Transcript CONGESTIVE HEART FAILURE

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.