Week 11 Sherpath: Aortic Aneurysm and Aortic Dissection

The patient has a history of aortic dissection repair 1 month ago. The patient calls the clinic and states he started having discomfort in his chest 30 minutes ago. What is the nurse's best response? A. "Call 911 immediately." B. "You should drive to your primary care office to be examined." C. "Be sure to make a follow-up appointment with your surgeon this week." D. "It is common to have chest discomfort after an aortic dissection repair."

A. "Call 911 immediately." For patients with a history of aortic dissection, they should activate emergency response system (ERS) for immediate care if symptoms reoccur. This could indicate further dissection, which is a medical emergency.

The nurse is caring for a patient with aortic dissection preoperatively. The patient rates his pain 7/10 on a numeric scale. The patient's blood pressure is 137/82, heart rate 92 beats per minute, respirations 18 per minute, oxygen saturation 98%, and oral temperature 98.4°. What is the nurse's priority action? A. Administer IV morphine B. Administer IV beta-blocker C. Contact the surgeon immediately D. Use nonpharmacologic techniques to decrease pain

A. Administer IV morphine The morphine will help decrease the patient's pain. Morphine is a vasodilator that will also help decrease the patient's blood pressure.

The nurse is caring for a postoperative aneurysm repair patient. What assessment finding would cause the nurse to contact the provider? A. Blood pressure 86/54 B. Urine output 40 mL/hr C. Bilateral pedal pulses 3+ D. Hypoactive bowel sounds

A. Blood pressure 86/54 A BP of 86/54 needs to be communicated to the provider. An adequate BP is important to maintain graft patency. Prolonged hypotension may result in graft thrombosis.

The nurse is caring for a patient after an open aneurysm repair (OAR). What laboratory finding would cause the nurse to contact the health care provider? A. Creatinine 4.1 mg/dL B. Hemoglobin 10.8 grams/L C. White blood cell (WBC) count 7500 mcL D. Partial pressure of carbon dioxide (PaCO2) 41 mmHg

A. Creatinine 4.1 mg/dL An increased creatinine level such as 4.1 mg/dL may indicate a kidney issue. There is a risk of postoperative renal complications such as acute kidney injury in patients who have had an OAR of AAAs located above the level of the renal arteries. This finding needs to be communicated to the surgeon.

Which patient is at highest risk for developing an aortic aneurysm? A. 47-year-old male with a BMI of 23 B. 59-year-old female with an LDL level of 98 mg/dL C. 67-year-old female with an arterial lower extremity ulcer D. 73-year-old male who has smoked 4 packs a day for 25 years

D. 73-year-old male who has smoked 4 packs a day for 25 years A 73-year-old male with a history of smoking is at the highest risk for developing an aneurysm due to his increasing age and his long-term tobacco use. This patient's gender puts him at an increased risk as well. Other risk factors include high cholesterol, family history, obesity, and hypertension.

The nurse is caring for the patient with aortic dissection postoperatively. What assessment finding would cause the nurse to contact the provider immediately? A. Absent bowel sounds B. NG in place with green-brown output C. Pain near incision site with ambulation D. Decreased response to physical stimulation

D. Decreased response to physical stimulation A decreased level of consciousness likely indicates decreased perfusion and complication from the aortic dissection repair; further assessment and treatment are needed.

The patient presents to the emergency department with a blood pressure of 76/52 mmHg. What subjective symptom from the patient would be most concerning to the nurse? A. Painful urination B. Decreased sensation of feet C. Chills and sweating during the night D. Tearing and ripping sensation in the anterior chest

D. Tearing and ripping sensation in the anterior chest A tearing and ripping sensation in the anterior chest would be the most concerning symptom because it may indicate aortic dissection. This is a medical and surgical emergency. Other symptoms may include altered level of consciousness, weak pulses, and dizziness from internal hemorrhage.

The nurse is providing patient discharge education postoperative open aortic aneurysm repair on the ascending aorta. What patient statement would indicate to the nurse further education is needed? A. "I should contact my provider if I notice any weakness in my hands." B. "It is most important for me to feel for pulses on my feet and notice if they are cool." C. "Heavy lifting, like vacuuming or carrying groceries, should be avoided for 6 weeks." D. "I will contact my provider if I notice any redness, swelling, or drainage coming from the incision."

B. "It is most important for me to feel for pulses on my feet and notice if they are cool." The patient should feel the pulses on the feet if they have undergone a descending, not ascending, aortic repair. When the ascending aorta and aortic arch are involved, the carotid, radial, and temporal artery pulses should be assessed.

The patient newly diagnosed with a 4.1 cm aortic aneurysm states, "My provider said that the aneurysm will be treated conservatively. What does that mean?" What is the nurse's best response? A. "The clinic will call you this week to schedule your aneurysm repair surgery." B. "Lifestyle changes and medications will be used to help control your heart rate and blood pressure." C. "A medication called a beta-blocker will be prescribed for you to help decrease the size of the aneurysm." D. "You will need to increase your physical activity and take your prescribed hypertension medication to fix the aneurysm."

B. "Lifestyle changes and medications will be used to help control your heart rate and blood pressure." Conservative medical therapy of small, asymptomatic AAAs (4.0-5.4 cm) is the best practice and consists of risk factor modification: ceasing tobacco use, optimizing lipid profile results, gradually increasing physical activity, heart rate (HR) control, reducing aortic wall stress by decreasing heart rate to ≤60 beats/minute with IV β-blocker.

The nurse is caring for a patient recovering from endovascular graft aortic repair. The family states, "I think he's lying on a tube under his back. I'll move it from underneath him so he's more comfortable." What is the nurse's best response? A. "The tube needs to be in that position in order to function correctly. Please do not move it." B. "The tube needs to be handled by nurses only because of the risk of infection. I will put on gloves and reposition the tube." C. "The nursing assistant and I will help you move the tube to a more comfortable position as more people are needed to move it safely." D. "Please be sure to wash your hands and put on gloves before you move the tube. He can turn on his side and then you can move it."

B. "The tube needs to be handled by nurses only because of the risk of infection. I will put on gloves and reposition the tube." A temporary lumbar drain may be inserted for cerebrospinal fluid removal to reduce spinal cord edema and help prevent paralysis. If a lumbar drain is used, strict aseptic techniques are essential to avoid introducing infection.

The nurse is prepping the patient with a history of cardiovascular disease (CVD) for aortic aneurysm surgical repair. What medication order would cause the nurse to contact the health care provider for further clarification? A. Aspirin 325 mg PO hold B. Metoprolol 50 mg PO after surgery C. Cefazolin 1 gm IV 30 minutes prior to surgery D. Hibiclens skin cleanse the day prior to surgery

B. Metoprolol 50 mg PO after surgery Patients undergoing an aneurysm repair with a history of CVD should be given a beta-blocker preoperatively, not postoperatively. This ordering provider should be contacted to clarify the order. A beta-blocker should be given prior to surgery to slow the heart rate and reduce aortic wall distress.

Which statement best describes a fusiform aneurysm? A. The pouch-like bulge is on one side of the arterial wall. B. The shape is comparatively uniform and circumferential. C. The tear between the inner and middle layers of the arterial wall has caused a false lumen. D. The arterial wall layers are disrupted and bleeding is contained by surrounding anatomic structure.

B. The shape is comparatively uniform and circumferential. A true aneurysm is one in which the wall of the artery forms the aneurysm, but there is at least one vessel layer still intact. A fusiform aneurysm is circumferential and relatively uniform in shape.

The nurse is caring for a patient with aortic dissection preoperatively in the ICU. The family member states, "Usually his heart rate is in the 80s. Why is it 53?" What is the nurse's best response? A. "It is common for patients with aortic dissection to experience a lower heart rate. His heart rate should return to baseline after the surgery." B. "I will call the provider immediately. We may need to give a medication to increase his heart rate so that he is sufficiently perfusing throughout his body." C. "A beta-blocker was administered to decrease his heart rate. A slower heart rate is needed so that there will be less blood leaking from the aortic dissection." D. "This may be due to the stress or his feelings of anxiety from being in the hospital. I will go look at his chart to see what his heart rate has been during hospitalization."

C. "A beta-blocker was administered to decrease his heart rate. A slower heart rate is needed so that there will be less blood leaking from the aortic dissection." Heart rate control reduces aortic wall stress. The goal should be to decrease heart rate to ≥60 beats/minute with IV β-blocker BP control. This also reduces aortic wall stress by managing systolic BP between 100 and 110 mm Hg and myocardial activity.

The nurse is preparing the patient with EVAR for discharge. The patient states, "I am glad this procedure is done and I won't have to keep seeing doctors and having scans." What is the nurse's best response? A. "It must be relieving not to worry about your aneurysm any more. You should schedule one more follow-up appointment to check for infection around your incision." B. "Be sure to gradually increase your physical activity at home, refrain from smoking, and monitor your blood pressure. Call the clinic if you notice any side effects from your medications." C. "With the aneurysm repair surgery you had, there will always be a risk of developing a leak. You will need to have imaging done periodically throughout your life to monitor for this complication." D. "You should return to the hospital immediately if you notice any dizziness, pain where the aneurysm was located, or shortness of breath. You should also return if you notice any foul-smelling discharge or redness and warmth to the incision site."

C. "With the aneurysm repair surgery you had, there will always be a risk of developing a leak. You will need to have imaging done periodically throughout your life to monitor for this complication." Patients undergoing EVAR require periodic imaging for the rest of their lives to monitor for an endoleak, document stability of the aneurysm sac, and determine the need for surgical intervention.

The nurse is caring for a postoperative open aortic aneurysm repair. The patient complains of feeling "bloated." What should be the nurse's priority assessment? A. Assess lung sounds B. Assess urine output C. Assess for bowel sounds D. Assess for incisional infection

C. Assess for bowel sounds After an OAR, postoperative ileus may develop due to anesthesia and handling of the bowel during surgery. If the blood supply to the bowel is disrupted during surgery, temporary ischemia or infarction (death) of intestinal tissue may result. Observe for absent bowel sounds, fever, abdominal distention and pain, diarrhea, and bloody stools.

The patient presents to the emergency department with a suspected aortic dissection. What assessment finding would be most concerning to the nurse? A. Pulse 96 beats/min, creatinine level 1.3 mg/dL, low urine output B. Respirations 24, lower extremity weakness, tingling in fingers C. BP 86/64, positive jugular vein distention, muffled heart sounds D. Temperature 99.1 degrees Fahrenheit, decreased bowel sounds, abdominal pain

C. BP 86/64, positive jugular vein distention, muffled heart sounds These clinical manifestations would be most concerning because they indicate cardiac tamponade. The patient is hypotensive and has a narrowed pulse pressure (22). Jugular vein distention and muffled heart sounds are also signs of cardiac tamponade.

The patient with a chronic aneurysm presents to the clinic with back pain. What objective assessment finding is most concerning to the nurse? A. Diffuse pain extending to the interscapular area B. A palpable mass is located in the periumbilical area C. Bilateral lower extremities are mottled, dusky, and cool D. Bruit heard on auscultation over the anterior midline chest

C. Bilateral lower extremities are mottled, dusky, and cool Bilateral lower extremities that are gray and cool would be most concerning because this indicates inadequate blood flow. Occasionally, aneurysms spontaneously embolize plaque, causing "blue toe syndrome" (patchy mottling of the feet and toes in the presence of palpable pedal pulses).