Aortic aneurys mppt

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2. DEFINITION An aneurysm is a localized sac or dilationformed at a weak point in the wall of theaorta. Because of the high pressure in the arterialsystem, aneurysms can enlarge, producingcomplications by compressing surroundingstructures 3. CLASSIFICATION 4. A fusiform aneurysm is a diffuse dilation thatinvolves the entire circumference of the arterialseg-ment. A saccular aneurysm is a distinct, localized out-pouching of the artery wall. A dissecting aneurysm is created when bloodsepa-rates the layers of an artery wall, forming acavity between them.A false aneurysm (pseudoaneurysm) occurswhen the clot and connective tissue are outsidethe arterial. 5. ABDOMINAL AORTIC ANEURYSMS 6. INCICENCE 1. Approximately 36.5 abdominal aorticaneurysms are diagnosed per 100,000 individuals. Abdominal aneurysms are most common inindividu-als older than 50 years of age. They are more common in men than women, withratios of 2:1. Three fourth of true aortic aneurysm occur inabdomen and one fourth in the thoracic aorta The average mortality rate for persons undergoingelective abdominal aneurysm repair is 4 to 5percent. 7. Rupture of abdominal aortic aneurysm isthe 15th most common cause of death formen in the United States. Fifty percent of all persons whoseaneurysms rupture before they can betransported into the operatingroom will die. For persons who undergo emergencysurgical repair mortality rate is also high,around 54 percent. 8. ETIOLOGY Atherosclerosis Uncontrolled hypertension inherited or congenital syndromes, such as Marfansyndrome or Ehlers-Danlos syndrome. Infection Tobacco use Anastomotic (postarteriotomy) and graftaneurysms Blunt or sharp trauma, including operative trauma,can damage the aortic wall. 9. PATHOPHYSIOLOGY Most commonly, atherosclerotic plaque collectson the intimal surface of the aorta. This plaque formation will cause degenerativechanges in the media The destruction of the medial layer of a segmentof the aorta leads to loss of elasticity, weakening Dilation of the aorta 10. CLINICAL MANIFESTATIONTHORACIC AORTIC ANEURYSMS Pulse and BP difference in upper extremities Pain and pressure symptoms Constant pain because of pressure Intermittent and neuralgic pain Dyspnea, Abnormal pulsation apparent on chest 11. CONTINUED.. Hoarseness, voice weakness, or completeaphonia, Dysphagia Dilated superficial veins on chest Cyanosis Distended neck veins and edema of the headand leg Decreased venous drainage Ipsilateral dilatation of pupils 12. ABDOMINAL ANEURYSM Asymptomatic Abdominal pain is most common, eitherpersistent or intermittent often localizedin middle or lower abdomen to the left ofmidline Lower back pain Feeling of an abdominal pulsating mass Thrill, auscultated as a bruit 13. CONTINUED Hypertension Distal variability of BP, pressure in arm greaterthan thigh Thrombi may form and and thenembolize,traveling to other arteries andcausing ischemia to affected limb If rupture, will present with hypotensionand/or hypovolemic shock 14. DIAGNOSTIC EVALUATIONHealth historyPhysical examinationAbdominal ultrasoundArteriographyX-rayComputed tomography 15. COMPLICATIONS Fatal hemorrhage Myocardial ischemia Stroke Paraplegia due to interruption ofanterior spinal artery Abdominal ischemia 16. Continued. Graft occlusion Graft infections Acute renal failure Impotence Lower extremity ischemia Death 17. PROGNOSIS With early diagnosis and treatment theprognosis is good When the aneurysm ruptures survival ratedrops dramatically to below 50 percent 18. COLLABORATIVE CARE Early treatment and detection isimperative If aneurysm is larger than 5-6cm orincreasing aneurysm by 0.5 cm over a sixmonth period surgical repair is thetreatment For individuals with small aneurysm lessthan 4cm conservative therapy is initiated Coronary and carotid artery should beassessed for atherosclerotic disease 19. SURGICAL THERAPY 20. OPEN SUGERY1. Incising the diseased seg-ment of the aorta;2. Removing intraluminal thrombus or plaque;3. Inserting a synthetic graft (dacron orpolytetrafluoroethylene), which is sutured to thenormal aorta proximal and distal to theaneurysm; and4. Suturing the native aortic wall around the graft sothat it will act as a protective cover If the iliac arteries are also aneurysmal, the entirediseased segment is replaced with a bifurcationgraft. 21. Incising the diseased segment of the aorta 22. 1. insertion of synthetic graft 23. 3.suturing native aortic wall over synthetic graft 24. ENDOVASCULAR GRAFTING Endovascular grafting involves thetransluminal placement and attachment of asutureless aortic graft prosthesis across ananeurysm 25. COMPLICATIONS OF ENDOVASCULAR GRAFTING bleeding, hematoma, wound infection at the femoral insertion site; distal ischemia or embolization; dissection orperforation of the aorta; 26. CONTINUED. Graft thrombosis; graft infection; breakof the attachment system; Graft migration; proximal or distal graftleaks; delayed rupture Bowel ischemia. 27. NURSING DIAGNOSIS Ineffective Tissue Perfusion related toaneurysm or aneurysm rupture or dissection Risk for Infection related presence ofprosthetic vascular graft and invasive lines Acute Pain related to pressure of aneurysmon nerves and postoperatively 28. PATIENT EDUCATION AND HEALTHMAINTENANCE Instruct patient about medications to controlBP and the importance of taking them. Discuss disease process and signs andsymptoms of expanding aneurysm orimpending rupture, For postsurgical patients, discuss warningsigns of postoperative complications (fever,inflammation of operative site, bleeding, andswelling). 29. CONTINUED.. Encourage adequate balanced intake for woundhealing. Encourage patient to maintain an exercise schedulepostoperatively. Instruct patient that due to use of a prosthetic graftto repair the aneurysm, he will require prophylacticantibiotic use for invasive procedures, includingroutine dental examinations and dental cleaning 30. EVALUATION: EXPECTED OUTCOMES TISSUE COLOR, SENSATION, ANDTEMPERATURE NORMAL; NONTENDER,NONSWOLLEN, AND INTACT NO SIGNS OF INFECTION REPORTS CONTROL OF PAIN WITHMEDICATION 31. AORTIC DISSECTION 32. DEFINITION Aortic dissection, occurring mostcom-monly in the thoracic aorta, is theresult of a tear in the intimal (innermostlining of the arterial wall) that allowsblood to enter between the intima andmedia, thus creating a false lumen 33. CLASSIFICATIONType A dissections Include types I and II of DeBakeysclassification Involve the ascending aorta or the ascendingand descending aorta Are the most common and lethal type Require immediate surgicaL treatment 34. CONTINUED.Type B dissections Do not involve the ascending aorta Begin distal to the subclavian artery andextend downward into the descending andabdominal aorta Are also known as type III of DeBakeysclassifi-cation often initially treated with medical therapy 35. INCIDENCE They are three times more common in men than inwomen most commonly in the 50- to 70-year-old age group Approximately 60,000 cases are diagnosed eachyear in the United States. 36. ETIOLOGY Marfan syndrome Congenital heart disease A history of hypertension Pregnancy Trauma Iatrogenic injuries Atherosclerosis 37. Continued A rupture may occur through adventitia orinto the lumen through the intima, Allows blood to reenter the main channel Resulting in chronic dissection or occlusionof branches of the aorta. As the heart contracts, each systolicpulsation causes increased pressure on thedamaged area, which further increases thedissection 38. The dissection of the aorta may progressbackward in the direction of the heart,obstructing the openings to the coronaryarteries or producing hemopericardium(effusion of blood into the pericardial sac) oraortic insufficiency, it may extend in the opposite direction,causing occlusion of the arteries supplying thegastrointestinal tract, kidney, spinal cord, andlegs 39. Sudden onset of pain that is described as severe andtearing. The pain is typically associated withdiaphor-esis. The typical patient with acute aortic dissection usuallyhas sudden, severe pain in the anterior part of thechest or intra scapular pain radiating down the spineinto the abdomen or legs Location of the pain depends on the site of thedissec-tion. Typically, the pain is localized to either the front or theback of the chest. The pain may migrate along the direction of thedis-section. 40. Cardiac tamponade Hypertension or hypotension Absence of peripheral pulses Aortic regurgitation from damage to the aorticvalve Pulmonary edema Neurologic findings are due to dissection of majorarteries. Carotid artery obstruction produces hemiplegia orhemi anesthesia. Spinal cord ischemia can cause paraplegia. Compression of adjacent structures 41. DIAGNOSTIC EVALUATION Health history and physical examination ECG-Left hypertrophy Chest x-ray CT scan Transesophageal echocardiogram (TEE)- Atransesophageal echocardiogram (TEE) canidentify dissections that are closest to the aorticroot Angiogram Magnetic resonance imaging (MRI) 42. COMPLICATION Cardiac tamponade-Hypotension, narrowedpulse pressure, distended neck veins, muffledheart sounds and pulsus paradoxus Haemmorhage Ischemia Death 43. NURSING MANAGEMENT Bed rest Pain relief with narcotics Control of bloodpressure trimethaphan (Arfonad) sodium nitroprusside (Nipride) Control ofmyocardial contractility propranolol (Inderal) labetalol (Normodyne) Aortic resection andrepair 44. Continued Type A dissections usually are repairedsurgically Type B dissections often are managedmedically 45. SURGICAL TREATMENT Surgical treatment is indicated in severalcircumstances: (1) location of dissection in ascending aorta, (2) development of ischemic complication, (3) poor response to medical managementwith continued pain, (4) aneurysmal degeneration (5) in selected Stanford type B patients 46. Surgical management Aortic replacement, Fenestration of the intimal flap Extra-anatomic bypass 47. NURSING MANAGEMENT Provide semi fowlers position-to ma