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Aortic aneurysms incidence

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Affects males more than females over the age of 60 peaks at 70 and 80-year-olds 13th leading cause of death 80% to 90% mortality if ruptured If the aortic bulge is greater than 6 cm it will rupture within the first year

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Pathophysiology of aneurysms

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Atherosclerosis hypertension

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Sites of aneurysms

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25% in thoracic 75% abdominal aortic One third are asymptomatic Aneurysms greater than 3 cm in diameter

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Aneurysm risk factors

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Hypertension smoking atherosclerosis genetics Gender

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Thoracic assessment of neurological gastrointestinal and oxygenation

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Sudden onset chest pain with widening mediastinum Hoarseness hallmark sign Dysphasia Distended neck veins Edema of head and arms Coughing dyspnea airway obstruction Pressure on systemic venous circulation pressure on pulmonary structures

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Abdominal aortic aneurysm assessment

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Most are below renal artery Lumbar back pain pressure of pulsating aneurysm on vertebrae Epigastric discomfort Pulsatile. Umbilical mass Diminished femoral pulses Blue toe syndrome- patchy mottling feet and toes

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Common causes of abdominal aortic aneurysms related to Degenerative Congenital Mechanical Inflammatory Infectious

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Degenerative equals atherosclerosis Congenital equals familial tendency Mechanical equals trauma can cause small tears Inflammatory equals aortitis Infectious equals hypertension and STDs

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Ruptured aneurysm complications Posterior and anterior

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Posterior: Severe back pain tamponade disruption of renal blood flow Turner sign- leaky aortic aneurysm Anterior: shock and rapid death no signs or symptoms anterior is nothing but soft tissue

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Collaborative goals to prevent rupture

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Early detection by assessment of total body systems Assess coexisting conditions

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Diagnostic test for aneurysms

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CT MRI ultrasound chest abdominal x-rays EKG labs angiography

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Aneurysm surgical treatment resectioning graft indications

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Symptomatic greater than 5 cm mortality less than 5%

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Post operative priorities

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Graft patency

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Risk for altered tissue perfusion related to

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Coagulopathy and decreased flow rate Graft occlusion disruption embolism blood loss dilution Bypass method used = flow rate

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To dilated aortic vessel administer

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Nitroglycerin or IV nitroprusside cyanide-based dilate

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Hourly assessments in CCU critical care unit

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Put on ventilator given nitroglycerin IV Check distal circulation Doppler pulses for blood-pressure differentiate pain reports skin signs Monitor hemodynamic status administer blood and fluids to maintain systemic blood pressure Report sustained increase blood pressure

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Ventricular dysrhythmias preoperative priorities Potential complications Interventions

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Hypothermia electrolyte imbalances coexisting coronary artery disease Warming blanket assess sodium potassium calcium magnesium monitor O2 sats ABGs monitor EKG and treat according to parameters

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Post operative priorities renal perfusion Potential complications and interventions For fluid and electrolyte imbalances

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Altered renal perfusion related to renal artery embolism prolonged hypotension prolonged aortic cross clamping Check daily weights with Eisen owes every 30 to 60 minutes for urinary output Document urinary output characteristics BUN, Serum creatinine Administer fluids and meds to retain renal perfusion

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Post operative priorities for the G.I. tract Potential complications paralytic ileous related to

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Preoperative bowel manipulation side effects of pain medication and immobility

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Interventions of potential complications of paralytic ileous

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Assessed for abdominal bowel sounds nausea and vomiting abdominal distention NG tube low suction to decompress stomach and prevent aspiration irrigate NG tube to assess patency

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Aneurysm discharge teaching recovery signs and symptoms potential problems

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Recovery 4 to 6 weeks May feel fatigued poor appetite irregular bowel movements Signs and symptoms may include infection redness increased pain incisional drainage from chest tubes temperature greater than 101 Fahrenheit Potential problems sexual dysfunction in males prophylactic antibiotics needed for future invasive procedures

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Aortic dissection

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A longitudinal splitting of the medial layer of the artery Highest incidence in men aged 40 to 70

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Aortic dissection most common sites

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Ascending arch aortic arch descending aorta beyond left subclavian

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Arterial occlusive is Ischemic disease

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Limb threatening emergencies sudden onset usually emboli lodged in bifurcation - valve junction

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Causes of arterial occlusive Ischemic disease

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Embolism infective endocarditis MI mitral valve disease chronic arterial fibrillation cardiomyopathy prosthetic valves post op vascular surgery thrombus trauma

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6 P's of acute arterial occlusion ischemic disorder assessment

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Pain pallor pulselessness paresthesia paralysis Poikilothermia

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Collaborative care of acute arterial occlusion

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Altered peripheral tissue perfusion must administer anticoagulant prescription Continuous IV heparin Thrombolytics or fibrinolytic's for clot busters

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Interventions to increase bloodflow pharmacology

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Anticoagulants indirect thrombin inhibitors direct thrombin inhibitors thrombolytics Activase TNKase - must initiate within a few hours especially for stroke patients streptokinase Urokinase

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Arterial occlusive disease continuum

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Pain equals ischemia at rest equals poor wound healing equals gangrene equals amputation

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Peripheral arterial chronic occlusion disease

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affects 10% of adults over 70 males more than females affects lower extremities especially diabetes below the knee Prolonged and chronic Usually affects diabetes and chronic renal disease patients

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Risk factors for peripheral arterial disease

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Hyperlipidemia smoking diabetes hypertension Gender

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Hypertension doubles the risk for:

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Symptomatic peripheral arterial disease

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Diabetes accelerates what condition

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Atherosclerosis

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Smoking contributes to

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Vasoconstriction and increased coagulopathy

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Hyperlipidemia contributes to

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Increased viscosity and atherosclerosis

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Clinical manifestations of peripheral arterial disease

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Intermittent claudication pain at rest 50 to 70% occlusion before symptomatic

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Inspection assessment

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Dependent rubor skin integrity capillary refill hair loss from affected limb nails usually unhealthy

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Auscultation assessment

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Listen for bruits Doppler for blood pressure since flow is so poor document

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Palpation assessment

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Temperature usually cool pulses are decreased thrills and masses

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Collaborative goals for peripheral arterial occlusion disease

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Function promote self-care lifestyle changes smoking diet and exercise find people to help patient follow treatment regimen

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Interventions to increase bloodflow pharmacologically

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Antiplatelets such as platelet aggregation inhibitors, platelet adhesion inhibitors Glycoprotein Ilb IIIa inhibitors Antihemorrheologics - improves microcirculation Ace inhibitors Statins Thiazides

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Increase bloodflow through exercise

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Enhance collateral circulation increased tissue perfusion and tolerance to muscle ischemia Should build up to 30 or 40 minutes of walking a day

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Endocascular procedures

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Balloon angioplasty Arthrectomy stenting

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Fem pop statistic

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40% usually occlude within the first year

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Fem pop post op priorities

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Circulation anticoagulation prescriptions with heparin warfarin or antiplatelets graft patency fluid balance and wound healing

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Buerger's disease

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Inflammatory thrombotic effects medium-sized arteries and veins upper and lower extremities ages 25 to 40 years old

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Clinical manifestations

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Intermittent claudication pain at rest color and temperature changes paresthesia thrombophlebitis cold sensitivity

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Collaborative nursing interventions - Buerger's disease

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Stop smoking avoid trauma pharmacological heparin and Coumadin Take extra care not to get infections pay close attention to footcare

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Raynaud's phenomenon arterio spastic disease

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Episodic vasospastic small cutaneous arteries Absence of color comes and goes only last for a few minutes feels achy afterwards Skin can turn reddish purple one blood returns to extremity

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Raynaud's pathophysiology

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Exaggerated reflex sympathetic vasoconstriction

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Raynauds Riskfactors

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Collagen disease environmental more common in colder regions

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Raynauds clinical manifestations

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Pallor Cyanosis numbness Rubor throbbing aching pain Tingling swelling no radial or ulnar pulses

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Ray nods collaborative care Symptomatic and preventative

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Calcium channel blockers beta blockers immerse hands and Warm water Loose warm clothing gloves avoid temperature extremes no smoking or caffeine decrease anxiety

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Venus thromboembolism umbrella term includes

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Post thrombolytic syndrome deep vein thrombosis superficial vein thrombosis

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Venous thromboembolism includes:

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Includes both deep vein thrombosis and pulmonary embolism

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One episode of deep vein thrombosis can increased risk of:

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Post thrombotic syndrome

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Post thrombotic syndrome

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Tissue injury that can follow deep vein thrombosis and last indefinitely Causes valve damage resulting in blood reflux

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Signs and symptoms of posts from Bodick syndrome

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Pain cramps paresthesia paresthsia Pruritis induration hyperpigmentation venous dilation and or ulceration Edema

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Deep vein thrombosis Virchow's Triad Consists of

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Venous stasis endothelial damage hypercoagulbility

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Virchows Triad venous stasis includes

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Dysfunctional valves inactivity of extremity muscles

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Virchow's Triad Endothelial damage includes

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Trauma external pressure medications prolonged presence of an IV and fractures

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Virchow's Triad Hypercoagulbility includes

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Hematologic disorders systemic infections Estrogen based oral contraceptives smoking

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Deep vein thrombosis pathophysiology

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Blood units & fibrin adhere to valve cusps formation of thrombus Partial occlusion covered by endothelium process stops Lysis or firm in 5 to 7 days Turbulence thrombosis embolism

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Deep vein thrombosis clinical manifestations

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Pain and tenderness unilateral leg edema warm temperatures greater than 100.4 Homans sign Edema cyanosis

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Diagnostic labs for DVT

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AC T - active clotting time APTT INR H&H Platelet count Bleeding time D-dimer - inappropriate coagulation time

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Other diagnostic studies for DVT

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Venous compression ultrasound duplex ultrasound CT venography MR venography contract venography

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DVT complications

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Jarring of thrombus by mechanical forces sudden standing Valsalva maneuver Atrial fib fat emboli air emboli amniotic fluid emboli tumor emboli

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DVT nursing diagnosis pain related to

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Impaired circulation in extremities as evidenced by presence of edema

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DVT nursing diagnosis risk for impaired tissue integrity elated to

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Altered tissue perfusion valvular disorder altered skin pigmentation pain open ulcer presence of edema

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DVT potential complications Pulmonary embolism related to

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Dehydration immobility Embolization of thrombus

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DVT discharge teaching Altered health maintenance related to

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Lack of knowledge about diagnosis and treatment plan multiple questions no questions

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Other patient teaching DVT

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Anticoagulation clothing activity and diet

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Pulmonary emboli Assessment

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Size of emboli size and number of vessels occluded

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Pulmonary emboli clinical manifestations

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Sudden onset of unexplained dyspnea tachypnea tachycardia coughing chest pain hemoptysis crackles increased S2 sounds change in mental status

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DVT surgical interventions

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Vena cava interruption with Greenfield filter or umbrella filter These are permanent devices inserted into the venous vessel below the renal vein

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Superficial vein thrombosis varicose veins

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Includes superficial saphenous system

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Superficial vein thrombosis primary risk factors and secondary varicosities

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Risk factors include familial obesity pregnancy standing occupations Secondary varicosities include esophageal varices hemorrhoids AV malformations

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Varicose veins clinical manifestations

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Cosmetic disfigurement ache or pain after prolonged standing relieved by walking or elevating limb swelling Cramp like pain nocturnal leg cramps

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Stasis ulcers and chronic venous insufficiency pathophysiology

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Incompetent valves ruptured capillaries Rbc's breakdown release hemosiderin contributes to brown discoloration

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Venous ulcers collaborative care

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Elevate extremity Extrinsic compression with compression stockings or ace bandages Wound assessment and care with circulation and sensory antibiotics Hydro colloid dressings wet to moist dressings laser light treatment Endovascular ablation skin grafting is last resort

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Collaborative wound care includes

answer

Culture and sensitivity antibiotic therapy referral to wound care specialist

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