Pulmonary EmbolismAortic AneurysmAortic Dissection

Nursing 313, Fall 2011

Incidence >650,000 cases diagnosed per year in US Third most common cause of death in

hospitalized patients Greatest risk those who have a DVT Recent trends: men > women Risk doubles every ten years after 60

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Risk Factors

http://www.cholesterolcholestrol.com/virchows-triad.jpg3

PathophysiologyClot lodges in PA or branches

↑ in Dead Space → VQ Mismatch

↑ PA Pressures

↑ in Vaso & Bronchoconstriction

↑ RV workload → RV Failure

Release of Vasoactive Substances

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Respiratory System

A balancing act between ventilation (V) and perfusion (Q)

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Perfusion / ventilation mismatchV/Q mismatch

Obstructed area has absent or diminished blood flow

Alveoli ventilated but not perfused which causes increased dead space

Severity depends on size of embolism and degree of vascular obstruction

Possibility of severe hypotension and shock

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Pulmonary Embolism

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Signs and Symptoms

Sudden onset of dyspnea Sudden onset of pleuritic chest pain General signs of hypoxemia Feeling of impending doom ↑ Anxiety Cough, possible hemoptysis Mild fever Diaphoresis

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If severe, then cardiac involvement Cardiac s/s are due to loss of the forward flow

of blood JVD S3 or S4 Syncope Tachycardia Tachypnea Rales Signs of right sided heart failure

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Diagnosis D-Dimer assay – possible method of ruling

out a PE Spiral CT scan Pulmonary Angiography (gold standard) V/Q scan CXR, ECG, ABGs

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Emergency Management Stabilize the cardiopulmonary system

Oxygen Insertions of IV lines Treat hypotension – vasoactive drugs if ↓BP Diagnostic testing: scans, ABGs, labs Indwelling urinary catheter Sedatives or pain relief as needed Prevent further emboli from forming

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Pharmacological ManagementHeparin Heparin- initial and preferred treatment Does not affect the existing clot PTT/ therapeutic range 1.5 to 2 times normal Antidote: protamine sulfate

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Warfarin Warfarin (Coumadin) Interferes with the synthesis of the vitamin K 3-4 days for therapeutic benefit INR between 2.0 – 2.5 for those with PE Antidote – Vitamin K

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Thrombolytic Therapy tPA, Alteplase, Reteplase Converts plasminogen to plasmin Specific contraindications:

Recent CVA; active bleeding; surgery in past 10 days; trauma; recent labor and delivery, severe hypertension

Major complication: bleeding

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Nursing Management of Patients on Anticoagulation Therapy

Frequent vital signs Hematest stools Handle patient gently Avoid IM injections & veni-punctures Use electric shaver & soft toothbrushes Nothing per rectum Avoid foods containing vitamin K Monitor labs

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Surgical Management

Thrombectomy or Embolectomy Vena Cava Interruption (Filters)

Indicated in patients who may not tolerate anticoagulation

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Greenfield Filter

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Nursing Management

Identify patients at risk Manage pain! Psychosocial support for patient and family Utilize nursing interventions to minimize risk

Early ambulation Watch labs, VS, targeted assessments for

cardiopulmonary system Patient & family teaching on importance of lifestyle

changes18

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Aortic Aneurysms

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Flash from the past….

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Factoids Atherosclerosis damages the lining of the aorta Majority below the renal arteries Exact cause of aneurysm unknown More common in Caucasians More common in men than women

Higher risk of rupture and death in women compared with men with same size aneurysms

Rare in young females, but related to pregnancy

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Incidence & Risk Factors 13th leading cause of death in men aged 65-75 Up to 13% of individuals with AA have multiple aneurysms Causes about 9,000 deaths / year Risk factors:

Atherosclerosis Patients born with bicuspid aortic valves (new) Hypertension Age Smoking, cholesterol, ↑lipids Genetic CT disorders (Marfan’s) History of crack use in pregnancy Positive family history

Often found incidentally23

Classification: Morphology

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Abdominal More common (75%) Usually infra-renal

Thoracic Less common (25%) > chance of rupture &

dissection

Classification: Location

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Clinical Manifestations

Abdominal Aortic Aneurysms Asymptomatic (early) Symptoms caused by expansion (later)

Chest or abdominal pain, flank pain, scrotal pain Pulsatile mass palpated (80%) , bruit + Feels like heart beating in abdomen

Ruptured aneurysm is a medical emergency

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Thoracic Aortic Aneurysms Asymptomatic (early) Symptoms by compression of tissue (later)

Ascending: CHF due to aortic regurgitation, edema of the UE and face

Arch or descending: wheeze, cough, hemoptysis, dysphagia, hoarseness

Chest or back pain is common to both

Clinical Manifestations

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Aortic Aneurysm Rupture

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Aortic Dissection Occurs when there is a tear in the intimal

lining (or adventitia) and blood gets diverted into the channel → ↓ intravascular volume

http://www.youtube.com/watch?v=ZtanUq95pTk

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More common in More common in thoracic aneurysmsthoracic aneurysms

May interfere with May interfere with major aortic branches major aortic branches causing organ failurecausing organ failure

Classification system:Classification system: Debakey Debakey StanfordStanford

Clinical manifestation:Clinical manifestation:PAIN!!!!PAIN!!!!

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Aortic Dissection Classifications DeBakey Classification: Type I - originated in ascending

aorta Type II - originated in and is

confined to ascending aorta Type III - originated in

descending aorta

Stanford Classification A - Originated and involves

ascending aorta. B - Originated and involves

descending aorta

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Dx tests for Aortic Dissections Trans thoracic echocardiogram (TTE) Trans esophageal echocardiogram (TEE) Computed Tomography Angiography (CTA) Magnetic Resonance Angiography Ultrasonography Aortography

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Medical Management ofAortic Aneurysm

Control /eliminate risk factors F/U every 3 to 6 months (ultrasounds) Medications

Beta-blockers/calcium channel agents (older) Recent evidence favors ACE inhibitors over BB Statins, Doxycycline: both inhibit matrix

metalloproteinases (MMPS) MMPs are enzymes that break down elastin and collagen in the

aortic wall – contributes to aneurysm formation

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General Indications for Surgical Repair of Aortic Aneurysms Diameter ≥5.5 cm (men) For women, 4.5-5.0 cm (due to greater incidence of

rupture) Ascending Thoracic Diameter ≥5.5 cm (5 cm in patients with Marfan

syndrome) Symptoms suggesting expansion or compression of

surrounding structures Rapidly expanding aneurysms (growth rate >0.5 cm

over a 6-month period) Symptomatic aneurysm

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http://www.cvtsa.com/ListofConditions/A-444-62.html 35

Open AneurysmectomyOpen Aneurysmectomy

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Endovascular Stent Grafts (EVSG)Endovascular Stent Grafts (EVSG)

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EVAR 60% of aneurysm repairs in the US Fewer immediate complications than

conventional surgery More interventions are needed after 2 years

with EVAR (graft leaks, graft migration or infection, bowel perforation, etc)

Similar survival rates at 6 years (EVAR vs. open)

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Post op care of surgical repair of AAA Post op complications

MI Cerebral infarct or ischemia to spinal cord Hypovolemia Respiratory distress Paralytic ileus Renal Failure

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Postoperative nursing management Cardiovascular

Monitor for dysrhythmias Control of BP Monitor labs

Renal Hourly urines Monitor renal indicators

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Postoperative nursing management Respiratory

Prevention of complications Meticulous pulmonary hygiene Control pain

Gastrointestinal Assess motility

NGT for suctioning (ileus) Monitor girth Provide nutrition Administer antibiotics

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Postoperative nursing management Neurological

Neurovascular checks Graft Occlusion or Rupture

Assess for changes in pulses; temperature & color of extremities; severe pain

Abdominal distention Decreased urine output

Post endovascular stent procedure complications

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