’2 and 150 lbs (BMI: 27.4; Overweight is 2529.9)
Patient is on oral contraceptives
S.J. is being hospitalized following surgery for
excision of internal and external
hemorrhoids.




Left calf pain; swollen and warm to touch
(L>R)
Positive Homan’s Sign.
Doppler Flow study a left popliteal DVT.
Patient on Heparin.



Patient complains of shortness of breath and
left anterior chest pain (worsens with deep
inspiration)
Patient is restless and afraid.
Vital Signs:
◦
◦
◦
◦
BP: 160/88
HR: 120
RR: 34 and labored
Temp: 99° F


X-ray: left lower lobe atelectasis
ABG results:
◦
◦
◦
◦
PH: 7.52 (high)
PaCO2: 28 (low)
PaO2: 131
SaO2: 99%



Ventilation perfusion scan reveals perfusion
defects of the anterior and posterior
segments of the left upper lobe. Ventilation is
normal.
PT: 16.7 sec (normal: 12-15 seconds)
PTT: 46.9 sec (normal: 30-45 seconds)


S.J. exhibits tachycardia, diaphoresis, and
cyanosis.
Another ABG drawn 30 minutes later:
◦
◦
◦
◦
PH: 7.48 (high)
PaCO2: 30
PaO2: 45
SaO2: 81%


S.J. is intubated, moderate amount of blood
tinged secretions are suctioned.
Pulmonary angiogram reveals emboli in the
left upper lobe lingular and right main
pulmonary arteries.
•Spiral
CT scan
•Ventilation-Perfusion scan
•Pulmonary angiography
•Capnogram
•D-Dimer and Fibrin Degradation
•Cardiac Markers
•Venous Ultrasound
•Phosphorus Serum
•ABG
•Not
diagnostic but help in diagnosing: Chest X-ray, history and
physical examination, CBC count with WBC differential
•
•
•
•
•
•
Spiral CT is similar to the regular CT, but the spiral
CT actually spirals around the body giving a 3D
image.
1st line test for Pulmonary Embolism
“The spiral CT scan is able to continuously rotate
while obtaining slices and does not have to start and
stop between each slice. This allows visualization of
entire anatomic regions such as the lungs,”(Lewis et
al.,599).
Testing is quick and accurate, within 20 seconds.
This type of visualization is helpful to identify if
there is an emboli in either lung.
Risks: exposure to radiation, allergic reaction to
contrast medium



•
•
Most commonly used to test for PE
Purpose: “test is used to identify areas of the lung not
receiving ariflow or blood flow. Ventilation without
perfusion suggests the probability of a pulmonary
embolus,” (Lewis et al., p. 528)
Two parts to the test:
1. Perfusion scan: Radioisotope IV injection. Scans to
detect anything in the pulmonary circulation
2. Ventilation scan: Inhale radioactive gas (xenon). This
displays how the gas within the lungs distributes.
(Lewis et al., p. 599).
“In the first part of the test, you inhale a small amount of
radiopharmaceutical while a camera that’s able to detect
radioactive substances takes pictures of the movement of
air in your lungs. A small amount of a different
radiopharmaceutical is then injected into a vein in your
arm, and pictures are taken of blood flow in the blood
vessels of your lungs,” (Mayoclinic.com, 2007)
Testing: < 1hour

Type of test: Radiography

Purpose: Used to confirm pulmonary embolism diagnosis.

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
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
How it’s Done: Radio contrast is injected into the pulmonary artery or it’s branches. This is
an invasive procedure. The patient is supine and a catheter is inserted via the antecubital or
femoral vein to the left or the right of the pulmonary artery.
Normal Findings: Pulmonary vessels fill symmetrically and quickly with no defects or
obstruction.
Risks: allergy to the contrast medium
Dysrythmias
Infection of the venous site


Type of test: Spectrometry
Purpose: monitoring of exhaled CO2 levels.
Decreased CO2 levels can be indicative of a
pulmonary embolism.

How it’s Done: The exhaled CO2 is measured
with a gas analyzer. The analyzer is usually
attached to the exhalation tube on a ventilator.

Normal Findings: 35-45mm Hg
Risks: none

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
Type of Test: Blood
Purpose: D-dimer helps determine the presence of a
clot when there is a diagnosis of deep vein
thrombosis, DIC, or an acute M.I.
How it’s Done: Venipuncture
Normal Findings: D-dimers <0.5 mcg/mL
Risks: none
Type of test: Serum
 Purpose: To determine if Creatine Kinase
(CK) levels are elevated. Elevated CK can
indicate a pulmonary embolism.
 How its Done: Blood is drawn by
venipuncture at the bedside
 Normal findings:
Adult male: 38-174 units
Adult female: 26-140 units
Risks: none

•
•
•
•
“A noninvasive “sonar” test known as a
duplex venous ultrasonography, uses
high- frequency sound waves to check
for blood clots in your thigh veins,”
(Mayoclinic.com, 2007).
A transducer is used to transmit any
sound waves found and provides an
image on a computer screen.
Test is fast and pain-free.
(Mayoclinic.com, 2007)

Type of Test: Blood

Purpose: Elevated levels of Serum phosphorus can
indicate can indicate pulmonary embolism.
How It’s Done: Venipuncture
Normal Findings: Adult: 2.5-4.5mg/dL
Risks: none
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Type of Test: Arterial Blood
Purpose: Shows whether a patient is experiencing
Respiratory alkalosis, which can be indicative a
pulmonary embolism.
How it’s Done: Arterial blood sample is obtained via
an arterial puncture or a arterial line.
Normal Findings:
pH: 7.35-7.45
pCO2: 35-45mm Hg
HCO3: 21-28mEq pO2: 80-100mm Hg
SaO2: adult >95% Base excess/deficit: +2
Risks: none

These tests are not considered diagnostic
tests for a pulmonary embolism but help in
the diagnostic process:
◦
◦
◦
◦
Chest X-ray
ECG monitoring
CBC count with WBC differential
History and Physical examination

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Impaired gas exchange R/T altered oxygen
supply S/T ventilation perfusion mismatch.
Acute Pain R/T inflammatory process caused
by thrombus formation.
Risk for injury R/T hypercoagulable state.
Ineffective protection R/T prolonged bleeding
S/T anticoagulation therapy.
Anxiety R/T pain and intrusive diagnostic and
surgical tests and procedures.
•Frequent
ambulation
•Pneumatic Leg Compression Devices
•PT consult for immobile patients
•Pharmacologic interventions as per DOs
•Proper IV set up
•Patient education

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Risk level assessment
Weight Loss
Exercise
Smoking cessation
Medication adherence

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Long airplane rides
Occupational hazards
Pregnancies
Oral Contraceptives and Hormone
Replacement Therapy
Hypoxemia is a deficient
oxygenation of the blood. A
pulmonary embolism is a sudden
blockage in a lung artery, most often
caused by a traveling blood clot from
a vein in the leg. These clots are
formed via the condition of deep vein
thrombosis.


A pulmonary embolism brings about lung
tissue damage, hypoxia and other organ
impairment as a result of your blood’s
hypoxic state. Death can ensue.
Other sources of embolism include Air
embolism, Fat embolism, Amniotic fluid
embolism, Septic embolism, Foreign body
embolism and Tumor embolism.

Larger emboli can cause a reflex increase in
ventilation (tachypnea), hypoxemia from
ventilation/perfusion (V/Q) mismatch and
shunting, atelectasis from alveolar
hypocapnia and abnormalities in surfactant,
and an increase in pulmonary vascular
resistance caused by mechanical obstruction
and vasoconstriction.
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Sudden onset of dyspnea or tachypnea
Tachycardia
Sharp chest pain
Restlessness and anxiety
Nonproductive cough or hemoptysis
Palpitations
Nausea
Syncope
Mild to moderate hypoexmia with a low
PaCO2
1.
2.
3.
4.
Fat Emboli
Air Emboli
Amniotic Fluid Emboli
Thrombus (Clot Emboli)
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Long term immobility
Oral contraceptive use
Estrogen therapy
Smoking
Hypercoagulability
Obesity
Surgery
Heart failure
Chronic Atrial fibrillation
Autoimmune hemolytic anemia (sickle cell)
Long bone fractures
Advanced age

In most cases there are multiple emboli
(Corrêa, i Cavalcanti, & Amaral Baruzzi,
2007).
The presentation of patients with PE can
be categorized into 4 classes based on
the acuity and severity of pulmonary
arterial occlusion. (Sharma, 2006)
◦
◦
◦
◦
Massive pulmonary embolism
Acute pulmonary infarction
Acute embolism without infarction:
Multiple pulmonary emboli
THE KEY POINT – THE BIGGER THE CLOT /
OCCLUSION – THE WORSE THE SEVERITY

There is a predominant involvement of the
lower lobes because they have a higher blood
flow than the other lobes. (Lewis, SL.,
Heitkemper, MM., 2007)

YOUR TURN TO ANSWER

HANDS PLEASE 
(Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 599)
1.
2.
3.
Prevent further growth or multiplication of
thrombi in the lower extremities
Prevent embolization from the upper or lower
extremities to the pulmonary vascular system
Provide cardiopulmonary support if indicated



Anticoagulant drugs are given to prevent existing
blood clots from enlarging and additional clots
from forming.
Thrombolytic drugs break up and dissolve blood
clots.
Other Methods:
◦ Oxygen is given if blood oxygen levels are low.
◦ Analgesics are given to relieve pain.
◦ If blood pressure is low, intravenous fluids are
given and sometimes drugs that increase blood
pressure are given.
◦ Mechanical ventilation (a breathing tube) may be
needed if respiratory failure develops.
Anticoagulant: Parental: Heparin, Low
Molecular Weight Heparin (LMWH)
 Anticoagulant: Oral: Warfarin
 Thrombolytics: Streptokinase, Alteplase (tPA)

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

Heparin is given intravenously to achieve a rapid effect,
and doctors carefully regulate the dose. Doctors strive
to achieve a full anticoagulant effect (targeted to an INR
of 2.0 to 2.5 times normal) within the first 24 hours of
treatment.
Low-molecular-weight heparin is probably as effective
as traditional heparin and does not require the blood
test monitoring that is commonly recommended for
conventional heparin.
Warfarin , which also inhibits clotting but takes longer
to start working, is given next. Because warfarin is
taken by mouth, it can be used long-term.
Heparin and warfarin are given together for 5 to 7 days,
until blood tests show that the warfarin is effectively
preventing clotting. Then, the heparin is discontinued.
•
Although both drugs decrease fibrin formation,
they do so by different mechanisms:
• Heparin inactivates thrombin and factor Xa, whereas
warfarin inhibits synthesis of clotting factors.
•
•
Effects of heparin begin and fade rapidly,
whereas effects of warfarin begin slowly but then
persist for several days.
Different tests are used to monitor therapy:
• PT is used to monitor warfarin: Normal range for the PT
is between 10 and 13 sec.
• aPTT is used to monitor heparin: Normal range for aPTT
is between 28 to 34 sec.
•
Vitamin K is given to counteract warfarin whereas
protamine is given to counteract heparin.
•
•
•
•
LMWHs are simply heparin preparations composed
of molecules that are shorter than those found in
unfractionated heparin.
LMWHs are associated with a much lower incidence
of heparin-induced thrombocytopenia than heparin
and a lower incidence of osteoporosis.
Administration of LMWHs is in a fixed dose by
subcutaneous injection and don’t require aPTT
monitoring, as opposed to heparin.
As a result, LMW heparins can be used at home, an
advance that would reduce cost and improve
patient convenience.





How long anticoagulants are given depends on the
person's situation.
If pulmonary embolism is caused by a temporary risk
factor, such as surgery, treatment is given for 2 to 3
months.
If the cause is some longer-term problem, such as
prolonged bed rest, treatment usually is given for 3
to 6 months, but sometimes it must continue
indefinitely.
For example, people who have recurrent pulmonary
embolism, often because of a hereditary clotting
disorder, usually take anticoagulants indefinitely.
While taking warfarin, people periodically have to
have a blood test to determine if the dose needs to
be adjusted.


Changes in diet and use of other drugs may affect the
degree of warfarin's anticoagulant effects. If
excessive anticoagulation occurs, severe bleeding in a
number of body organs can develop.
Because many drugs can interact with warfarin,
people who take anticoagulants should be sure to
check with their doctor before taking any other
drugs, including drugs that can be obtained without a
prescription (over-the-counter drugs)
◦ Such as acetaminophen or aspirin, herbal preparations, and
dietary supplements.

Foods that are high in vitamin K (which affects blood
clotting)
◦ Such as broccoli, spinach, kale, and other leafy green
vegetables, liver, grapefruit and grapefruit juice, and green
tea, may also need to be avoided.
•
•
Thrombolytic drugs such as streptokinase
or tissue plasminogen activator (TPA) break up
and dissolve blood clots.
Thrombolysis is more expensive than
anticoagulant therapy and is associated with a
higher risk of bleeding, so its use should be
restricted to patients who are likely to benefit
from it.
• They can be used for people who appear to be in danger
of dying of pulmonary embolism.
•
However, except in the most dire situations,
these drugs cannot be given to people who have
had surgery in the preceding 2 weeks, are
pregnant, have had a recent stroke, or tend to
bleed excessively.
•
The fibrinolytic enzymes streptokinase, and
Alteplase (tPA) accelerate the rate of
dissolution of thrombi and emboli by
converting plasminogen to plasmin, an
enzyme that degrades the fibrin matrix of
thrombi.



Depending on the severity of the pulmonary
embolism and the patient’s ABG results,
supplemental oxygen may be needed by
mask or nasal cannula.
In some cases, patients may even need
endotracheal intubation and mechanical
ventilation
Perform nursing interventions to prevent or
treat atelectasis and maintain perfusion






Inferior vena cava interruption
Filters – most commonly used for procedure
Ligation and external clips – rarely used
Pulmonary embolectomy
Surgery is performed to remove clot
Another type of embolectomy involves an
introduced catheter to remove the clot




Prior to the surgery, a pulmonary angiography
should be performed to visualize or rule out an
embolus
A filter is placed into the inferior vena cava
typically beneath the renal vein under
fluoroscopic guidance
The filter will prevent large clots from travelling
to the lungs by mechanically blocking their
migration
There are several types of filters and they fall into
two categories: Permanent or Retrievable
Indications 
A patient that has a contraindication to
anticoagulants, complications of anticoagulation
therapy, or failure to anticoagulant therapy.

Prophylactic measure for patients with complications
where a small PE would have severe consequences

Patient undergoing pulmonary embolectomy
Contraindications –

A thrombus in the inferior vena cava blocking
possible placement

Uncorrectable, severe coagulapathy

Bacteremia - the presence of bacteria in the blood
Benefits –
 Short-term reduction of occurrence of PE in
patients with DVT with a likely sequelae of PE
 High rate of long term patency
Complications – (Retrieved from the British Journal
of Haematology)
 Immediate - Misplacement (1-3%),
 Early - Insertion site thrombosis (8.5%), and
Infection
 Late - Recurrent DVT (21%), IVC thrombosis (210%), Post-thrombotic syndrome (15-40%), and
IVC penetration (0.3%)
Panel A showing a postoperative picture of the IVC filter encased in
blood clot.
Panel B showing an intraoperative picture of the IVC filter in the
right pulmonary artery.
Abouzgheib W. et al.; Eur J Cardiothorac Surg 2008;33:507
Copyright ©2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved.


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A rare procedure where a clot is surgically
removed from the pulmonary system
Preoperative angiography must be done to
find and confirm the pulmonary embolism
An emergent embolectomy may be indicated
for a patient with a severe obstruction who
did not respond to the usual therapy
IVC filter is placed after embolectomy
Lewis et al. mentions the mortality rate of the
procedure is 50%.

1.
2.
3.
Respiratory measures When atelectasis was found on the chest x-ray,
she was placed on 4L/min of oxygen via nasal
cannula
The next day, Ms. James has an oxygen
saturation of 81%, her ABG results show that her
PaO2 is 45, and she is showing sings of
tachycardia, diaphoresis, and cyanosis. Because
she has a suspected PE, she is intubated and
placed on a volume ventilator.
Nursing actions are performed by suctioning
the blood-tinged secretions from her
endotracheal tube.

1.
2.
o
o
o
o
Surgical Intervention
Pulmonary angiogram is performed revealing
an emboli in the left upper lobe lingular and
right main pulmonary arteries
Bilateral iliac vein Greenfield filters are placed
under fluoroscopy.
Bilateral – inserted on both left and right side
Fluoroscopy – use of x-rays to guide insertion
Greenfield filters – Permanent, stainless steel
Iliac vein:
NURSES – WHAT DO YOU THINK ?????
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