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Disorders of the Aorta
Chapter 38
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Aorta
Largest artery
Responsible for supplying oxygenated blood to essentially all vital organs
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Disorders of the Aorta
Most common vascular problems of aorta
Aneurysms
Aortoiliac occlusive disease
Aortic dissection
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Aortic Aneurysms
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Aortic AneurysmsDefinition
Outpouching or dilation of the arterial wall
Common problems involving aorta
Occur in men more often than in women
Incidence ↑with age
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Abdominal Aortic Aneurysm
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Aortic AneurysmsDefinition
Abdominal aortic aneurysms (AAA)
Affect about 1.1 million adults between 55 and 84 years of age
Most occur below renal arteries
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Aortic AneurysmsEtiology and Pathophysiology
May have aneurysm in more than one location
Aorta larger than 3 cm in diameter is considered aneurysmal
Growth rate unpredictable
The larger the aneurysm, the greater the risk of rupture
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Aortic AneurysmsEtiology and Pathophysiology
Dilated aortic wall becomes lined with thrombi that can embolize
Leads to acute ischemic symptoms in distal branches
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Case Study
E.O., a 74‐year‐old woman, comes to the ED with deep chest pain radiating throughout the chest to the back.
She reports that she smoked 1 pack of cigarettes/day for 20 years, quitting 5 years ago.
She weighs 212 lb.
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Aortic AneurysmsEtiology and Pathophysiology
Causes
Degenerative
Congenital
Mechanical
Penetrating or blunt trauma
Inflammatory
Infectious
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Age
Male gender
High blood pressure (BP)
Coronary artery disease
Family history
High cholesterol
Lower extremity PAD
Carotid artery disease
Previous stroke
Aortic AneurysmsRisk Factors
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Smoking
Being overweight or obese
White and Native Americans have higher risk than African Americans, Hispanics, and American Asians.
Aortic AneurysmsRisk Factors
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Bicuspid aortic valve Coarctation of the aorta Turner’s syndromeAutosomal dominant polycystic kidney disease Ehlers‐Danlos syndrome Loeys‐Dietz syndromeMarfan’s syndrome
Aortic AneurysmsGenetic Link
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Aortic AneurysmsClassification
Two basic classifications
True
False
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True vs. False Aneurysm
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Aortic AneurysmsClassification
True aneurysm
Wall of artery forms the aneurysm
At least one vessel layer still intact
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Aortic AneurysmsClassification
True aneurysm
Further subdivided
Fusiform
Circumferential, relatively uniform in shape
Saccular
Pouchlike with narrow neck connecting bulge to one side of arterial wall
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Aortic AneurysmsClassification
False aneurysm
Also called pseudoaneurysm
Not an aneurysm
Disruption of all layers of arterial wall
Results in bleeding contained by surrounding structures
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Aortic AneurysmClinical Manifestations
Thoracic aorta aneurysms
Often asymptomatic
Most common manifestation
Deep diffuse chest pain
Pain may extend to the interscapular area
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Aortic AneurysmClinical Manifestations
Ascending aorta/aortic arch
Angina
Hoarseness
If presses on superior vena cava
Decreased venous return
Distended neck veins
Edema of face and arms
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Aortic AneurysmClinical Manifestations
Abdominal aortic aneurysms (AAA)
Often asymptomatic
Frequently detected
On physical exam
When patient examined for unrelated problem (i.e., CT scan, abdominal x‐ray)
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Aortic AneurysmClinical Manifestations
AAA
May mimic pain associated with abdominal or back disorders
May spontaneously embolize plaque
Causing “blue toe syndrome”
Patchy mottling of feet/toes with presence of palpable pedal pulses
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Case Study
Based on E.O.’s symptoms, which type of aneurysm would you suspect?
What are the immediate concerns for her?
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Aortic AneurysmComplications
Rupture—serious complication
Rupture into retroperitoneal space
Bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death.
Severe back pain
May/may not have back/flank ecchymosis
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Aortic AneurysmComplications
Rupture—serious complication related to untreated aneurysm
Rupture into thoracic or abdominal cavity
Massive hemorrhage
Most do not survive long enough to get to the hospital
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Aortic AneurysmDiagnostic 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
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Aortic AneurysmDiagnostic Studies
Echocardiography
Assists in diagnosis of aortic valve insufficiency
Ultrasonography
Useful in screening for aneurysms
Monitors aneurysm size
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Aortic AneurysmDiagnostic Studies
CT scan Most accurate test to determine Anterior‐to‐posterior length
Cross‐sectional diameter
Presence of thrombus
Best type of surgical repair
MRI Diagnose and assess the location and severity
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Aortic AneurysmDiagnostic Studies
Angiography
Anatomic mapping of aortic system using contrast
Not reliable method of determining diameter or length
Can provide accurate information about involvement of intestinal, renal, or distal vessels
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Aortic AneurysmCollaborative Care
Goal – prevent aneurysm from rupturing
Early detection/treatment imperative
Once detected
Studies done to determine size and location
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Case Study
E.O. has an ECG in the ED that rules out an acute MI.
Chest x‐ray is suspicious for thoracic aneurysm.
She is now scheduled to go to radiology for CT scan of her chest.
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Aortic AneurysmCollaborative Care
If carotid and/or coronary artery obstruction present, may need to correct before repair Small aneurysm (4‐ 5.5 cm) Conservative therapy used Risk factor modification
↓ blood pressure Ultrasound, MRI, CT scan monitoring annually
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Aortic AneurysmCollaborative Care
5.5 cm is threshold for repair Intervention at >5 cm in women with AAA
Surgical intervention may occur earlier in Patients with a genetic disorder
Rapidly expanding aneurysm
Symptomatic patients
High rupture risk
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Case Study
E.O. returns from CT scan with a diagnosis of a thoracic aortic aneurysm measuring 5.2 cm.
A surgical consult is ordered and E.O. is scheduled for surgery in the next hour.
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Aortic AneurysmCollaborative Care
Surgical therapy
If ruptured, emergent surgical intervention required
90% mortality with ruptured AAAs
Preop
Hydration
Stabilize electrolytes, coagulation, and hematocrit
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Aortic AneurysmCollaborative Care
Surgical technique
Open aneurysm repair (OAR)
Incising diseased segment of aorta
Removing intraluminal thrombus or plaque
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Aortic AneurysmCollaborative Care
Surgical technique –OAR
Inserting synthetic graft
Dacron or polytetrafluoroethylene (PTFE)
Suturing the native aortic wall around graft
Acts as protective cover
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Surgical Repair of Aneurysm
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Aortic AneurysmCollaborative Care
Autotransfusion reduces need for blood transfusion during surgery
AAA resection
Require cross‐clamping of aorta proximal and distal to aneurysm
Can be completed in 30 to 45 minutes
Clamps are removed and blood flow to lower extremities is restored
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Aortic AneurysmCollaborative Care
AAA resections If extends above renal arteries or if cross‐clamp must be applied above renal arteries Check for adequate renal perfusion after clamp removal and before closure of incision.
Risk of postop renal complications ↑significantly when repair is above renal arteries.
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Aortic AneurysmCollaborative Care
Endovascular graft procedure
Alternative to conventional surgical repair
Involves placement of sutureless aortic graft into abdominal aorta inside aneurysm
Minimally invasive
Done through femoral artery cutdown
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Aortic AneurysmCollaborative Care
Endovascular graft procedure
Graft
Constructed from Dacron cylinder
Surface supported with rings of flexible wire
Delivered through sheath to predetermined point
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EVAR
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Aortic AneurysmCollaborative Care
Endovascular graft procedure
Graft
Deployed against vessel wall by balloon inflation
Anchored to vessel by series of small hooks
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Aortic AneurysmCollaborative Care
Endovascular graft procedure
Blood then flows through graft, preventing expansion of aneurysm
Aneurysm wall will begin to shrink over time
Must meet strict eligibility criteria to be a candidate
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Aortic AneurysmCollaborative Care
Endovascular graft procedure Benefits
↓ anesthesia and operative time
Smaller operative blood loss
↓morbidity and mortality
More rapid resumption of physical activity
Shortened hospital stay
Quicker recovery
Higher patient satisfaction
Reduction in overall costs
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Aortic AneurysmCollaborative Care
Endovascular graft procedure
Potential complications
Endoleak
Aneurysm growth
Aneurysm rupture
Aortic dissection
Bleeding
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Aortic AneurysmCollaborative Care
Endovascular graft procedure
Potential complications
Stent migration
Renal artery occlusion
Graft thrombosis
Incisional site hematoma
Site infection
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Aortic AneurysmCollaborative Care
Endovascular graft procedure
Graft dysfunction may require traditional surgical repair
Need for long‐term follow‐up
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Intraabdominal hypertension (IAH)
Potentially lethal complication in emergency repair
Associated with abdominal compartment syndrome (ACS)
Reduces blood flow to viscera
End‐organ perfusion impaired
Aortic AneurysmCollaborative Care
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Nursing ManagementAssessment
Thorough history and physical exam
Watch for signs of cardiac, pulmonary, cerebral, and lower extremity vascular problems
Establish baseline data to compare postoperatively
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Case Study
E.O.’s assessment findings include
Alert and oriented to person and place‐disoriented to time
BP 158/98, P 92, R 22
Verbalizes pain at 6 on 0‐10 scale
Bilateral pedal pulses audible by Doppler
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Nursing ManagementAssessment
Note quality and character of peripheral pulses and neurologic status
Mark/document pedal pulse sites and any skin lesions on lower extremities before surgery
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Nursing ManagementAssessment
Monitor for indications of rupture
Diaphoresis
Pallor
Weakness
Tachycardia
Hypotension
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Nursing ManagementAssessment
Monitor for indications of rupture
Abdominal, back, groin, or periumbilical pain
Changes in level of consciousness
Pulsating abdominal mass
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Nursing ManagementPlanning
Overall goals include
Normal tissue perfusion
Intact motor and sensory function
No complications related to surgical repair
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Nursing ManagementNursing Implementation
Health promotion
Alert for opportunities to teach health promotion to patients and their caregivers
Encourage patient to reduce cardiovascular risk factors
These measures help ensure graft patency after surgery
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Nursing ManagementNursing Implementation
Acute intervention
Patient/caregiver teaching
Providing emotional support for patient/caregiver
Careful assessment of all body systems
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Case Study
E.O.’s daughter is called and arrives in the E.D.
Her daughter is very anxious and has many questions regarding the impending surgery.
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Nursing ManagementNursing Implementation
Acute intervention
Preop teaching
Brief explanation of disease process
Planned surgical procedure
Preop routines
Bowel prep
NPO
Shower
IV antibiotics right before incision made
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Nursing ManagementNursing Implementation
Acute intervention
Preop teaching
Expectations after surgery
Recovery room, tubes, drains
ICU
Beta blocker
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Nursing ManagementNursing Implementation
Acute intervention
Postop
ICU monitoring
Arterial line
Central venous pressure (CVP) or pulmonary artery (PA) catheter
Mechanical ventilation
Peripheral IV lines
Urinary catheter
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Nursing ManagementNursing Implementation
Acute intervention
Postop
ICU monitoring
Nasogastric tube
ECG
Pulse oximetry
Pain medication
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Case Study
E.O.’s surgery goes well and she arrives in ICU.
What are your priorities in monitoring her in the immediate postoperative period?
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Nursing ManagementNursing Implementation
Acute intervention
Postop
Maintain graft patency
Normal blood pressure
IV fluids and blood components
CVP or PA pressure monitoring
Urinary output monitoring
Avoid severe hypertension Drug therapy may be indicated
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Nursing ManagementNursing Implementation
Acute Intervention
Postop
Cardiovascular status
Continuous ECG monitoring
Electrolyte monitoring
Arterial blood gas monitoring
Oxygen administration
Antidysrhythmic and antihypertensive meds
Pain control
Resume cardiac medications
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Nursing ManagementNursing Implementation
Acute intervention
Postop
Infection
Antibiotic administration
Assessment of body temperature
Monitoring of WBC
Adequate nutrition
Observe surgical incision for signs of infection
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Nursing ManagementNursing Implementation
Acute intervention
Postop
GI status
Record amount and character of NG tube output
Abdominal assessment
Passing of flatus = return of bowel function
Assess for signs of bowel ischemia
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Nursing ManagementNursing Implementation
Acute intervention
Postop
Neurologic status
Level of consciousness
Pupil size and response to light
Facial symmetry
Speech
Ability to move upper extremities
Quality of hand grasps
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Nursing ManagementNursing Implementation
Acute Intervention
Postop
Peripheral perfusion status
Pulse assessment Mark pulse locations with felt‐tip pen
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Nursing ManagementNursing Implementation
Acute intervention
Postop
Peripheral perfusion status
Extremity assessment Temperature, color, capillary refill time, sensation, and movement of extremities
May need to use a Doppler to assess
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Nursing ManagementNursing Implementation
Acute intervention
Postop
Renal perfusion status
Urinary output
Fluid intake
Daily weight
CVP/PA pressure
Blood urea nitrogen/creatinine
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Case Study
E.O. progresses well through the postoperative phase and is scheduled to be discharged.
Her daughter is present and they are ready for discharge instructions.
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Nursing ManagementNursing Implementation
Ambulatory and home care
Encourage patient to express concerns
Instruct patient to gradually increase activities
No heavy lifting
Teach about signs and symptoms of complications
Infection
Neurovascular changes
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Nursing ManagementEvaluation
Expected outcomes
Patent arterial graft with adequate distal perfusion
Adequate urine output
No signs of infection
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Aortic Dissection
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Aortic Dissection
Often misnamed “dissecting aneurysm”
Not a type of aneurysm
Result of a false lumen through which blood flows
Classified by location and duration of onset
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Aortic Dissection
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Aortic Dissection
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Aortic Dissection
Affects men more often than women
Occurs most frequently between sixth and seventh decades of life
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Aortic DissectionEtiology and Pathophysiology
Due to degeneration of the elastic fibers in the arterial wall
Chronic hypertension hastens the process
Tear in inner layer allows blood to “track” between inner and middle layer
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Aortic DissectionEtiology 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
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Aortic DissectionClinical Manifestations
Depend on location of intimal tear and extent of dissection
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Aortic DissectionClinical Manifestations
Pain characterized as
Sudden, severe pain in anterior part of chest, or intrascapular pain radiating down spine to abdomen or legs
Described as “sharp” and “worst ever”
May mimic that of MI
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Aortic DissectionClinical Manifestations
Cardiovascular, neurologic, and respiratory signs may be present
If aortic arch involved
Neurologic deficiencies may be present
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Aortic DissectionComplications
Cardiac tamponade
Severe, life‐threatening complication
Occurs when blood escapes from dissection into pericardial sac
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Aortic DissectionComplications
Cardiac tamponade
Clinical manifestations include
Hypotension
Narrowed pulse pressure
Distended neck veins
Muffled heart sounds
Pulsus paradoxus
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Aortic DissectionComplications
Aorta may rupture
Results in exsanguination and death
Hemorrhage may occur in mediastinal, pleural, or abdominal cavities
Occlusion of arterial supply to vital organs
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Aortic DissectionDiagnostic Studies
ECG to rule out MI
Chest x‐ray
3‐D CT scan
Transesophageal echocardiography
MRI
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Aortic DissectionCollaborative Care
Initial goal
↓ BP and myocardial contractility to diminish pulsatile forces within aorta
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Aortic DissectionCollaborative Care
Drug therapy
IV β‐adrenergic blocker
Esmolol (Brevibloc)
Other antihypertensive agents
Calcium channel blockers
Nitroprusside
Angiotensin‐converting enzyme inhibitors
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Aortic DissectionCollaborative Care
Conservative therapy
If no symptoms
Can be treated conservatively for a period of time
Pain relief and BP control
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Aortic DissectionCollaborative Care
Endovascular dissection repair
Standard to treat acute descending aortic dissections with complications
Similar to EVAR
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Aortic DissectionCollaborative Care
Surgical therapy
Emergency surgery for acute ascending aortic dissection
When drug therapy is ineffective or when complications of aortic dissection are present
Surgery is delayed to allow edema to decrease and to permit clotting of blood
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Aortic DissectionCollaborative Care
Surgical therapy
Involves resection of aortic segment and replacement with synthetic graft material
Women experience poorer surgical outcomes and higher mortality than men
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Aortic DissectionNursing Management
Preoperative
Semi‐Fowler’s position
Maintaining a quiet environment
Anxiety and pain management
Opioids and tranquilizers as ordered
Continuous IV administration of antihypertensive agents
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Aortic DissectionNursing Management
Preoperative
Continuous ECG and intraarterial pressure monitoring
Observation of changes in quality of peripheral pulses
Frequent vital signs
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Aortic DissectionNursing Management
Postoperative See aneurysm postop care (discussed earlier)
Discharge teaching Therapeutic regimen Antihypertensive drugs and side effects
If pain returns or symptoms progress, instruct patient to seek immediate help
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Following an aortic aneurysm repair, the patient suddenly develops severe pain in the right lower extremity. The right pedal pulse is decreased, and the right foot is cool and pale. Which complication should the nurse suspect?
a. Hypothermia
b. A wound infection
c. Bleeding from the graft site
d. An embolization or graft occlusion
Audience Response Question
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