peripheral arterial disease, aortitis, arterial thrombosis aortic Aneurysm, aortic dissection and nursing care plan

2. ***Peripheral artery disease.
***Aortic aneurysm.
***Aortic dissection.

4. Peripheral artery disease (PAD), also known as
peripheral vascular disease (PVD),
peripheral artery occlusive disease, and
peripheral obliterative arteriopathy, is a
narrowing of the arteries other than those that
supply the heart or the brain.
When narrowing occurs in the heart it is called
coronary artery disease while in the brain it is called
cerebrovascular disease. Peripheral artery disease
most commonly affects the legs, but other arteries
may also be involved.

5. Aortitis is inflammation of the aorta, particularly
of the aortic arch.
Two types are known to occur: Takayasu’s disease
(chronic inflammatory disease of the aortic
arch and its branches) .
syphilitic aortitis (is very rare).

6. Acute vascular occlusion may be caused by an embolus or acute
thrombosis. Acute arterial occlusions may result from iatrogenic
injury, which can occur during insertion of invasive catheters
such as those used for arteriography, PTA or stent placement, or
an intra-aortic balloon pump. Other causes include trauma from
a fracture, crush injury, and penetrating wounds that disrupt the
arterial intima. The accurate diagnosis of an arterial occlusion as
embolic or thrombotic in origin is necessary to initiate
appropriate treatment.

7. The classic symptom is leg pain when walking which
resolves with rest, known as intermittent claudication.
Other symptoms including skin ulcers, bluish skin,
cold skin, or poor nail and hair growth may occur in
the affected leg. Complications may include an
infection or tissue death which may require
amputation, coronary artery disease, or stroke.Up to
50% of cases of PAD are without symptoms.

9. An aortic aneurysm is enlargement (dilation) of the aorta
to greater than 1.5 times normal size. They usually cause
no symptoms except when ruptured. Occasionally there
may be abdominal, back or leg pain.
They are most commonly located in the abdominal aorta,
but can also be located in the thoracic aorta. Aortic
aneurysms cause weakness in the wall of the aorta and
increase the risk of aortic rupture. When rupture occurs,
massive internal bleeding results and, unless treated
immediately, shock and death can occur.

10. Aortic aneurysms resulted in about 152,000 deaths in 2013
up from 100,000 in 1990.
• Each year in the United States, some 45,000 people die
from diseases of the aorta and its branches. Acute aortic
dissection, a life-threatening event due to a tear in the
aortic wall, affects 5 to 10 patients per million population
each year, most often men between the ages of 50 and 70;
of those that occur in women younger than 40, nearly half
arise during pregnancy. The majority of these deaths
occur as a result of complications of thoracic aneurysmal
disease

12. • Coronary artery disease.
• Hypertension.
• Hypercholesterolemia.
• Elevated C-reactive protein.
• Tobacco use.
• Peripheral vascular disease.
• Marfan syndrome.
• Bicuspid Aortic Valve.
• Syphilis.
• IgG4-relate disease.

13. An aortic aneurysm can occur as a result of trauma,
infection, or, most commonly, from an intrinsic
abnormality in the elastin and collagen components
of the aortic wall. While definite genetic
abnormalities were identified in true genetic
syndromes (Marfan, Elher-Danlos and others)
associated with aortic aneurysms, both thoracic and
abdominal aortic aneurysms demonstrate a strong
genetic component in their aetiology.

15. • Aortic aneurysms are classified by their location on the
aorta.
• An aortic root aneurysm, or aneurysm of the sinus of
Valsalva.
• Thoracic aortic aneurysms are found within the chest;
these are further classified as ascending, aortic arch, or
descending aneurysms.
• Abdominal aortic aneurysms, "AAA" or "Triple A," the
most common form of aortic aneurysm, involve that
segment of the aorta within the abdominal cavity.
Thoracoabdominal aortic aneurysms involve both the
thoracic and abdominal aorta.

17. A thoracic aortic aneurysm is an aortic aneurysm
that presents primarily in the thorax.
A thoracic aortic aneurysm is the "ballooning" of the
upper aspect of the aorta, above the diaphragm.
Untreated or unrecognized they can be fatal due to
dissection or "popping" of the aneurysm leading to
nearly instant death. Thoracic aneurysms are less
common than an abdominal aortic aneurysm.
However, a syphilitic aneurysm is more likely to be a
thoracic aortic aneurysm than an abdominal aortic
aneurysm.

20. An aortic aneurysm occurs when the walls of the main
blood vessel that carries blood away from the heart (the
aorta) bulge or dilate. An abdominal aortic aneurysm
(AAA) is located in the abdominal area, near the navel.
Aneurysms can also occur in other areas of the aorta, but
the abdomen is the most common site. Abdominal aortic
aneurysms are not related to aneurysms of the blood
vessels in the brain.
Intact abdominal aortic aneurysms cause no health
problems. However, large aneurysms can burst, or
rupture, and cause heavy bleeding into the abdomen. A
ruptured aortic aneurysm is a medical emergency
requiring immediate treatment.

23. Most abdominal aortic aneurysms are small and do not
cause any symptoms. People without symptoms are
usually unaware that they have an aneurysm.
Some aneurysms cause a noticeable, small pulsating mass
near the navel. This may not be noticed by the patient, but
can be detected by a healthcare provider during a routine
physical examination. Approximately 30 percent of
asymptomatic AAA are discovered in this manner. Other
aneurysms are identified during imaging (ie, X-ray,
ultrasound, CT scan, MRI) of the abdomen, done for
other reasons.

24. Some aneurysms can cause abdominal or back pain. Such
aneurysms are typically detected during an evaluation for pain.
Because blood can pool in the part of the aorta that is bulging,
some people develop blood clots inside the aneurysm. If one
of these clots breaks loose, it can end up clogging a blood
vessel in one of the legs. This can lead to symptoms, such as
pain, numbness, or tingling in the leg. In some cases, parts of
the leg or foot may even turn pale and become cool to the
touch.
Most patients have little warning before rupture. Patients who
develop abdominal pain or tenderness may have had a recent
increase in aneurysm size, which may predict rupture.

25. • Surgery (open or endovascular) is the definite
treatment of an aortic aneurysm. Medical therapy is
typically reserved for smaller aneurysms or for
elderly, frail patients where the risks of surgical repair
exceed the risks of non-operative therapy
(observation alone).

26. • Medical therapy of aortic aneurysms involves strict blood
pressure control. This does not treat the aortic aneurysm
per se, but control of hypertension within tight blood
pressure parameters may decrease the rate of expansion
of the aneurysm.
• The medical management of patients with aortic
aneurysms, reserved for smaller 0aneurysms or frail
patients, involves cessation of smoking, blood pressure
control, use of statins and occasionally beta blockers.
Ultrasound studies are obtained on a regular basis (i.e.
every six or 12 months) to follow the size of the
aneurysm.

27. For abdominal aneurysms, the current treatment
guidelines for abdominal aortic aneurysms suggest
elective surgical repair when the diameter of the
aneurysm is greater than 5 cm (2 in). However, recent
data on patients aged 60–76 suggest medical
management for abdominal aneurysms with a
diameter of less than 5.5 cm (2 in).

28. • Open surgery typically involves exposure of the dilated
portion of the aorta and insertion of a synthetic (Dacron
or Gore-Tex) graft (tube). Once the graft is sewn into the
proximal (toward the patient's head) and distal (toward
the patient's foot) portions of the aorta, the aneurysmal
sac is closed around the graft. Alternatively, the
anastomosis can be carried out with expandable devices,
a simpler and quicker procedure
• The aorta and its branching arteries are cross-clamped
during open surgery. This can lead to inadequate blood
supply to the spinal cord, resulting in paraplegia, when
repairing thoracic aneurysms. Cerebrospinal fluid
drainage, when performed in experienced centers, reduces
the risk of ischemic spinal cord injury by increasing the
perfusion pressure to the spinal cord.

29. • Endovascular treatment of aortic aneurysms is a minimally
invasive alternative to open surgery repair. It involves
placement of an endo-vascular stent through small incisions at
the top of each leg into the aorta.
• As compared to open surgery, EVAR has a lower risk of death
in the short term and a shorter hospital stay but may not
always be an option. There does not appear to be a difference
in longer term outcomes between the two. After EVAR, repeat
procedures are more likely to be needed.
• Better results are only in uncomplicated, elective descending
thoracic and infrarenal aorta. Moreover, recent USA data from
2006–2007 of isolated descending thoracic aorta aneurysms
found 23% of ideal candidate (uncomplicated, elective
descending aortic aneurysms) underwent to TEVAR, the
remaining 77% underwent open surgical repair

31. The principal causes of death due to thoracic
aneurysmal disease are dissection and rupture. Once
rupture occurs, the mortality rate is 50–80%, and
most deaths in patients with the Marfan syndrome are
the result of aortic disease.

33. Other aneurysm complications — Other complications of
AAA are less common and not as well recognized. These
include:
●Inflammatory aneurysm, swelling and inflammation of the
aneurysm wall that causes abdominal pain
●Aorto-venous fistula, an abnormal connection between the
aorta and a vein
●Primary aortoenteric fistula, an abnormal connection between
the aorta and the bowel
●Thromboembolism, blood clots or debris from the AAA that
block blood flow to the legs [4].
●Infected aneurysm
These complications can be limb- and life-threatening, and,
when diagnosed, indicate the need for repair.

34. Before surgery, nursing assessment is guided by
anticipating a
rupture and by recognizing that the patient may have
cardiovascular,
cerebral, pulmonary, and renal impairment from
atherosclerosis.
The functional capacity of all organ systems should be
assessed. Medical therapies designed to stabilize
physiologic function
should be promptly implemented.
Signs of impending rupture include severe back pain or
abdominal
pain, which may be persistent or intermittent and is often

36. Aortic dissection occurs when a tear in the
tunica intimae of the aorta causes blood to
flow between the layers of the wall of the
aorta, forcing the layers apart. In most cases
this is associated with severe characteristic
chest or abdominal pain described as "tearing"
in character, and often with other symptoms
that result from decreased blood supply to
other organs.

38. * Aortic dissection is a medical emergency and can
quickly lead to death, even with optimal
treatment, as a result of decreased blood supply
to other organs, heart failure, and sometimes
rupture of the aorta.

39. ** The earliest fully documented case of aortic
dissection is attributed to Frank Nicholls in his
autopsy report of King George II of Great Britain,
who had been found dead on 25 October 1760; the
report describes dissection of the aortic arch and into
the pericardium.

40. The term "aortic dissection" was introduced by the
French physician J.P. Maunoir in 1802, and René
Laennec labelled the condition "dissecting
aneurysm". London cardiologist Thomas Bevill
Peacock contributed to the understanding of the
condition by publishing two series of the cases
described in the literature so far: nineteen cases
in an 1843 review, and eighty in 1863.
The characteristic symptom of tearing pain in the chest
was recognised in 1855, when a case was diagnosed
in life.

41. Surgery for aortic dissection was first introduced and
developed by Michael E. DeBakey, Denton Cooley
and Oscar Creech, cardiac surgeons associated with
the Baylor College of Medicine, Houston, Texas in
1954. DeBakey developed aortic dissection himself at
age 97 in 2005,and underwent surgery in 2006.
Endovascular treatment of aortic dissection was
developed in the 1990s.

42. It has been difficult to establish the incidence of aortic
dissection because many cases are only diagnosed
after death (which may have been attributed to
another cause), and is often initially misdiagnosed. It
is estimated that aortic dissection affects 2–3.5 people
out of every 100,000 every year. Studies from
Sweden suggest that the incidence of aortic dissection
may be rising.

43. Men are more commonly affected than women: 65% of
all people with aortic dissection are male. The mean
age at diagnosis is 63 years. In females before the age
of 40, half of all aortic dissections occur during
pregnancy (typically in the 3rd trimester or early
postpartum period).

44. As with all other arteries, the aorta is made up of three
layers, the intima, the media, and the adventitia. The
intima is in direct contact with the blood inside the
vessel, and mainly consists of a layer of endothelial
cells on a basement membrane.
The initiating event in an aortic dissection is a tear in
the intimal lining of the aorta. Due to the high
pressures in the aorta, blood enters the media at the
point of the tear.

48. The force of the blood entering the media causes the
tear to extend.
It may extend proximally (closer to the heart) or
distally (away from the heart) or both. The blood will
travel through the media, creating a false lumen (the
true lumen is the normal conduit of blood in the
aorta). Separating the false lumen from the true
lumen is a layer of intimal tissue. This tissue is
known as the intimal flap.

49. The vast majority of aortic dissections originate with an
intimal tear in either the ascending aorta (65%), the
aortic arch (10%), or just distal to the ligamentum
arteriosum in the descending thoracic aorta (20%).
As blood flows down the false lumen, it may cause
secondary tears in the intima. Through these
secondary tears, the blood can re-enter the true
lumen.

50. Aortic dissection is associated with hypertension (high
blood pressure) and many connective tissue
disorders. Vasculitis (inflammation of an artery) is
rarely associated with aortic dissection. It can also be
the result of chest trauma. 72 to 80% of individuals
who present with an aortic dissection have a previous
history of hypertension.

51. A bicuspid aortic valve (a type of congenital heart
disease involving the aortic valve) is found in 7–14%
of individuals who have an aortic dissection. These
individuals are prone to dissection in the ascending
aorta. The risk of dissection in individuals with
bicuspid aortic valve is not associated with the degree
of stenosis of the valve.

52. Marfan syndrome is noted in 5–9% of individuals who
suffer from aortic dissection. In this subset, there is
an increased incidence in young individuals.
Individuals with Marfan syndrome tend to have
aneurysms of the aorta and are more prone to
proximal dissections of the aorta.

53. Chest trauma leading to aortic dissection can be
divided into two groups based on etiology: blunt
chest trauma (commonly seen in car accidents) and
iatrogenic. Iatrogenic causes include trauma during
cardiac catheterization or due to an intra-aortic
balloon pump.
Syphilis will only potentially cause aortic dissection in
its tertiary stage.

54. Aortic dissection may be a late sequela of cardiac
surgery. 18% of individuals who present with an
acute aortic dissection have a history of open heart
surgery. Individuals who have undergone aortic valve
replacement for aortic insufficiency are at particularly
high risk. This is because aortic insufficiency causes
increased blood flow in the ascending aorta. This can
cause dilatation and weakening of the walls of the
ascending aorta.

56. Several different classification systems have been used
to describe aortic dissections. The systems commonly
in use are based on either the anatomy of the
dissection or the duration of onset of symptoms prior
to presentation. The Stanford system is used more
commonly now, as it is more attuned to the
management of the patient.

57. The Stanford classification is divided into two groups;
A and B depending on whether the ascending aorta is
involved.
• A – Involves the ascending aorta and/or aortic arch,
and possibly the descending aorta. The tear can
originate in the ascending aorta, the aortic arch, or,
more rarely, in the descending aorta.
• B – Involves the descending aorta or the arch (distal
to the left subclavian artery), without involvement of
the ascending aorta.

61. (1) chest pain:
About 96% of individuals with aortic dissection present with
severe pain that had a sudden onset. It may be described as
tearing, stabbing, or sharp in character. 17% of individuals will
feel the pain migrate as the dissection extends down the aorta.
The location of pain is associated with the location of the
dissection. Anterior chest pain is associated with dissections
involving the ascending aorta, while interscapular (back) pain
is associated with descending aortic dissections. If the pain is
pleuritic in nature, it may suggest acute pericarditis caused by
bleeding into the pericardial sac. This is a particularly
dangerous eventuality, suggesting that acute pericardial
tamponade may be imminent. Pericardial tamponade is the
most common cause of death from aortic dissection.

62. While the pain may be confused with the pain of a
myocardial infarction (heart attack), aortic dissection is
usually not associated with the other signs that suggest
myocardial infarction, including heart failure and ECG
changes.
Less common symptoms that may be seen in the setting of
aortic dissection include congestive heart failure (7%),
fainting (9%), stroke (6%), ischemic peripheral
neuropathy, paraplegia, and cardiac arrest.[ If the
individual had a fainting episode, about half the time it is
due to bleeding into the pericardium leading to
pericardial tamponade.

63. (2)Blood pressure:
While some patients with an aortic dissection have a
history of hypertension, the blood pressure is quite
variable at presentation with acute aortic dissection,
and tends to be higher in individuals with a distal
dissection. In individuals with a proximal aortic
dissection, 36% present with hypertension, while
25% present with hypotension.

64. (3)Aortic insufficiency:
Aortic insufficiency (AI) occurs in half to two-thirds of
ascending aortic dissections, and the murmur of
aortic insufficiency is audible in about 32% of
proximal dissections. The intensity (loudness) of the
murmur is dependent on the blood pressure and may
be inaudible in the event of hypotension

65. (4) Myocardial infarction:
Myocardial infarction (heart attack) occurs in 1–2% of
aortic dissections. The etiology of the infarction is
involvement of the coronary arteries (the arteries that
supply the heart) in the dissection. The right coronary
artery is involved more commonly than the left
coronary artery. If the myocardial infarction is treated
with thrombolytic therapy, the mortality increases to
over 70%, mostly due to bleeding into the pericardial
sac causing pericardial tamponade.

66. (5)Pleural effusion:
A pleural effusion (fluid collection in the space
between the lungs and the chest wall or diaphragm)
can be due to either blood from a transient rupture of
the aorta or fluid due to an inflammatory reaction
around the aorta. If a pleural effusion were to develop
due to an aortic dissection, it is more commonly in
the left hemithorax rather than the right hemithorax.

67. Because of the varying symptoms and signs of aortic
dissection depending on the initial intimal tear and
the extent of the dissection, the proper diagnosis is
sometimes difficult to make.
While taking a good history from the individual may be
strongly suggestive of an aortic dissection, the
diagnosis cannot always be made by history and
physical signs alone. Often the diagnosis is made by
visualization of the intimal flap on a diagnostic
imaging test.

68. Common tests used to diagnose an aortic dissection
include a CT scan of the chest with iodinated contrast
material and a trans-esophageal echocardiogram. The
proximity of the aorta to the esophagus allows the use
of higher-frequency ultrasound for better anatomic
images. Other tests that may be used include an
aortogram or magnetic resonance angiogram (MRA)
of the aorta. Each of these tests have varying pros and
cons and they do not have equal sensitivities and
specificities in the diagnosis of aortic dissection.

69. A blood D-dimer level less than 500 ng/ml may be able
to rule out the diagnosis of aortic dissection, avoiding
the need for further imaging.
This appears to only apply to those at low risk and if
the test is done within 24 hours of the onset of
symptoms.
The American Heart Association does not advise using
this test in making the diagnosis, as evidence is still
tentative.

70. Widening of the mediastinum on an x-ray of the chest ,
Pleural effusions may be seen on chest x-ray. They are
more commonly seen in descending aortic dissections. If
seen, they are typically in the left hemithorax.
About 12 to 20% of individuals presenting with an aortic
dissection have a "normal" chest x-ray; therefore, a
normal chest radiograph does not rule out aortic
dissection. If the clinical index of suspicion is high, it is
imperative to rule out dissection with another imaging
modality (CT angiogram, MRA, aortogram, or
transesophageal echo).

72. Computed tomography angiography is a fast non-
invasive test that will give an accurate three-
dimensional view of the aorta.
These images are produced by taking rapid thin cut
slices of the chest and abdomen, and combining them
in the computer to create cross-sectional slices.
Contrast is injected and the scan performed using a
bolus tracking method. This is a type of scan timed to
an injection to capture the contrast as it enters the
aorta.

74. Magnetic resonance imaging (MRI) is currently the gold
standard test for the detection and assessment of aortic
dissection, with a sensitivity of 98% and a specificity of
98%.
An MRI examination of the aorta will produce a three-
dimensional reconstruction of the aorta, allowing the
physician to determine the location of the intimal tear, the
involvement of branch vessels, and locate any secondary
tears. It is a non-invasive test, does not require the use of
iodinated contrast material, and can detect and quantitate
the degree of aortic insufficiency.

76. The transesophageal echocardiogram (TEE) is a relatively
good test in the diagnosis of aortic dissection, with a
sensitivity of up to 98% and a specificity of up to 97%. It
has become the preferred imaging modality for suspected
aortic dissection. It is a relatively non-invasive test,
requiring the individual to swallow the echocardiography
probe. It is especially good in the evaluation of AI in the
setting of ascending aortic dissection, and to determine
whether the ostia (origins) of the coronary arteries are
involved. While many institutions give sedation during
transesophageal echocardiography for added patient
comfort, it can be performed in cooperative individuals
without the use of sedation.

78. An aortogram involves placement of a catheter in the
aorta and injection of contrast material while taking
x-rays of the aorta. The procedure is known as
aortography. Previously thought to be the diagnostic
gold standard, it has been supplanted by other less
invasive imaging modalities.

80. In an acute dissection treatment choice depends on its
location. For Stanford type A (ascending aortic)
dissection, surgical management is superior to
medical management. For uncomplicated Stanford
type B (distal aortic) dissections (including
abdominal aortic dissections), medical management
is preferred over surgical.

81. The risk of death due to aortic dissection is highest in the
first few hours after the dissection begins, and decreases
afterwards. Because of this, the therapeutic strategies
differ for treatment of an acute dissection compared to a
chronic dissection. An acute dissection is one in which
the individual presents within the first two weeks. If the
individual has managed to survive this window period,
his prognosis is improved. About 66% of all dissections
present in the acute phase. Individuals who present two
weeks after the onset of the dissection are said to have
chronic aortic dissections. These individuals have been
self-selected as survivors of the acute episode, and can be
treated with medical therapy as long as they are stable.

82. Calcium channel blockers can be used in the treatment
of aortic dissection, particularly if there is a
contraindication to the use of beta blockers.
The calcium channel blockers typically used are
verapamil and diltiazem, because of their combined
vasodilator and negative inotropic effects.

84. • Open aortic surgery:
with replacement of the damaged section of aorta with a tube
graft (often made of dacron) when there is no damage to the
aortic valve.
• Bentall procedure:
Replacement of the damaged section of aorta and replacement
of the aortic valve.
• David procedure:
Replacement of the damaged section of aorta and reimplantation
of the aortic valve.
• TEVAR (thoracic endovascular aortic repair):
a minimally invasive surgical procedure usually combined with
on-going medical management

87. The risk of death is highest in the first two years after
the acute event, and individuals should be followed
closely during this time period. 29% of late deaths
following surgery are due to rupture of either the
dissecting aneurysm or another aneurysm.
In addition, there is a 17% to 25% incidence of new
dissection formation. This is typically due to
dilatation of the residual false lumen. These new
disections are more likely to rupture, due to their
thinner walls.

89. Of all people with aortic dissection, 40% die
immediately and do not reach a hospital in time. Of
the remainder, 1% die every hour, making prompt
diagnosis and treatment a priority. Even after
diagnosis, 5–20% die during surgery or in the
immediate postoperative period. In ascending aortic
dissection, if there is a decision that surgery is not
appropriate, 75% die within 2 weeks. With aggressive
treatment 30-day survival for thoracic dissections
may be as high as 90%.

90. An aortic dissection can lead to:
• Death due to severe internal bleeding
• Organ damage, such as kidney failure or life-
threatening intestinal damage
• Stroke
• Aortic valve damage (aortic regurgitation) or rupture
into the lining around the heart (cardiac tamponade).

91. Here are a few tips to reduce your risk of an aortic
dissection:
• Control blood pressure. If you have high blood pressure, get
a home blood pressure measuring device to help you monitor
your blood pressure.
• Don't smoke. If you do smoke, take steps to stop.
• Maintain an ideal weight. Follow a low-salt diet with plenty
of fruits, vegetables and whole grains and exercise regularly.
• Wear a seat belt. This reduces the risk of traumatic injury to
your chest area.
• Work with your doctor. If you have a family history of aortic
dissection, a connective tissue disorder or a bicuspid aortic
valve, tell your doctor. If you have an aortic aneurysm, find
out how often you need monitoring and if surgery is necessary
to repair your aneurysm.

93. Preopreative nursing care:
**Immediate patient transfer to the intensive care unit
(ICU) is a high priority. Nursing interventions should
begin as soon as aortic dissection is suspected, and
typically include the following:
**Institute intubation or mechanical ventilation, as
ordered, if the patient is hemodynamically unstable.
**Begin continuous cardiac monitoring. Assess for
tachycardia and other irregular rhythms.
**Provide continuous blood pressure monitoring with
an arterial line; desired systolic pressure is 100 to 120
mm Hg.

94. **Insert two large-bore I.V. lines.
**Check vital signs every 15 minutes, or according to
protocol.
**Observe the patient’s mental status and check for
neurologic and peripheral vascular changes.
**Measure urine output frequently.
**Restrict patient activity.
**Provide reassurance and a calm environment.

95. Postoperative nursing care:
**Postoperative nursing interventions in the ICU
or step-down unit include administering drugs,
maintaining target blood pressure and heart
rate, monitoring and observation, preventing
skin breakdown, and providing patient teaching.

96. **Expect to give pain medications (such as morphine
sulfate) as needed for pain control; beta blockers and
vasodilators (such as nitroprusside or nitroglycerin) to
control heart rate and blood pressure; and norepinephrine
to prevent hypotension. As ordered, maintain systolic
pressure between 100 and 120 mm Hg to prevent graft
occlusion and reduce pressure on the repaired aorta.
Maintain MAP at 65 to 75 mm Hg and heart rate between
50 and 60 bpm.
**For the first 2 or 3 days postoperatively, keep the head of
the bed lower than 45 degrees and elevate the patient’s
legs 20 to 30 degrees, to avoid pressure on incision sites.

98. :Patient Assessment
1.Assess neurologic status to evaluate the course of
dissection. Confusion or changes in sensation and
motor strength may indicate compromised cerebral
blood flow (CBF).
2.Auscultate for changes in heart sound and signs and
symptoms of heart failure, which may indicate that
the dissection involves the aortic valve.
3.Compare BP and pulses in both arms and legs to
determine differences.

99. :Diagnostic Assessment
1.Review serial BUN and creatinine levels to evaluate
renal function.
2.Review cardiac enzymes because a dissection
involving coronary arteries may result in
Myocardial Infarction.
3.Review the ECG for patterns of ischemia, injury, and
infarction.
4.Review results of radiology test such as CT scan,
MRI, and aotogram.

100. (1) Ineffective tissue perfusion related to
compromised arterial blood flow secondary to
blood extravasation via aortic dissection,aortic
anyrsim.

101. :Outcome Criteria
* Patient alert and oriented
* Skin war and dry
* BP 80 to 100 mm Hg or as low as can possibly
maintain systemic perfusion.
* Urine output 30 mL/hr or 0.5 to 1 ml/kg/hr
* Pulses strong and equal bilaterally
* Capillary refill <3 sec in all extremities
* Pupils equal and nonreactive
* Motor strength strong and equal bilaterally

102. patient Monitoring:
* Continuously monitor arterial BP during acute
phase to evaluate the patient’s response to therapy.
* Monitor hourly urine output because a drop in
output may indicate renal artery dissection or a
decrease in arterial blood flow.
* Continuously monitor ECG for dysrythmia
formation, ST segment or T-wave changes,
suggesting coronary sequelae or a decrease in
arterial blood flow.

103. Patient Management:
* Administer oxygen therapy as ordered.
* Keep the patient on bed rest to prevent further
dissection
*Nitroprusside may be ordered to lower BP.
* adrenergic blocking agent such as atenolol,
esmolol, or propranolol may be ordered to
reduce stress on the aortic wall.
* Anticipate surgical intervention.

104. 1.Acute pain.
2.Deficient fluid volume.
3.Decreased cardiac output.
4.Impaired gas exchange.
5.Impaired physical mobility.
6.Impaired skin integrity.
7.Ineffective tissue perfusion: Renal, cardiopulmonary.
8.Risk for fluid volume deficit related to hemorrhage.
9.Anxiety.

105. 1.Express feelings of increasing comfort and decreased
pain.
2.Maintain adequate fluid volume.
3.Maintain adequate cardiac output.
4.Maintain adequate ventilation and oxygenation.
5.Maintain joint mobility and muscle strength.
6.Patient's skin will remain intact.
7.Pulses will remain palpable distal to the aneurysm site.
8.Maintain adequate urine output (output will be equivalent
to intake).
9.Verbalize strategies to reduce his anxiety level.

106. **Pain Management: Alleviation of pain or a reduction in pain
to a level of comfort that is acceptable to the patient
Analgesic Administration: Use of pharmacologic agents to
reduce or eliminate pain.
**Fluid Management: Promotion of fluid balance and
prevention of complications resulting from abnormal or
undesired fluid levels
**Hypovolemia Management: Reduction in extracellular and/or
intracellular fluid volume and prevention of complications
Shock Management: Volume: Promotion of adequate tissue
perfusion for a patient with severely compromised
intravascular volume.
Environmental Management: Comfort: Manipulation of the
patient’s surroundings for promotion of optimal comfort.

107. Hemodynamic Regulation: Optimization of heart rate,
preload, afterload, and contractility
**Cardiac Care: Limitation of complications resulting from
an imbalance between myocardial oxygen supply and
demand for a patient with symptoms of impaired cardiac
function
Circulatory Care: Mechanical Assist Devices: Temporary
support of the circulation through the use of mechanical
devices or pumps
Respiratory Monitoring: Collection and analysis of patient
data to ensure airway patency and adequate gas exchange
**Oxygen Therapy: Administration of oxygen and
monitoring of its effectiveness

108. **Anxiety Reduction: Minimizing apprehension,
dread, foreboding, or uneasiness related to an
unidentified source or anticipated danger.
Calming Technique: Reducing anxiety in patient
experiencing acute distress.