Download CONGESTIVE HEART FAILURE

Valvular Heart
Disease/Myopathy/Aneurysm
By Nancy Jenkins
Definition
• Abnormal dilation of a blood vessel at a site
of weakness or a tear in the vessel wall.
• Usually secondary to atherosclerosis.
• Most commonly affect the aorta
Bing Video: Abdominal Aortic
Aneurysm Surgery
Aortic Aneurysms
• Atherosclerotic plaques deposit beneath the intima
– Plaque formation is thought to cause degenerative changes in
the media
– Leading to loss of elasticity, weakening, and aortic dilation
• Dilated aortic wall can become lined with thrombi than can
embolize
– Leads to acute ischemic symptoms in distal branches
– Important to assess peripheral pulses
Aorta
• Largest artery
• Responsible for supplying oxygenated
blood to essentially all vital organs
• **Aneurysm can occur in any artery but the
aorta is most common
• Growth rate unpredictable
– **Larger the aneurysm greater risk of rupture
May also involve the
aortic arch or the
thoracic aorta,
Most (3/4) are found
in abdominal aorta
below renal arteries
¼ are found in the
thoracic area
Aortic Aneurysms
– Studies suggest strong genetic predisposition
• *Male gender and smoking stronger risk factors
than hypertension and diabetes
• Abdominal aortic aneurysms (AAA)
– Occur in 4.1% to 14.2% of men
– 0.35% to 6.2% of women over 60
– Cause of 16,000 deaths per year
Risk Factors- Atherosclerosis
Fusiform
Most AAA are fusiform and 98% are below the
renal artery
Aortic Aneurysms
Classification
• False aneurysm
– Also called pseudoaneurysm
– Not an aneurysm
– Disruption of all layers of arterial wall
• Results in bleeding contained by surrounding structures
• Pseudoaneurysm: an outpouching of a blood vessel,
involving a defect in the two innermost layers (the
tunica intima and media) with continuity of the
outermost layer, the adventitia. Alternatively, all
three layers are damaged and bleeding outside of the
vessel is contained by a clot or by surrounding
tissue.
False Aneurysms
• May result from
– Trauma
– Infection
– After peripheral artery bypass graft surgery at
site of anastomosis
– Arterial leakage after cannulae removal
Aortic Aneurysm
Diagnostic Studies
• X-rays- Most are diagnosed without symptoms on
routine X-ray
– Chest - Demonstrate mediastinal silhouette and any
abnormal widening of thoracic aorta
– Abdomen -May show calcification within wall of AAA
• ECG -to rule out MI
Aortic Aneurysm
Diagnostic Studies
• Echocardiography
– Assists in diagnosis of aortic valve
insufficiency
• Related to ascending aortic dilation
• Ultrasonography
– Useful in screening for aneurysms
– Monitor aneurysm size
Aortic Aneurysm
Diagnostic Studies
• CT scan
– Most accurate test to determine
• Anterior to posterior length
• Cross-sectional diameter
• Presence of thrombus in aneurysm
• MRI
– Diagnose and assess the location and severity
Aortic Aneurysm
Diagnostic Studies
• Angiography
– Anatomic mapping of aortic system using
contrast
– Not reliable method of determining diameter or
length
– Can provide accurate info about involvement of
intestinal, renal or distal vessels
Clinical Manifestations By
LocationThoracic Aortic Aneurysm
• Frequently asymptomatic
• May have substernal, neck or back pain
• Coughing, due to pressure placed on
the windpipe (trachea)
• Hoarseness
• Difficulty swallowing
• Swelling (edema) in the neck or arms
• Myocardial infarction, or stroke due to
dissection or rupture involving the
branches of the aorta
Ascending Aortic Aneurysm
Aortic Arch
Clinical Manifestations
ASH
– Angina
– Hoarseness
– If presses on superior vena cava
• Decreased venous return can cause
– Distended neck veins
– Edema of head and arms
Abdominal Aortic Aneurysm
Clinical Manifestations
• Abdominal aortic aneurysms (AAA)
– Often asymptomatic
– Frequently detected
• On physical exam
– Pulsatile mass in periumbilical area (Grey’s Anatomy)
– Bruit may be auscultated
• When patient examined for unrelated problem (i.e.,
CT scan, abdominal x-ray)
Aortic Aneurysm
Clinical Manifestations
• AAA, con’t
– May mimic pain associated with abdominal or back
disorders
– Pain correlates to the size- can be excrutiating
– May spontaneously embolize plaque
• Causing “blue toe syndrome” patchy mottling of feet/toes with
presence of palpable pedal pulses
• It can rupture, causing shock and death in 50% of
rupture cases
–
Nursing Diagnoses
•
•
•
•
•
Risk for Ineffective Tissue Perfusion
Risk for Injury
Anxiety
Pain
Knowledge Deficit
Medical Treatment of Aneurysms- if
less than 5cm
• Anti-hypertensives
–
–
–
–
Beta blockers,
Vasodilators
Calcium channel blockers
Nipride
• Sedatives
• Niacin, mevocor, statins
Post-op anti-coagulants
Complication
Aortic Dissection
• Blood invades or dissects the layers of the
vessel wall- most often thoracic
Aortic dissection - Wikipedia, the
free encyclopedia
Dissecting aneurysms are unique and life threatening. A break or tear
in the tunica intima and media allows blood to invade or dissect the
layers of the vessel wall. The blood is usually contained by the
adventitia, forming a saccular or longitudinal aneurysm.
Aortic Dissection
• Affects men more often
than women
• Occurs most frequently
between fourth and
seventh decades of life
• Acute and life
threatening
• Mortality rate 90% if
not medically or
surgically treated
Aortic Dissection
Etiology and Pathophysiology
• As heart contracts, each systolic pulsation ↑
pressure on damaged area
– Further ↑ dissection
– May occlude major branches of aorta
• Cutting off blood supply to brain, abdominal organs,
kidneys, spinal cord, and extremities
• People with Marfan’s at risk
Manifes tations of Aortic D is s ection
Aneurys m
 Abrupt, s evere, ripping or
tearing pain in area of
aneurys m
 Mild or marked
hypertens ion early
 Weak or abs ent puls es and
blood pres s ure in upper
extremities
 S yncope
C omplications : hemorrhage,
is chemic kidneys (renal
failure), MI, heart failure,
cardiac tamponade, s eps is ,
weaknes s or paralys is of
lower extremities .
Aortic Dissection
Collaborative Care
• Initial goal
– ↓ BP and myocardial contractility to diminish pulsatile
forces within aorta
• Drug therapy
– IV β-adrenergic blocker
• Esmolol (Brevibloc)
– Other hypertensive agents
• Calcium channel blockers
• Sodium Nitroprusside
• Angiotensin-converting enzyme
Aortic Dissection
• Surgical therapy
– When drug therapy is ineffective
or
– When complications of aortic dissection are present
• Heart failure, leaking dissection, occlusion of an artery
– Surgery may be delayed to allow edema to decrease and
permit clotting of blood.
– Even with prompt surgical intervention
• 30-day mortality of acute aortic dissections remains high
(10%-28%)
AAA-Medical Treatment - Surgery
or Stent
• Usually repaired if >5cm
• Open procedure- abd incision, cross clamp
aorta,aneuysm opened and plaque removed, then
graft sutured in place. Care much like after CABG
(Not done as much anymore unless a rupture)
– Pre-op assess all peripheral pulses
– Post-op-check urine output and peripheral pulses hourly
for 24 hours- (when to call Dr.)
• Endovascular stents- placed through femoral
artery
Stent Graft Repair
http://www.y
Aortic Aneurysm
• Endovascular graft procedure, con’t
– Approach is percutaneous femoral access
• Advantages
–
–
–
–
Shorter operative time
Shorter anesthesia time
Reduction in use of general anesthesia
Reduced groin complications within first 6 months
Open Repair of AAA
• Post-Op- Similar to CABG
• ICU monitoring
– Arterial line
– Central venous pressure (CVP) or pulmonary artery (PA)
catheter
– Mechanical ventilation
– Urinary catheter
– Nasogastric tube
– ECG
– Pulse oximetry
– Pain medication
Nursing Management
Nursing Implementation
• Acute Intervention
– Postop, continued
• Cardiovascular status
–
–
–
–
–
Continuous ECG monitoring
Electrolyte monitoring
Arterial blood gas monitoring
Oxygen administration
Antidysrhythmic/pain medications
Nursing Management
Nursing Implementation
• Acute Intervention
– Postop, continued
• Infection
–
–
–
–
–
Antibiotic administration
Assessment of body temperature
Monitoring of WBC
Adequate nutrition
Observe surgical incision for signs of infection
Nursing Management
Nursing Implementation
• Acute Intervention
– Postop, continued
• Gastrointestinal status
–
–
–
–
Nasogastric tube
Abdominal assessment
Passing of flatus is key sign of returning bowel function
Watch for manifestations of bowel ischemia
Nursing Management
Nursing Implementation
• Acute Intervention
– Postop, continued
• Neurologic status
–
–
–
–
–
–
Level of consciousness
Pupil size and response to light
Facial symmetry
Speech
Ability to move upper extremities
Quality of hand grasps
Nursing Management
Nursing Implementation
• Acute Intervention
– Postop, continued
• Peripheral perfusion status
– Pulse assessment
• Mark pulse locations with felt-tip pen
– Extremity assessment
• (5P’s) Temperature, color, capillary refill time,
sensation and movement of extremities
Nursing Management
Nursing Implementation
• Acute Intervention
– Postop, continued
• Renal perfusion status
–
–
–
–
–
Urinary output
Fluid intake
Daily weight
CVP/PA pressure
Blood urea nitrogen/Creatinine
Nursing Management
• Ambulatory and Home Care
•
•
•
•
Encourage patient to express concerns
Patient instructed to gradually increase activities
No heavy lifting
Educate on signs and symptoms of complications
• Infection
• Neurovascular changes
Prevention
• 1.Ultrasound is extremely effective at
detecting AAAs.The U.S. Preventive
Services Task Force (USPSTF)
recommends that anyone aged 65 to 75
who has ever smoked undergo a onetime ultrasound screening for AAA
• 2.Prevent atherosclerosis
• 3.Treat and control hypertension
• 4.Diet- low cholesterol, low sodium and
no stimulants
• 5.Careful follow-up if less than 5cm. It
can grow .5cm /year
Other Complications
• Rupture- signs of ecchymosis (triad)
– Back pain
– Hypotension
– Pulsating mass
• Thrombi
• Renal Failure
Rupture Triad
Back
pain
Hypotension
Pulsating
hematoma
Rupture
• Rupture- serious complication related to untreated
aneurysm
– Posterior rupture
• Bleeding may be tamponaded by surrounding structures, thus
preventing exsanguination and death
• Severe pain
• May/may not have back/flank ecchymosis
Anterior rupture
• Massive hemorrhage
• Most do not survive long enough to get to the hospital WHY??
Rupture
False Aortic Aneurysm with Rupture of the
Aorta : Medical Animation
http://www.austincc.edu/adnlev4/rnsg2331online/m
odule05/aneurysm_case_study.htm
Student Case Study
Patient History
27 year old male
African American
L ives alone in apartment
F amily hx D M
Morbid obesity (314.6 lbs )
Height: 5’11
Ambulates with walker
F ull C ode
Medical His tory:
E T O H abuse
S moker
Hypertens ion
DOE
S leep apnea
T rach (8/30)
E jection F raction 50%
Hemodialys is (M-W-F )
Mitral insufficiency, Mild regurgitation(mitrial, tricuspid)
P ress ure ulcer on coccyx
R espiratory failure with trach , pneumonia, delirium
 (8/13) P t appeared in E R
w c/o flank and abd pain
 B /P 270/159
(C ardene drip which decreas ed pres sure to 185/73)
Na 138 K 4.4 C h108 B UN 24 C reat 3.0
G lucos e 147 C a 8.5 H gb 12.5
Admis s ion diagnos is :
Malignant hypertens ion
T ype B Aortic D is s ection
R enal ins ufficiency
Morbid obes ity
P t teaching:
S moking ces s ation
C ontrol H TN
L ifes tyle changes
D iet control
Us e of s tool s ofteners (increase fluid and fiber in diet)
• E X T R A DX DE VE L O P E D
DUR ING HO S P IT AL
S T AY :
• Myopathy
• Acute res piratory failure
• C hronic kidney dis eas e
• P neumonia due to S taph
and Hemophilus
Influenze
• HT N encephalopathy
acute renal dis eas e with
les ion of tubular necros is
• Delirium
• Uns pec d/o of kidney and
ureter
S urgery
•
S urgery is done when an
aneurys m is 6 cm in diameter,
expanding fas t or s ymptomatic.
T ype B dis s ections are
s urgically repaired depending
on extent of involvement and
ris k for rupture.
• Aneurys m excis ed and
replaced with s ynthetic fabric
graft.
Ns g D x:
• R is k for Ineffective tis s ue
perfus ion.
• Anxiety
Medications
Allergy:PCN
T reated with long term beta blocker therapy and antihypertens ive drugs as needed to control heart
rate and blood pres s ure. Initially treated with I.V beta blockers s uch as propranolol (Inderal),
metoprolol (L opres s or), Normodyne or B revibloc to reduce heart rate to 60 bpm. Nipride
infus ion to reduce s ys tolic to 120mmHg. C alcium channel blockers may als o be us ed. Direct
vas odilators are avoided becaus e they may wors en the dis s ection. After s urgery anticoagulants
may be initiated; us ed indefinitely and maybe even lifelong.
P t meds : Albuterol 2.5mg IH q8h
H eparin 5000u S Q q8h
F lonas e nas al s pray 2 s prays each nos e q12h
Amphojel 1020mg q8h
C atapres s 0.2mg q4h
Minoxidil 10mg P O q12h
E ns ure s upp 240ml P O T ID
P rotonix 40mg po d
Multivitamin 1 tab P O d
L exapro 20mg P O d
R enal D iet
P rocrit 10000u S Q MWF
R P ermacath, R AC , S L