Aortic Aneurysm & Aortic Dissection

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.

Pain in aortic dissection:

"sharp", "worst ever", "tearing", "ripping", or "stabbing".

Place the pathophysiology of an aortic dissection in order 1. blood-filled channel ruptures through the outside aortic wall 2. elastic fibers in the arterial wall degenerate 3. a tear develops in the inner later of the aorta 4. blood surges causing the inner and middle layers to separate.

2, 3, 4, 1

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 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. WBC count 7500 mcL d. partial pressure of carbon dioxide (PaCO2) 41. mmHg

A. an increased creatinine level such as 4.1 mg/dL may indicate a kidney issue. There is a risk of post renal complications such as AKI

Post-Op Infection Prevention:

Antibiotics, temperature assessment, monitor labs (WBCs), assess surgical incision

Post-Op Neurologic:

Ascending aorta & aortic arch involved, assess LOC, pupil size/response to light, facial symmetry, tongue position, speech, UE movement, & hand grasp quality; descending aorta - prefer neuromuscular assessment of LE

Which statement best describes a fusiform aneurysm? a. The pouch-like bulge is on one side of the arterial wall. 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 true saccular aneurysm is pouchlike with a narrow neck connecting the bulge to one side of the arterial wall. Correct 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. c. The tear between the inner and middle layers of the arterial wall has caused a false lumen. A tear between the inner and middle layers of the arterial wall that causes a false lumen best describes aortic or arterial dissection. Aortic dissection results from the creation of a false lumen between the intima (inner lining) and the media (middle layer) of arterial wall. d. The arterial wall layers are disrupted and bleeding is contained by surrounding anatomic structure. Disrupted arterial walls and bleeding contained by anatomic structure best describes a false aneurysm or pseudoaneurysm. A false aneurysm, or pseudoaneurysm, is not an aneurysm but a disruption of all arterial wall layers with bleeding that is contained by surrounding anatomic structures.

B

Post-Op nursing interventions for cardiovascular system:

ECG monitoring, intraarterial BP monitoring, frequent electrolyte & ABGs, oxygen admin, IV antidysrhythmic & antiHTN meds & electrolytes as needed, pain control & resumption of cardiac drugs.

Post-Op Renal:

Indwelling catheter (remove after 48 hrs), immediate hourly urine output; monitor BUN & serum creatinine; maintenance accurate fluid intake/output & daily weights, watch for signs of hypotension - caused from dehydration (prolonged aortic clamping, blood loss, or embolism)

Symptoms of cardiac tamponade include:

JVD, sharp chest pain worse with deep breathing & relieved by leaning forward, muffled heart sounds, narrowed pulse pressure.

Aorta

Largest artery; provides oxygen, nutrients and blood to vital organs.

Post-Op Gastro:

NG tube, record input/output, ice chips/lozenges help sooth throats, assess bowel sounds q4hr (gas is good), early ambulation, observe for absent bowel sounds/fever/abdominal distention/bloading/pain/diarrhea/bloody stools as it may indicate disruption of blood flow to intestines; H2 blocker or proton-pump inhibitor for NPO status.

Thoracic Aortic Aneurysms (TAA)

Often asymptomatic; symptoms include deep, defuse chest pain that may extend to the inter scapular area.

Manifestations of aortic dissection in geriatric patients:

Older patients are less likely to have abrupt onset of chest or back pain and more likely to have hypotension & vague symptoms.

Aneurysm

Permanent localized out pouching or dilation of vessel wall.

Neurological symptoms of aortic dissection (aortic arch involvement):

altered level of consciousness, weakened or absent carotid & temporal pulses, dizziness or scope.

Aneurysm may involve:

aortic arch, thoracic aorta or abdominal aorta (3/4 occur in the abdomen, mostly below the renal arteries).

mesenteric ischemia is an

area of the intestine supplied by a mesenteric artery. It may be either occlusive or nonexclusive & may progress into a mesenterric infarction.

Type A Aortic Dissection affects:

ascending aorta & arch.

Surgical repair may be recommended in patients with what diameter?

asymptomatic aneurysm > or = 5.5cm in diameter; correction of existing carotid or coronary artery blockages may be needed before repair. If it is ruptured, emergent surgical intervention is needed.

Manifestations of Abdominal Aortic Aneurysm (AAA)

back pain, epigastric discomfort, altered bowel elimination, intermittent claudication, pulsatile mass in the periumbilical area slightly to the left of midline, bruits heard over aneurysm, "blue toe syndrome" (patchy mottling of the feet and toes in the presence of palpable pedal pulses) caused by aneurysm spontaneously embolizing plaque.

Complications of an aortic dissection include:

cardiac tamponade, hemorrhage (mediastinal, pleural or abdominal cavities), spinal cord ischemia (weakness & decreased sensation), rental ischemia (renal failure), mesenteric ischemia (abdominal pain, decreased bowel sounds, altered bowel ruction & bowel necrosis), results in exsanguination & death.

Pathophysiology of aortic dissection

caused by degenerated elastic fibers in the arterial wall, a tear develops in the inner layer of the aorta, blood surges through this tear causing the inner & middle laters to separate. If the blood-filled channel ruptures through the outside aortic wall, it is often fatal.

Diagnostic studies to evaluate aortic dissection include:

chest x-ray - indicates widening of mediastinum & pleural effusion. 3-D CT, transeophagela echocardiography (TEE), or MRI - diagnose acute aortic dissection.

Diagnostic studies of an aneurysm includes:

chest x-rays; reveal abnormal widening of the thoracic aorta; abdominal may show calcification within aortic wall. echocardiography; assess the function of the aortic valve. abdominal US: useful for screening & monitor size. CT scans thorax and abdomen is most accurate test to determine length & cross-sectional diameter and presence of thrombus in the aneurysm. MRI of thorax & abdomen may help to diagnose & assess location & severity.

Fusiform Aneurysm

circumferential & relatively uniform in shape

Ascending Aorta & Aortic Arch Aneurysms manifestations include

decreased blood flow to coronary & carotid arteries - angina & TIA's pressure on the laryngeal nerve - coughing, dyspnea, hoarseness, dysphagia decreased venous return - JVD & edema of the face/arms.

Primary causes include:

degenerative, congenital, mechanical (penetrating/blunt trauma). inflammatory (aortas[takayosu's arteritis), infections (clamydia penumonaie).

How often should aneurysms be monitored?

every 6-12 myths using US or CT; small AAA's every 2-3 years with US.

What are the two types of a true aneurysm

fusiform & saccular

Acute type B dissection. pain is:

in the back, abdomen, or legs.

Type B Aortic Dissection begins:

in the descending aorta.

Open Aneurysm Repair (OAR) steps:

incision is cut through the abdomen & into the diseased aortic segment; the thrombus or plaque is removed; synthetic graft to the aorta proximal & distal to there aneurysm is placed; native aortic wall around the graft is sutured in place to act as protective cover.

Post-Op nursing care includes:

infection prevention, cardiovascular/gastrointestinal/neurologic/renal systems

Complication of an aortic dissection:;

intraabdominal hypertension (IAH), with associated abdominal compartment syndrome; endoleak (seepage of blood backs into the old aneurysm from an inadequate seal at either graft end, a tear through the graft fabric or leave between overlapping graft segments); ischemia below the aneurysm graft site; aneurysm growth above/below graft; rupture; aortic dissection & bleeding; renal artery occlusion (may lead to kidney failure); incisional site hematoma; incisional infection; myocardial ischemia or infarction (due to decreased myocardial oxygen supply or increased demands.

Aortic dissection

localized dilation of an artery most commonly the aorta, characterized by a longitudinal separation of the outer and middle layers of the vascular wall. Blood entering a tear in the intimal lining of the vessel causes a separation of weakened elastic and fibromuscular elements in the medial layer and leads to the formation of cystic spaced filled with matrix. May be fatal in less than an hour.

Predisposing factors of an aortic dissection include:

male, age, aortic diseases, atherosclerosis, trauma, tobacco, cocaine or meth use, congenital heart disease, family hx, hx of heart surgery, pregnancy, HTN poorly controlled, marafan syndrome.

Pre-Op nursing actions include:

monitoring the patient (diaphoresis, pallor, weakness, tachycardia, hypotension, abdominal/back/groin/periumbilical pain, changes to LOC, pulsating abdominal mass; establishing baseline data; preparing the patient during pre-op period (bowel prep, skin cleansing, NPO, IV antibiotics, beta blockers, emotional support, teaching)

PreOp care goals include:

normal tissue perfusion, intact motor & sensory function and no complication r/t surgical repair such as thrombosis, infection or rupture.

Cardiac tamponade

occurs when blood from the dissection leaks into the pericardial sac.

Post-Op Cardiovascular:

peripheral pulses hourly & then routinely; decreased or absent pulse together with a cool, pale, mottled, or painful extremity may indicate embolization or graft occlusion;

Endovascular Aneurysm (EVAR) is minimally invanvesive and an alternative to OAR,. Repair steps:

placement of a sutures aortic graft into the abdominal aorta inside he aneurysm via the femoral artery; main section of the graft is bifurcated & delivered through. femoral artery catheter; 2nd part of graft inserted through opposite femoral artery; all graft components in place, they are released against the vessel wall by inflation-blood flows through there endovascular graft preventing further expansion of the aneurysm.

Saccular Aneurysm

pouch-like with narrow neck connecting the bulge to one side of arterial wall.

Aortic dissection

results from the creation of a false lumen between the intimate (inner lining) & media (middle layer) of arterial wall.

Conservative Treatment is ideal for small asymptomatic AAAs. Best practice & consists of risk factor modification"

stopping tobacco use, optimizing lipid profile results, gradually increasing physical activity, HR control (reduces aortic wall stress by decreasing HR to 60 bpm or less with IV beta blocker), BP control (reduces stress on aortic wall; systolic BP between 100-110 mmHG and myocardial activity with IV beta blocker or calcium channel blocker can be used if beta blocker ins contraindicated; ace inhibitors may also be used.

Complications of an aneurysm:

the larger it is the greater risk of rupture. if rupture occurs in the retroperitoneal space the patient often has back pain and may have back or flank ecchymosis. if rupture occurs into the thoracic or abdominal cavity, patients may die from massive hemorrhage. if the patient has a rupture outside the hospital, they will be in hypovolemic shock upon arrival.

True Aneurysm is when:

the wall of the artery forms aneurysm with at least one vessel layer still intact.

False aneurysms may result from:

trauma, infection, peripheral artery bypass graft surgery.

Risk factors for an aneurysm include:

age, male, tobacco, high cholesterol, obesity, HTN, CAD, LE artery disease, & family history.

The patient newly diagnosed with a 4.1 cm aortic aneurysm states, "my provider said that the aneurysm with be treated conservatively. What does this mean? What is the nurses BEST response? a. the clinic will call you this week to schedule your aneurysm repair surgery. ' b. lifestyle changes & 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 decreased the size of th aneurysm. d. you will need to increase your physical activity and take your prescribed HTN medication to fix the aneurysm.

B. Conservative medical therapy of small asymptomatic AAA's (4.0-5.4cm) is the best practice and consists of risk factor modifications.

Drug therapy used for an aortic aneurysm:

Beta blockers (propranolol) ACE inhibitors (captopril) Angiotensin II receptor blockers (losartan) Statins (simvastatin) Antibiotics (doxycylcine)

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 A pulse of 96 beats/min is considered normal. While an elevated creatinine level and low urine output may indicate a renal issue, these are not the most concerning findings at this time. Aortic dissection can cause renal ischemia due to the lack of blood flow. Low urine output may be expected if the patient is hemorrhaging. b. Respirations 24, lower extremity weakness, tingling in fingers An increased respiratory rate may indicate pain, hemorrhage, or anxiety. Aortic dissection can cause spinal cord ischemia. While these findings do need further assessment and treatment, this is not the priority at this time. Correct 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. d. Temperature 99.1 degrees Fahrenheit, decreased bowel sounds, abdominal pain Aortic dissection can lead to mesenteric ischemia that would cause abdominal pain and decreased bowel sounds. While this needs further assessment and treatment, it is not the highest priority at this time. A temperature of 99.1 is not concerning.

C

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 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."

C. "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 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. BLE are mottled, dusky & cool d. bruit heard on auscultation over the anterior midline chest

C. BLE that are gray & 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 & toes in the presence of palpate pedal pulses).

Which patient is at highest risk of developing an aortic aneurysm? a. 47 y/o male with BMI 23 b. 59 y/o female with LDL of 98 mg/dl c. 67 y/o female w/ arterial LE ulcer d. 73 y/o male smokes 4 packs a day last 25 years.

D. 73 y/o male with history of smoke is at highest risk for developing an aneurysm due to his increasing age and his long term tobacco use.

The patient presents to the emergency department with a BP of 76/52 mmHG. What subjective symptoms from the patient would be MOST concerning to the nurse? a. painful urination. b. decreased sensation of feet c. chills & sweating during the night d. tearing & ripping sensation in the anterior chest

D. Tearing & ripping sensation in the anterior chest would be the most concerning because it ay indicate aortic dissection. Other symptoms may include altered level of consciousness, weak uses, & dizziness from internal hemorrhage.

False Aneurysm (pseudoaneurysm)

a disruption of all arterial wall layers with blending that is contained by surrounding anatomic structures.

Marfan syndrome:

a hereditary condition that affects the musculoskeletal system & is often associated with abnormalities of the cardiovascular system and of the eyes.

Acute type A dissection pain is:

abrupt onset of excruciating anterior chest pain.