Chapter 38 Flashcards
What are symptoms of thoracic aorta aneurysms?
Most common asymptomatic; May have deep diffuse chest pain that can extend into the interscapular area
What are symptoms of ascending aorta/aortic arch aneurysms?
Angina (decrease blood flow), hoarseness (compression of laryneal nerve), dysphagia (pressure on the esophagus), JVD, facial/arm edema
AAA symptoms
Most Common Asymptomatic, usually found on unrelated routine exams or unrelated diagnostic testing, pulsatible massin the preiumbilical (slightly left), Bruits (difficult to hear in obese), Mimics pain associated with ab or back pain (nerve compression), Epigastric discomfort (bowel compression), may spontaneously embolized plaque and will cause blue toe syndrome (patchy mottling toes c pulse)
Aortic Aneurysm Complications
Most serious comp is rupture. Rupture in retroperitoneal space bleeding may be tamponaded by surrounding organs preventing exsanguination and death (MB severe back pain, flank ecchymosis) Rupture in thoracic or ab cavity will cause massive hemorrhagic and death; Pt will experience shock (tachy, low bp, pale, clammy, low urine output, altered loc, ab tenderness)
Aneurysm Diagnostics
Chest/Abdominal X-rays, ECG r/o MI, Echocardiogram (aorta valve function), Ultrasound (screening, monitor size), CT scan (most accurate), MRI, Angiography (anatomical mapping of aortic system; abs and below)
Collaborative Treatment: Surgery considerations
Initiated when size >5.5cm in men and >5.0 cm in women; surgery intervention may occur soon in younger low risk pts, or if it grows more than 1cm per year, if it becomes symptomatic, or if the risk of rupture is high
Existing Carotid and or coronary artery obstructions must be clear before surgery. For ruptures emergency surgery is done. Elective: pt must be hydrated (coagulation, hct, or f/e must be corrected preop)
Collaborative Treatment: conservative
initiated for small aneurysms (less than 5cm); Factor mods: lower BP, annual monitoring for size (US, CT, MI)
Etiologies: Arterial Aneurysms
Congential, Mechanical (hemodynamic), Traumatic (blunt injury), Inflammatory (noninfectious: KS, Lupus) Infectious, Pregnancy, anastomotic/postgraft aneurysm
Thoracic aortic aneurysm
85% of all cases caused by atherosclerosis; ages:40-70; Most common site for dissecting aneurysms; 1/3 die from rupture
AAA risk factors
Higher in men, caucasians, and elderly; most are below the kidneys ; only 40% experience any symptoms
Aneurysms consideration before surgery
Electrolytes balance, systolic bp 100-120, controlled BP with meds or sodium nitroprusside to lower bp
Stent endovascular repair surgery complications
migration, endoleak (seeping blood into old aneurysm), rupture, aortic dissection, bleeding, renal artery occlusion (migration comp) graft thrombosis, incisional site hematoma, incisional infection; Will need routine exams and CT scans for the rest of your life
EVAR
Only used for AAA; reduces hospital stay, anesthesia, limits blood loss, decreased morbidity and mortality risk, faster physical activity, reduced costs
Aneurysm Preop interventions
Bowel prep, skin cleansed with antimicrobial day before, IV ABx immediately before incision is made, Beta-blockers (preop), Inform pt that they will be in ICU for 24-48 postop
Aneurysm Postop interventions
ICU 24-48 post op; Endotrachea tube for ventilation, arterial line, central venous pressure CVP or pulmonary artery PA catheter, peripheral IV lines, foley, possibly NG tube, ECG, pulse, O2 sat, chest tubes if thorax is opened during surgery; Pain meds via epidural catheter or PCA
Graft Patency (aneurysm post op interventions)
Adequate BP necessary, prolonged hypotension may result in graft thrombosis; Admin of IV fluids and blood components is important for blood flow; CVP/PA readings and urine output are monitored HOURLY to assess hydration and perfusion immediately post op; Severe HTN may cause leakage of blood or rupture at suture line; Give IV diuretics or IV antiHTNs as indicated
Cardiovascular Status (aneurysm post op interventions)
cardiac dysrhythmias may occur due to F/E imbalances(iv fluids), hypoxia (O2) hypothermia, or myocardial ischemia; Interventions: 1. montior ECG 2. F/E and ABGs monitoring 3. GIVE O2 4. IV anti-dysrhythmic and antiHTNs 5. Electrolytes PRN 6. Adequate pain control &. resume cardiac medications
Infection (aneurysm post op interventions)
Infection is rare but serious comp; interventions: give board-spectrum ABX, assess temp and report elevated ASAP, Monitor WBCs, ensure adequate nutrition, assess the surgical incision for signs of infection, All lines and catheters require strict aseptic technique, Meticulous perineal care for pt with foley, surgical site must be clean and dry
GI status (aneurysm post op interventions)
paralytic ileus (rarely last more than 4 days) may develop in open AAA sx, if NG present record amt and character of output, if NPO provide oral care and ice chips, Assess bowel sounds, Passing flatus signals return of bowel function*, Encourage ambulation (promotes bowel return) Rare cases: bowel temporary ischemia or infarction may result, s/s include absent bowel sounds, fever, ab distention, diarrhea, and bloody stools; If bowel infarction occurs immediate reoperation is needed to restore blood flow with likely resection of infarcted bowel
Neurological status (aneurysm postop interventions)
ASCENDING AORTA/AORTIC ARCH involvement monitor upper signs assessing loc, pupil size/response to light, facial symmetry, tongue deviation, speech, upper extremity movement, and quality of hand grasps. DESCENDING AORTA involvement will require assessment of lower extremities
Record all assessments and report changes from baseline
Peripheral Perfusion Status (aneurysm postop interventions)
location of aneurysm directs area of interest; check all peripheral pulses hourly for several hours and then routinely; Ascending aorta involvement: assess carotid, radial, and temporal artery pulses. Descending aorta: assess femoral, popliteal, posterior tibial and dorsalis pedis pulses; When assessing pulses mark locations with marker so that other may locate, Doppler might be needed to assess peripheral pulses; Check temp, color, capillary refill, and sensation/movement of extremities; Lower extremity pulses may be absent for a short time after surgery due to vasospasm and hypothermia; A decreased or absent pulse with a cool, pale, mottled or painful extremity may indicate embolization or graft occlusion REPORT immediately; always compare preop baseline with decreased pulses first
Renal Perfusion Status (aneurysm postop interventions)
postop pt has foley; Record hourly urine outputs, and record daily weights until pt resumes regular diet; CVP/PA pressures reveal info about hydration; Evaluate BUN and crt levels DAILY for signs of renal failure; Irreversiable renal failure may occur after aortic surgery esp. in high risk pts (dm)
Why does renal failure occur with aortic surgery?
Caused by decreased renal perfusion from embolization of aortic thrombus/plaque to one or both of the renal arteries; This causes ischemia. Hypotension, dehydration, prolonged aortic clamping during surgery, or blood loss can lead to decreased renal profusion
Post Op teaching for aortic surgery
Gradually increase activities after returning home; fatigue, poor appetite, and irregular bowel habits are common; Pt should avoid heavy lifting for 6 weeks after surgery; Any redness, swelling, increase pain, and drainage from incision, fever over 100F should be reported; Teach to look for changes in color, warmth of extremities, teach how to palpate peripheral pulses and to assess changes in their qualitiy; Sexual dysfunction in male patients is common after aortic surgery. preop document sexual baseline and refer to urologist if ED occurs
