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Valvular Heart Disease/Myopathy/Aneurysm By Nancy Jenkins Aortic Aneurysms Aortic Aneurysm - Page 5 Aorta • Largest artery • Responsible for supplying oxygenated blood to essentially all vital organs Aortic Aneurysms Etiology and Pathophysiology • Dilated aortic wall becomes lined with thrombi than can embolize – Leads to acute ischemic symptoms in distal branches – Important to assess peripheral pulses Aortic Aneurysms Etiology and Pathophysiology • 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 – *Male gender and smoking stronger risk factors than hypertension and diabetes • Studies suggest strong genetic predisposition Aortic Aneurysms Etiology and Pathophysiology • May involve the aortic arch, thoracic aorta, and/or abdominal aorta – Most are found in abdominal aorta below renal arteries • ¾ of true aortic aneurysms occur in abdominal aorta – ¼ found in thoracic Aortic Aneurysms Definition • 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 In Canada, account for 0.7% of all mortalities LocationThoracic Aortic Aneurysm Clinical Manifestations • 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 Location 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 – 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 – 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 – Aortic Aneurysms Etiology and Pathophysiology • May have aneurysm in more than one location • Growth rate unpredictable – Larger the aneurysm greater risk of rupture Aortic Aneurysms Classification • 2 basic classifications – True – False Aortic Aneurysms Classification • True aneurysm – Wall of artery forms the aneurysm – At least one vessel layer still intact Aortic Aneurysms Classification • True aneurysm – Further subdivided • Fusiform – Circumferential, relatively uniform in shape • Saccular – Pouchlike with narrow neck connecting bulge to one side of arterial wall Saccular Fusiform Most 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 Aortic Aneurysms Classification • May result from – Trauma – Infection – After peripheral artery bypass graft surgery at site of anastomosis – Arterial leakage after cannulae removal Types of Aneurysms Fig. 38-3 Dissecting • Blood invades or dissects the layers of the vessel wall 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 occurs when blood enters the wall of aorta, separating its layers, and creating a blood filled cavity. Aortic Dissection • Often misnamed “dissecting aneurysm” • Not a type of aneurysm • Occurs most commonly in thoracic aorta – Result of a tear in the intimal lining of arterial wall 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 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 Marfan’s Dissection of Thoracic Aorta 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 Aortic Dissection Collaborative Care • Drug therapy – IV β-adrenergic blocker • Esmolol (Brevibloc) – Other hypertensive agents • Calcium channel blockers • Sodium Nitroprusside • Angiotensin-converting enzyme Aortic Dissection Collaborative Care • Conservative therapy – If no symptoms • Can be treated conservatively for a period of time – Success of the treatment judged by relief of pain – Emergency surgery is needed if involves ascending aorta Aortic Dissection Collaborative Care • Surgical therapy, continued – Even with prompt surgical intervention • 30-day mortality of acute aortic dissections remains high (10%-28%) Aortic Dissection Collaborative Care • Surgical therapy – When drug therapy is ineffective or – When complications of aortic dissection are present • Heart failure, leaking dissection, occlusion of an artery – Surgery is delayed to allow edema to decrease and permit clotting of blood Aortic Aneurysm Diagnostic Studies • X-rays – 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 Angiography of Aneurysm Fig. 38-2 Medical Treatment • Anti-hypertensives – – – – Beta blockers, Vasodilators Calcium channel blockers Nipride • Sedatives • Niacin, mevocor, statins Post-op anti-coagulants Surgery • Usually repaired if >5cm • Open procedure- abd incision, cross clamp aorta,aneuysm opened and plaque removed, then graft sutured in place – 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 Aneurysm repair Live Search Videos: aneurysm End ovas cula r Rep air of an Abd omi nal Aort ic Ane urys m (Courtesy of Guidant Live Search Videos: aortic aneurysm Aortic Aneurysm Collaborative Care • Endovascular graft procedure, con’t – New 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 Nursing Management Nursing Implementation • Acute Intervention – Post-op • ICU monitoring – Arterial line – Central venous pressure (CVP) or pulmonary artery (PA) catheter – Mechanical ventilation – Urinary catheter Nursing Management Nursing Implementation • Acute Intervention – Post-op • ICU monitoring – – – – 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 Nursing Management Nursing Implementation • Acute Intervention – Postop, continued • Peripheral perfusion status – Extremity assessment • 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 Nursing Implementation • 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 Nursing Diagnoses • • • • • Risk for Ineffective Tissue Perfusion Risk for Injury Anxiety Pain Knowledge Deficit 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 Complications • Rupture- signs of ecchymosis – Back pain – Hypotension – Pulsating mass • Thrombi • Renal Failure Rupture Triad Back pain Hypotension Pulsating hematoma Aortic Aneurysm Complications • 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 Turner’s sign and Cullen’s sign Aortic Aneurysm Complications • Rupture- serious complication related to untreated aneurysm – Anterior rupture • Massive hemorrhage • Most do not survive long enough to get to the hospital WHY?? Rupture Live Search Videos: aortic aneurysm http://www.austincc.edu/adnlev4/rnsg2331online/mod ule05/aneurysm_case_study.htm Case study from Hospital 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 Labs Diagnostic Test C hes t X -ray to vis ualize thoracic aortic aneurys ms : C ardiac s ilhouette remains enlarged. P os ition of endotrachial tube opacity. P ulmonary vas cular conges tion pers ist. Aortic arch enlarged; mild perihilar interstitial pulmonary edema. Atelectas is or edema adjacent to left ventricular border improved. L ungs underinflated with evidence of pulmonary edema. C T to allow precis e meas urement of aneurys m: S tanford B thoracic aortic dis s ection distal to origin of L eft s ubclavian to above iliac arteries . C ompromis ed flow of left renal artery. L eft ventricular hypertrophy and left renal s tone. Vital S igns : B /P - 109/53 P -88 100.8 R - 18 T - WB C 12.9 ? R B C 3.13 ? Hgb 8.9 ? Hct 26 ? P lt 200 Na 129 K 3.6 C hl 90 ? B un 120 ? AG AP 16 ? Mg 2.3 C reat 10 ? G lucos e 115 ? P hos 8 ? 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 D is charge Ins tructions P t dis charged to C orners tone at S t David’s for R ehab with trach P s ychiatry cons ult for behavioral problems C ardiology s eeing pt for B /P control (ranging from 110-130 s ys tolic upon dis charge) R egular diet American Heart As s ociation P hys ical therapy being used but s till needs lots of rehab P lan is to medically manage aortic dis s ection for now and once s table he’ll follow up w vas cular s urgery for definitive treatment. F /U w vas cular s urgery and C ardiothoracic M.D when d/c from C orners tone, nephrology, internal medicine, infectious dis eas eps ychiatry Dis charged 09-26 Dis charge Medications : F lonas e daily Heparin 5000 u q 8h Albuterol MD I p.r.n Amphojel 30cc q8h Atenolol 50mg q 12h C lonidine 0.2 p.r.n Minoxidil 10mg B .I.D E ns ure T .I.D w meals P rotonix 40mg d Multivitamin d L exapro 20mg d P rocrit q M-W-F s ubcu 10,000u Ativan p.r.n Priority Question # 29 • During the initial post-operative assessment of a patient who has just transferred to the post-anesthesia care unit after repair of an abdominal aortic aneruysm all of these data are obtained. Which has the most immediate implications for the client’s care? • A. The arterial line indicates a blood pressure of 190/112. • B. The monitor shows sinus rhythm with frequent PAC’s. • C. The client does not respond to verbal stimulation. • D. The client’s urine output is 100ml of amber urine. Priority Question #30 • It is the manager of a cardiac surgery unit’s job to develop a standardized care plan for the post-operative care of client having cardiac surgery. Which of these nursing activities included in the care plan will need to be done by an RN? • A. Remove chest and leg dressings on the second post-operative day and clean the incisions with antibacterial swabs. • B. Reinforce patient and family teaching about the need to deep breathe and cough at least every 2 hours while awake. • C. Develop individual plan for discharge teaching based on discharge medications and needed lifestyle changes. • D. Administer oral analgesisc medications as needed prior to assisting patient out of bed on first post-operative day. Priority Question # 25 • These clients present to the ER complaining of acute abdominal pain. Prioritize them in order of severity. • A. A 35 year old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating. • B. An 11 year old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days. • C. A 40 year old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week. • D. A 56 year old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour.