Valvular Heart Disease/Myopathy/Aneurysm By Nancy Jenkins

Aortic Aneurysms Grey's anatomy AAA 5 minutes

Aorta Largest artery Responsible for supplying oxygenated blood to essentially all vital organs

Aortic Aneurysms Most Common- AAA Abdominal aortic aneurysms (AAA) Incidence –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

Aortic Aneurysms Locations May also 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 Etiology and Pathophysiology Risk Factors 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 What can happen?? Dilated aortic wall becomes lined with thrombi than can embolize –Leads to acute ischemic symptoms in distal branches –Important to assess peripheral pulses

Clinical Manifestations By Location- Thoracic 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 –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 –

Ascending Aortic arch

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 to fusiform and saccular 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 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.

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 in Summary Fig. 38-3

Complication Aortic Dissection Blood invades or dissects the layers of the vessel wall 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 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

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 may be delayed to allow edema to decrease and permit clotting of blood

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

Angiography of Aneurysm Fig. 38-2

Medical Treatment of Aneurysms 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. (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

Aneurysm repair YouTube - Endovascular Repair for Abdominal Aortic Aneurysm

End ovas cula r Rep air of an Abd omi nal Aort ic Ane urys m (Courtesy of Guidant Corporatio n) 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 one- time 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 Anterior rupture Massive hemorrhage Most do not survive long enough to get to the hospital WHY??

Rupture Live Search Videos: aortic aneurysm

ule05/aneurysm_case_study.htm

Case study from Hospital

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 analgesic 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.