CHAPTER 2Cardiovascular: Aortic Aneurysms pulmonary failure (e.g., acute respiratory distress
syndrome [ARDS]) (Tseng & Bush, 2016).
b. Cost: No recent fi gures of overall costs in the United States are found, partly owing to the number of reports regarding a par tic u lar type of aneurysm and its par tic u lar treatment. For example: One clinical trial carried out between 2002 and 2008 (and comparing costs between endovascular and open abdomen repair of ascending aortic aneurysms) reported that “total mean health care costs did not differ signifi cantly between the 2 groups (endovascular group, $142 745; open repair group, $153 533)” (Lederle et al, 2016).
Another recent study found that “the adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair”
(Haider et al, 2015).
b. Less common (not a complete list): Left hemothorax, pleural effusion; superior vena cava syndrome; airway obstruction, vocal cord paralysis; hematemesis; spinal cord injury; renal vascular hypertension
V. Statistics
a. Mortality: Aortic aneurysms were the primary cause of 9,863 deaths in the United States in 2014 (CDC, 2016).
i. Aneurysmal rupture is one of the 15 leading causes of death in most lists (Tseng & Bush, 2016).
ii. Up to 50% of patients with ruptured abdominal aortic aneurysms do not reach the hospital, and those who do survive to the operating room have a mortality rate as high as 50% (Aggarwal et al, 2011).
iii. Early morbidity and mortality are related to bleeding, neurologic injury (e.g., stroke), cardiac failure, and
Aorta: Largest blood vessel of the body. Is composed of four parts: (1) ascending aorta (supplies coronary arteries and aortic valve), (2) aortic arch (brings blood to head, neck, and arms), (3) descending thoracic aorta (supplies blood to ribs and some chest structures), and (4) abdominal aorta (most major organs receive blood from branches of the abdominal aorta). The walls of the aorta have three layers:
(1) inner (also known as the intima, a thin layer closest to blood fl ow); (2) middle (also called media), which provides the aorta its strength and elasticity; and (3) outer (also called adventitia), which provides structure and support. The intima is the portion that swells and forms a bulge (aneurysm) when the media weakens (Bellomo &
Cichminski, 2013; Hiratzka et al, 2010).
Aortic aneurysm (AA): Balloon- like bulge in aorta resulting in aortic dilation. Risk factors include (1) direct mechani- cal forces on the aortic wall, such as hypertension, and (2) factors that affect the composition of the aortic wall (e.g., connective tissue disorders) (Green & Kron, 2003; Strauss
& Davis, 2014). Symptomatic abdominal aortic aneurysms
(AAAs) that are not dissected are often treated with surgery and endovascular grafting. AA can be a cause of AD (see below).
Aortic dissection (AD): When aortic dissection (tearing) occurs, blood enters the linings of the aorta, tearing apart the layers of the wall, creating another pathway within which the blood runs (a false lumen). The dissection (a potentially life- threatening event) can travel along the length of the aorta, occluding blood vessels that arise from the aorta and causing damage to the organs supplied by those blood vessels. The primary tear is often more than 50% of the circumference of the aorta (Green &
Kron, 2003) and is more common in the ascending aorta.
Aortic rupture: Dissection can result in an early or late rupture (a catastrophic event). Because the aorta is the body’s main supplier of blood, rupture can cause life- threatening bleeding.
Endoleak: A condition in which blood leaks into a vessel that has had a stent graft inserted to correct an aortic aneurysm.
G L O S S A R Y
CARE SETTING
1. Emergency department: Screening may identify presence of aneurysm in patient being evaluated for pain. Patient risk and need for admission must be classifi ed as high, me- dium, or low. These levels are determined by presence of high- risk conditions, such as pain and outcome of physi- cal examination (White et al, 2013).
2. Acute care for emergent or elective surgical repair of aneurysm.
3. Community care for medical management of slow- growing aneurysms. Medical management includes peri- odic monitoring for changes in size of aneurysm and medi cations to reduce hypertension and lessen pulsatile load or aortic stress (White et al, 2013).
4. Note: Medical management is not addressed in this care plan.
Note: Focus of this care plan is postoperative care.
RELATED CONCERNS
Acute coronary syndrome, page 54
Cerebrovascular accident (CVA)/stroke, page 247 Cardiac surgery, page 98
Hypertension: severe, page 26 Myo car dial infarction, page 72
Upper gastrointestinal bleeding, page 340 Pneumothorax/hemothorax, page 169 Psychosocial aspects of care, page 835
Acute kidney injury (acute renal failure), page 595 Surgical intervention, page 873
D I A G N O S T I C D I V I S I O N
M A Y R E P O R T M A Y E X H I B I T
Circulation
• History of poorly controlled hypertension and current hypertension
• Hypertension (70% of patients with AD have chronic hyperten- sion) (White et al, 2013)
• Blood pressure differential >20 mm Hg between right and left arms (dissection)
• Hypotension (with rupture)
• Hypertension potentially followed by hypotension (with dissection)
• Pulses: Tachycardia (with rupture); bounding pulses, wide pulse pressure (dissection). Pulse defi cit is not always pres ent but occurs more commonly in type A dissections than in type B. Absence of upper extremity pulses may suggest ascending aortic aneurysm. Absent or reduced lower extremity peripheral pulses may occur if aneurysm is affecting either iliac artery.
• Heart rate and rhythm: Tachycardia and/or vari ous dysrhyth- mias may occur. ECG may show ischemia or patterns of myo car dial damage if coronary arteries are involved.
• Heart sounds: Abnormal sounds are not always pres ent. Aortic insuffi ciency murmurs are pres ent in about 44% of patients with type A dissections (White et al, 2013). Diastolic murmurs may be heard. Heart sounds are distant if pericardial tampon- ade is occurring.
• Skin: Pallor, clamminess, diaphoresis
Ego Integrity
• Feeling anxious • Restlessness, self- focus, alteration in attention; decreased
perceptual fi eld
Elimination
• May have decreased/or absent output if renal arteries are involved or hypotension/shock is pres ent
• May have decreased urinary output if renal arteries are involved or hypotension shock is occurring secondary to right coronary artery occlusion or cardiac tamponade due to rupture into pericardial space (Strauss & Davis, 2014).
Food/Fluid
• Nausea • Vomiting
• Diaphoresis
Neurosensory
• Dizziness • May have syncope; loss of consciousness
• Weakness on one side of body • May have symptoms similar to stroke if aortic arch is involved.
Pain/Discomfort
• Pulsating mass near navel • Mass may be palpated in abdomen (size must be about 4 cm
before it can be felt) (Thompson & Szalay, 2014).
• Pain reports: • Client may not experience pain (particularly in slow- developing
thoracic or abdominal aneurysm).
• Chest pain can mimic those of acute coronary syndromes • Differential diagnosis will clarify issues, but diagnostic studies are usually necessary.
• Pain with dissection: • Although opiates can positively infl uence hemodynamics, they
may not relieve patient’s pain because of its severity (White et al, 2013).
C L I E N T A S S E S S M E N T D A T A B A S E ( P R E R U P T U R E / P R E O P E R A T I V E )
Data depend on the duration and severity of under lying prob lem and involvement of other body systems. Refer to specifi c plans of care for or relevant data and Diagnostic Studies and nursing diagnoses.
T E S T
W H Y I T I S D O N E W H A T I T T E L L S M E
Blood Tests
• Complete blood count (CBC): Battery of screening tests that typically includes hemoglobin (Hgb); hematocrit (Hct); red blood cell (RBC) count; morphology, indices, and distribution width index; platelet count and size; and white blood cell (WBC) count and differential.
Presence of leukocytes in WBCs may indicate stress state.
Decreased Hgb and Hct levels in the CBC may be pres ent with leaking or rupture of dissection anywhere along the aorta.
• Cardiac enzymes, including troponin I and troponin T, also possibly creatinine kinase (CK) and myoglobin: Substances released from heart muscle when it is damaged.
Troponins are reliable markers for cardiac tissue damage (if coronary arteries involved). Myoglobin is not specifi c to cardiac muscle tissue, but if negative, it can help rule out MI.
• Smooth- muscle myosin heavy- chain assay: A cytoplasmic structural protein that is a major component of the contractile apparatus in smooth muscle cells.
Test is performed in the fi rst 24 hours. Increased levels in the fi rst 24 hours are 90% sensitive and 97% specifi c for aortic dissection. Levels are highest in the fi rst 3 hours (Mancini, 2016).
• Serum lipids, including total lipids, cholesterols, and triglycerides: A group of tests that make up a lipid profi le.
Presence of high cholesterol increases risk of atherosclerosis, which can cause aortic aneurysms, and increases risk of stroke when aneurysm is large or unstable.
M A Y R E P O R T (continued) M A Y E X H I B I T (continued)
• For acute type A dissections, pain is often “tearing or ripping.”
Pain is at maximal intensity at onset, rather than gradual (White et al, 2013).
• For type B dissections, chest pain and back pain may be about equally reported (Strauss & Davis, 2014; White et al, 2013).
• Pain may migrate as dissection increases in size.
• Pain with rupture:
• Pain may occur in abdominal, lower back, fl ank, groin
• Lower limb pain • Pallor, lack of pulses, cool extremity (if AAA rupture)
Respiration
• Shortness of breath • Respiratory distress or use of accessory muscles
• Tobacco use (smoking), which is a major risk factor • Adventitious breath sounds, such as crackles or wheezes
• Pallor or cyanosis generally associated with advanced cardiopulmonary effects of sustained or severe hypertension
Safety
• Lightheadedness; fainting
• Fever • May or may not be pres ent
Teaching/Learning
• Familial and individual risk factors, including hypertension, atherosclerosis; prior aneurysms in other large blood vessels (e.g., behind knee, thoracic aorta); diseases that cause blood vessels to become infl amed
• While certain risk factors (e.g., gender, age, race) are nonmodi- fi able, smoking and drug use are be hav iors that should be addressed in teaching.
Discharge Plan Considerations
• May require assistance with ADLs, transportation, homemak- ing tasks, dressing(s)/supplies
• Pos si ble placement in rehabilitation or long- term care fa cil i ty
➧ Refer to section at end of plan for post discharge considerations.
D I A G N O S T I C S T U D I E S ( P R E O P E R A T I V E )
(continues on page 114)
CHAPTER 2Cardiovascular: Aortic Aneurysms
W H Y I T I S D O N E (continued) W H A T I T T E L L S M E (continued)
• Blood urea nitrogen (BUN) and creatinine (Cr): These tests mea sure the amount of nitrogen and chemical waste product in the blood that passes through the kidneys to be fi ltered and eliminated in urine. When mea sured together (in certain ratios), information is obtained about kidney function.
Changes in kidney function may occur with renal artery involvement and/or with hypotension/shock state.