Aortic aneurysms
- Severe back pain with or w/o back/flank ecchymosis (Grey Turner sign) - massive hemorrhage - hypovolemic shock: tachycardia, hypotension, pale, clammy skin, decreased UOP, AMS, abdominal tenderness
Rupture of aneurysm signs and symptoms
Often asymptomatic When present, diffuse chest pain to inter-scapular area
Thoracic AA signs and symptoms
CT scan
What is the most accurate diagnostic test to monitor aneurysm size?
b. A 50-yr-old patient who is complaining of sudden sharp and severe upper back pain The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention. The other patients also require rapid intervention but not before the patient with severe pain.
23. After receiving change of shift report, which patient admitted to the emergency department should the nurse assess first? a. A 67-yr-old patient who has a gangrenous left foot ulcer with a weak pedal pulse b. A 50-yr-old patient who is complaining of sudden sharp and severe upper back pain c. A 39-yr-old patient who has right calf tenderness, redness, and swelling after a plane ride d. A 58-yr-old patient who is taking anticoagulants for atrial fibrillation and has black stools
b. trouble swallowing. Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms.
A patient has a 6-cm thoracic aortic aneurysm that was discovered during routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about a. low back pain. b. trouble swallowing. c. abdominal tenderness. d. changes in bowel habits.
b. Sudden, severe low back pain and bruising along his flank
A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm ruptured? a. Rapid onset of shortness of breath and hemoptysis b. Sudden, severe low back pain and bruising along his flank c. Gradually increasing substernal chest pain and diaphoresis d. Sudden, patchy blue mottling on feet and toes and rest pain
- age - male gender - HTN - CAD - family history - tobacco (modifiable) - high cholesterol - lower extremity PAD - carotid artery disease - previous stroke - obesity
AA risk factors
- *Asymptomatic - pulsatile mass - bruits - back pain, epigastric discomfort, altered bowel elimination, intermittent claudication
Abdominal aorta aneurysm signs and symptoms
a. Check the blood pressure. Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately.
An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first? a. Check the blood pressure. b. Draw blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of heart disease
permanent, localized out pouching of the vessel wall
Aortic aneurysm
"sharp" "worst ever" "tearing" "ripping" "stabbing"
Aortic dissection
Results from the creation of a false lumen between the intima (inner lining) and the media (middle layer) of the arterial wall.
Aortic dissection
Chest and/or back pain radiating to neck or shoulder
Aortic dissection Acute ascending signs and symptoms
pain in back, abdomen, legs
Aortic dissection Acute descending signs and symptoms
- IV beta-blocker: titrate to HR of 60 bpm - IV CCB: used to lower HR if beta-blocker contraindicated - IV ace inhibitor - Morphine: analgesic
Aortic dissection interprofessional care
- antihypertensives for life! SE of beta-blockers: dizziness, depression, fatigue, erectile dysfunction - follow up with MRIs/CTs
Aortic dissection postoperative interventions
- Semi-fowlers position - quiet environment - opioids/sedatives
Aortic dissection preoperative interventions
- angina - transient ischemic attacks - coughing - SOB - HOARSENESS, and/or DYSPHAGIA if pressing on superior vena cava: decreased venous return, JVD, edema of face and arms
Ascending aorta & aortic arch signs and symptoms
- cardiac tamponade - aortic rupture - occlusion of blood supply to organs: spinal cord, kidneys, abdomen
Complications of aortic dissection
The seepage of blood back into the old aneurysm. May be result of: inadequate seal at either graft end, a teat through the graft fabric, or leakage between overlapping graft segments solution? coil embolization for hemostasis
Endoleak - complication of AAA
Minimally invasive Involves placement of a suture-less aortic graft into the abdominal aorta inside the aneurysm via the femoral artery
Endovascular Aneurysm Repair (EVAR)
MI is more gradual in onset and has increasing intensity
How is an aortic dissection different from an MI?
AMS, weakened/absent carotid or temporal pulses, dizziness, syncope
If the aortic arch is involved what symptoms will pt. show?
Heart rate and BP control pain management
Initial goals of therapy for acute aortic dissection
- beta-blockers - statins - antibiotics [Doxyclycline] - ACE inhibitors - ARBs They lower the growth rates of the AA
Medications for pt. with AA What do these medications do?
- Angina - MI - new high-pitched heart murmur - left heart failure - cardiogenic shock - differences in left/right pulses in arm, differences in BP in arms - decrease in perfusion to lower extremities/lower organs
Other S/S or complications of aortic dissection
Monitor: - lower extremity neuro check
Post-surgical care Neuro status AAA
Monitor: - LOC - pupils - speech - response to light - facial symmetry - tongue position - upper extremity movement - quality of hand grasps
Post-surgical care Neuro status Ascending & aortic arch
- monitor daily urine output - monitor creatinine/BUN - I&O's - daily weights decreased renal perfusion can occur from embolization of aortic thrombus or plaque to one or both of the renal arteries
Post-surgical care Renal perfusion
- early ambulation - NGT tube - may have ileus from bowel manipulation during surgery
Post-surgical care GI status
Graft patency - keep BP just right! Low BP can lead to graft thrombosis Treat low BP with IV fluids/blood components
Post-surgical care for AA Low BP = ?
Graft patency - keep BP just right! High BP can lead to rupture of a graft Treat high BP with IV diuretics & antihypertensives
Post-surgical care for AA high BP = ?
These are common: - fatigue - poor appetite - irregular bowel habit - avoid heavy lifting for 6 weeks - monitor incision for infection - changes in color/warmth of extremities - palpate peripheral pulses - sexual dysfunction common
Post-surgical teaching
Prevent rupture of aneurysm
Primary goal
6-12 months
Pt.'s with AA should monitor size of aneurysm with ultrasound or CT every...
- tobacco cessation - decreasing BP - optimizing lipid profile - gradually increasing exercise
Risk factor modification
d. increased IV infusion rate. The decreased urine output suggests decreased renal perfusion and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.
Several hours after a patient had an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 45 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic c. serum creatinine level. d. increased IV infusion rate.
True
T/F The risk of postoperative renal complications such as acute kidney injury increases in patients who have OAR of AAA's above the level of the renal arteries.
a. Notify the surgeon and anesthesiologist. Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings should be reported to the surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse would know whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patient's legs.
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.
c. Blood pressure of 138/88 mm Hg The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that -blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure of 138/88 mm Hg d. 25 mL of urine output over the past hour
c. Administration of IV fluids and monitoring of kidney function
What are the priority nursing interventions after an abdominal aortic aneurysm repair? a. Assessment of cranial nerves and mental status b. Administration of IV heparin and monitoring of PT c. Administration of IV fluids and monitoring of kidney function d. Elevation of the legs and application of graduated compression stockings
c. Maroon-colored liquid stool Loose, bloody (maroon colored) stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.
When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Hypoactive bowel c. Maroon-colored liquid stool sounds d. Abdominal pain with palpation
d. Uncontrolled hypertension
When discussing risk factor modification for a patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension
b. Monitor fluid intake and urine output. Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.
Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Assess the abdominal incision for redness. d. Teach the patient to plan for a long recovery period.
d. Help the patient to use a pillow to splint while coughing. Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RN
Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.