الرحيم الرحمن الله بسم�university of medical science and technology

faculty of nursing sciencepost graduated college

MSC N batch(8)cardiothoracic

presention about:

Peripheral artery diseasesPresented By:Fatima Sayed Osman AshmiegMautha mahfoozSupervisor:Dr. faroooq abdalkani

Presentation content:

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

PERIPHERAL ARTERY DISEASE (PAD)

Peripheral artery disease

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 .

Aortitis

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).

Arterial Embolism And Arterial Thrombosis

Acute vascular occlusion may be caused by an embolus or acutethrombosis. Acute arterial occlusions may result from iatrogenicinjury, which can occur during insertion of invasive catheterssuch as those used for arteriography, PTA or stent placement, oran intra-aortic balloon pump. Other causes include trauma froma fracture, crush injury, and penetrating wounds that disrupt thearterial intima. The accurate diagnosis of an arterial occlusion asembolic or thrombotic in origin is necessary to initiate appropriate treatment.

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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.

AORTIC ANARYSIM

Introduction:

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.

Epideminology:

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

Risk factor:

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

Pathophysiology:

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.

Classification:• 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.

:)1 (thoracic aortic aneurysm

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.

)2 (Abdominal Aortic Aneurysm:

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.

Signs and symptoms: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.

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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.

Management:

•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).

Medical thearpy:

• 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.

Surgery:

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).

Open surgery:• 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.

Endovascular:• 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

Complications:

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.

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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 aneurysmThese complications can be limb- and life-threatening, and, when diagnosed, indicate the need for repair.

Nursing care plan:

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

AORTIC DISSECTION

introduction:

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 .

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*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.

History:

**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.

Continue.… 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.

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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.

:Epidemiology

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 .

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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).

Path physiology: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 .

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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.

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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.

Causes:

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.

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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.

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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.

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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.

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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.

Classification

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.

Stanford classifications:

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.

Signs and symptoms:(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.

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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.

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)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.

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)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

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)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.

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)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.

Diagnosis:

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 .

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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.

)1 (D-daimer:

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.

)2 (Chest x-ray:

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).

)3 (Computed tomography:

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.

)4 (MRI:

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.

)5 (Transesophageal echocardiography: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 .

)6 (Aortogram :

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.

Management:

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.

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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.

Medications:

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.

Surgery:

• 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

Follow up:

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.

Prognosis:

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%.

Complications:

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).

Preventions: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.

NURSING CARE PLAN

Nursing care plan: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.

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**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.

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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.

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**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.

NURSING PROCESS

)1 (assessment:

:Patient Assessment1.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.

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:Diagnostic Assessment1.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.

)2 (diagnosis:

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

)3 (planning:

: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

:)4(Intervention

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.

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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.

:Others nursing diagnosis

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.

Outcomes:

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.

Nursing management:

**Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patientAnalgesic 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 complicationsShock 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.

Continue.…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 functionCirculatory Care: Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumpsRespiratory 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

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**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.

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