Cardiovascular: Valvular, Cardiomyopathy, Aneurysm and Cardiac Surgery Heart valves at work! A&P Heart Valves- Click here Use these slide as supplement to Notes and Learning Guide Carolyn M Jacobs RN MSN ONC

Valvular Heart Disease Heart contains Two atrioventricular valves Mitral Tricuspid Two semilunar valves Aortic Pulmonic Valvular Disease Short video-valvular heart disease

Valvular Heart Disease Types of valvular heart disease depend on Valve or valves affected Two types of functional alterations Stenosis Regurgitation View HeartPoint:Valves; Flashcards MD Lecture on valvular disease

Pathophysiology Stenosis- narrowed valve, increases afterload Regurgitation or insufficiency- increases preload. The heart has to pump same blood **Blood volume and pressures > reduced in front of affected valve and inc behind affected valve > results in heart failure All valvular diseases have a characteristic murmur murmurs

Valvular Stenosis and Regurgitation A, Normal position of the valve leaflets, or cusps, when the valve is open and closed. B, Open position of a stenosed valve (left) and position of closed regurgitant valve (right). C, Hemodynamic effect of mitral stenosis. The stenosed valve is unable to open sufficiently during left atrial systole, inhibiting left ventricular filling. D, Hemodynamic effect of mitral regurgitation. The mitral valve does not close completely during left ventricular systole, permitting blood to reenter the left atrium. Fig. 37-8. Valvular stenosis and regurgitation. A, Normal position of the valve leaflets, or cusps, when the valve is open and closed. B, Open position of a stenosed valve (left) and position of closed regurgitant valve (right). C, Hemodynamic effect of mitral stenosis. The stenosed valve is unable to open sufficiently during left atrial systole, inhibiting left ventricular filling. D, Hemodynamic effect of mitral regurgitation. The mitral valve does not close completely during left ventricular systole, permitting blood to reenter the left atrium.

Normal function and sound of heart valves Normal aortic and mitral valves function You tube video-good review on heart sounds, S3, S4

Valvular Heart Disease Valvular disorders occur in children and adolescents primarily from congenital conditions in adults from degenerative heart disease Risk Factors Rheumatic Heart Disease MI Congenital Heart Defects Aging CHF

Mitral Valve Stenosis Pathophysiology Dec blood flow into LV LA hypertrophy Pulmonary pressures inc Pulmonary hypertension Dec CO

Fig. 37-9 Fish mouth

Mitral Valve Stenosis Manifestations Primary symptom is DOE Later > symptoms of R heart failure A fib common MVS murmur (low pitched rumbling) Usually secondary to rheumatic fever

Mitral Valve Regurgitation Pathophysiology Manifestations Regurgitation of blood into LA during systole LA dilation and hypertrophy Pulmonary congestion RV failure LV dilation and hypertrophy-to accommodate inc preload and dec CO Thready pulses Cool extremities Symptoms of LV failure Third heart sound (S3) MVR murmur *Acute- poorly tolerated: systolic murmur, shock, pulmonary edema *Chronic-weakness, fatigue, S3 gallop, holosystolic murmur

Mitral Valve Prolapse Fig. 37-10. Mitral valve prolapse. In this valvular abnormality, the mitral leaflets have prolapsed back into the left atrium. They also demonstrate hooding (arrow). The left ventricle is on the right.

Mitral Valve Prolapse Pathophysiology Manifestations Abnormality of mitral valve leaflets, papillary muscles or chordae Etiology unknown Most common valvular heart disease in US Female 2x > Male Usually asymptomatic Click murmur *Atypical chest pain does not respond to NTG Tachydysrhythmias may develop- SVT Risk for endocarditis may be inc heart association guidelines

Mitral Valve Prolapse May or may not be present with chest pain If pain occurs, episodes tend to occur in clusters, especially during stress Pain may be accompanied by dyspnea, palpitations, and syncope *Does not respond to antianginal treatment MVP murmur (mid-systolic click) Click to see video Mitral valve prolapse and consequent mitral valve regurgitation is seen during TEE examination in a patient undergoing mitral valve repair.

Aortic Valve Stenosis Aortic Valve Problems great YouTube Pathophysiology Aortic Valve Problems great YouTube Inc in afterload Incomplete emptying of LA LV hypertrophy Reduced CO RV strain Pulmonary congestion Poor prognosis when experiencing symptoms and not treated- 10-20% *sudden cardiac death (SCD)

Aortic Valve Stenosis Syncope Angina Dyspnea Manifestations Exertional Syncope, Angina, DOE -classic symptoms *Triad > LVF Later get signs of RHF May be asymptomatic for many years due to compensation AVS murmur (normal or sofot S1, systolic mormur, S4 (why) *Nitroglycerin contraindicated > reduces preload

Bicuspid Aortic Valve Congenital Heart Defect Most Common Congenital Heart Disease Familial Male>Female

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Aortic Valve Regurgitation Pathophysiology Inc preload- 60% of SV can be regurgitated Characteristic Water Hammer pulse; Corrigan's sign (what is it?) AVR (Austin Flint Murmur) Regurgitation of blood into LV LV dilation and hypertrophy *Dec CO Can have Acute onset *life threatening Physiologic consequence Retrograde blood flow from ascending aorta to left ventricle Results in volume overload Initially, left ventricle compensates by dilation and hypertrophy. Myocardial contractility eventually declines. Pulmonary hypertension and right ventricular failure to develop Clinical manifestations of sudden cardiovascular collapse Left ventricle exposed to aortic pressure during diastole Sudden weakness Severe dyspnea Chest pain Hypotension Constitutes a medical emergency *Severe aortic regurgitation -“Water-hammer” pulse (a strong quick beat that collapses immediately) Auscultatory findings-Soft or absent S1;Presence of S3 and S4; Soft, high-pitched diastolic murmur Austin-Flint murmur; Chronic aortic regurgitation Remains asymptomatic for years Exertional dyspnea Orthopnea Paroxysmal nocturnal dyspnea

Water Hammer pulse Pulse- “water hammer” -jerky pulse that is full, then collapses due to aortic insufficiency/regurgitation (blood ejected into aorta regurgitates back through aortic valve into L. ventricle ). AKA-called a Corrigan pulse or a cannonball, collapsing, pistol-shot, or trip-hammer pulse. (Click to view video) an abrupt distension and collapse of carotid arteries-sign indicating aortic incompetence

Aortic Valve Regurgitation Manifestations *Acute: sudden manifestations cardiovascular collapse Left ventricle exposed to aortic pressure during diastole Weakness Severe dyspnea Chest pain Hypotension Constitutes a medical emergency AVR murmur (Austin Flint-Soft or absent S1; presence of S3 and S4; Soft, high-pitched diastolic murmur)

Tricuspid and Pulmonic Valve Disease Pathophysiology Manifestations Uncommon Both conditions > inc in blood volume in R atrium and R ventricle > Right sided heart failure Tricuspid- Rheumatic, prior IV drugs; use dopamine agonist Pulmonic- Congenital RHF Tricuspit-Occurs almost exclusively in patients With rheumatic mitral stenosis Who are IV drug abusers Who are treated with a dopamine agonist *Pulmonic Almost always congenital Results in backward flow of blood from right ventricle Causes right ventricle hypertension and hypertrophy Results in right atrial enlargement and ↑ systemic venous pressures

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Collaborative Care Focus on preventing Exacerbations of heart failure Acute pulmonary edema Thromboembolism Recurrent endocarditis and recurrent rheumatic fever *Treatment depends on valve involved and severity of disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Diagnostic Tests Echo- assess valve motion and chamber size CXR EKG Cardiac cath- get pressures An echocardiogram reveals valve structure and function, and heart chamber size. Chest x-ray reveals heart size, altered pulmonary circulation, and valve calcification. An ECG identifies heart rate, rhythm, and any ischemia or ventricular hypertrophy. Cardiac catheterization detects pressure changes in the cardiac chambers, measures pressure gradients (differences) across the valves, and measures the size of valve openings.

Transesophageal echocardiogram

Medications/diet Like Heart Failure ACE inhibitors Beta Blockers Digoxin Diuretics Vasodilators Anticoagulants Prophylactic antibiotics Low sodium diet Anticoagulant therapy prevents and treats systemic or pulmonary emboli. It is used prophylactically in patients with atrial fibrillation. Dysrhythmias, especially atrial dysrhythmias, are common and are treated with digoxin, β-adrenergic blockers, antidysrhythmic drugs, or electrical cardioversion.

Percutaneous Aortic Valve Replacement Percutaneous AVR a) Balloon valvuloplasty; b) Balloon catheter with valve in the diseased valve; c) Balloon inflation to secure the valve; d) Valve in place Percutaneous aortic valve replacement (AVR)- new treatment being investigated for select patients with severe symptomatic aortic stenosis… a percutaneous technique for implanting a prosthetic valve inside diseased calcific aortic valve… performed in catheterization lab…a catheter is placed through femoral artery (in the groin) and guided into chambers of the heart. A compressed tissue heart valve is placed on the balloon-mounted catheter and is positioned directly over the diseased aortic valve. Once in position, the balloon is inflated to secure the valve in place. *For patients with severe peripheral vascular disease, surgeons and cardiologists are testing an alternative approach through the left ventricular apex of the heart.

Collaborative Therapy Surgical therapy for valve repair or replacement Valve repair typically the surgical procedure of choice. Valvular replacement may be required for certain patients. The decision for surgical intervention depends on the patient’s clinical state using the New York Heart Association classification system for functional disability. Valve repair has a lower operative mortality rate than valve replacement and is often used in mitral or tricuspid valvular heart disease. {Discuss mitral commissurotomy, vulvuloplasty, minimally invasive vulvuloplasty, and annuloplasty.} The surgical treatment of choice for combined aortic stenosis and aortic regurgitation is valve replacement. {See next slide for figure on types of prosthetic valves.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Mitral Stenosis Therapy Surgical Mitral Commissurotomy Mitral Valve Replacement Mechanical Bioprosthetic

Heart Valve replacement (Aortic valve, patient resource, mechanical, biological)

Important-teaching needs for valve replacement Excised porcine bioprosthesis; main advantage of bioprosthesis is lack of need for continued anticoagulation-drawback include limited lifespan, on average from 5 to 10 years (sometimes shorter) due to wear and calcification. (No immune suppressive agents required.) Mechanical valve prosthesis- modern tilting disk variety (for mitral valve); last indefinitely from structural standpoint; patient requires continuing anticoagulation due exposed non-biologic surfaces. Important-teaching needs for valve replacement

Ross Procedure

Summary Interventions Percutaneous balloon valvuloplasty Surgical therapy for valve repair or replacement: Valve repair-typically surgical procedure of choice Open commissurotomy- open stenotic valves Annuloplasty- can be used for both Valve replacement may be required for certain patients Heart valve surgery Mechanical-need anticoagulant Biologic-only last about 15 years Ross Procedure MedlinePlus: Interactive Health Tutorials (choose open heart surgery etc)

A balloon valvuloplasty would be contraindicated for the elderly. True A patient with mitral stenosis should be on an anticoagulant because atrial fibrillation is common ? 1. True 2. False A balloon valvuloplasty would be contraindicated for the elderly. True False Which can be serious complications of MVP? (may have more than one answer) Mitral insufficiency Sudden cardiac death (SCD) Infectious endocarditis (IE) Cerebral Ischemia MVP- usually benign- can have serious complications including MR, SCD, HF and cerebral ischemia A water hammer pulse is common in aortic stenosis because of aortic insufficiency ? True False

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. During the nursing assessment of a patient with an aortic stenosis, the nurse would expect to find: 1. A systolic murmur. 2. Systolic ejection click. 3. Pericardial friction rub. 4. Brisk, hammering pulses. Answer: 1 Rationale: Clinical manifestations of aortic stenosis include angina, syncope, dyspnea on exertion, and heart failure, along with normal or soft S1, diminished or absent S2, systolic murmur, and prominent S4. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Nursing Diagnoses Activity intolerance Excess fluid volume Decreased cardiac output Ineffective therapeutic regimen management

What Is New? Heart valve replacement without need for open heart surgery. Typically, diseased or defective valves replaced with an artificial valve or a tissue valve (from pig or cow). A new, less invasive procedure, known as percutaneous transcatheter heart valve implantation, involves use of balloon catheters and large stents… New heart valve transported via stent; stent then expanded to implant the valve. For patients not able to undergo open-heart surgery… percutaneous heart valve implantation may impact significantly on survival and quality of life. Click for more!

New Cont. New technologies…a tiny metallic clip is being studied for treatment of mitral regurgitation- MitraClip 3D Animation View video -procedure to correct Valves may last a lifetime for older patients, younger patients may need several replacement procedures over time. One focus of research-create longer-lasting replacement valves, particularly for patients with congenital heart disease. Research potential toward this goal: stem cell research and the use of endothelial cells.

Cardiomyopathy Condition in which ventricle has become enlarged, thickened or stiffened >heart’s ability as pump is reduced 3 Types Dilated Hypertropic Restrictive

3 Types Dilated Hypertrophic Restrictive

Cardiomyopathy Primary-idiopathic Secondary Ischemia- from CAD Infectious/viral disease Exposure to toxins Metabolic disorders Nutritional deficiencies Genetic

Cardiomyopathy Primary-idiopathic Secondary Ischemia- from CAD Infectious disease Exposure to toxins Metabolic disorders Nutritional deficiencies Pregnancy

Dilated Cardiomyopathy *Most common type Diffuse inflammation rapid degeneration myocardial tissue Heart chambers dilate; impaired systolic function, *atrial enlargement 40% dev. R & L heart failure; dec. EF *Dysrhythmias are common- SVT, A-fib, VT Prognosis poor-*need transplant

Dilated Cardiomyopathy Factors Causing: Genetic predisposition May follows infectious endocarditis & viral infections Alcohol related S&S- (heart failure) Fatigue, orthopnea, noctural dyspnea Irregular heart rate, pulmonary crackles, S3, S4 Heart murmurs, sudden cardiac death!

Cardiomyopathy- very large heart, circular shape, all chambers are dilated, flabby, myocardium poorly contractile Normal weight 350 gms –dilated cardiomegaly-700 gms

Dilated Cardiomyopathy Collaborative Care *Focus-control heart failure Enhance contractility; dec. afterload Dx Tests (signs heart failure) Doppler ECHO, EKG, heart cath Lab (BNP) Chest X-Ray Diet/Drugs Low Na HF meds

Dialated Cardiomyopathy Diagnostics Echocardiogram, CXR, ECG, labs Treatment-Control HF Diuretics Nitrates Ace inhibitors Beta blockers Digoxin Amiodarone Anticoagulants

Dilated Cardiomyopathy Collaborative Care Surgical/resynchronizationization therapy VAD or LVAD CRT (cardiac resynchronization therapy) Heart Transplant

Heart transplant (slide show) Virtual transplant (try it!)   Click here-YouTube- Heart-Lung machine

Hypertrophic Cardiomyopathy Massive ventricular hypertrophy Rapid, forceful contraction of the LV Impaired relaxation or diastole Obstruction to aortic outflow Primary defect is diastolic filling **HCM most common cause of SCD in young adulthood Genetic

Hypertrophic Cardiomyopathy Manifestations Dyspnea Fatigue-dec CO Angina, syncope S4 and systolic murmur Diagnostics Echo- TEE Heart cath

*Hypertropic Aortic Stenosis- *Note obstruction-aortic outflow (HCM)

Hypertrophic Cardiomyopathy (HCM) Collaborative Care Goals Improve ventricular filling *Reduce ventricular contractility Relieve L. ventricular outflow obstruction Diagnostic Tests “Forced” apical sound (laterally) EKG, ECHO (L. ventricular hypertrophy, abnormal wall motion) Heart cath Meds Negative inotropes (Ca channel blockers, beta blockers) *NO vasodilators, digitalis (usually), nitrates

Hypertrophic Cardiomyopathy Treatment Goal- improve ventricular filling and relieve LV outflow obstruction Beta blockers Calcium channel blockers Digoxin- only for A-fib if present Antidysrhythmics ICD AV pacing

Hypertrophic Cardiomyopathy (HCM) Collaborative Care Surgical/Other Interventions Cardioverter/defibrillator (At risk patients) AV pacing if outflow obstruction Ventriculomyotomy and septal myomectomy Alcohol septal ablation Live Search Videos: cardiomyopathy

Hypertrophic Cardiomyopathy Ventriculomyotomy and myomectomy- incising the septum muscle and removing some of the hypertrophied muscle PTSMA- alcohol induced percutaneous trans luminal septal myocardial ablation - inject alcohol into small branch of LAD which causes ischemia and MI of septal wall. Videos: cardiomyopathy

Restrictive Cardiomyopathy Least common Rigid ventricular walls that impair filling (impaired diastolic) Contraction (systolic) and EF normal Prognosis-poor S & S Fatigue, dyspnea, exercise intolerance R. sided heart failure cardiomyopathy? Restrictive cardiomyopathy is a serious problem that makes your heart muscle stiff. When your heart muscle is stiff, it can''t stretch to allow enough blood to enter its lower chambers, the ventricles . So blood that would normally enter the heart backs up in your circulatory system. Most of the time, this leads to heart failure. Heart failure does not mean that your heart stops pumping. It means that your heart can''t pump enough blood to meet your body''s needs. What causes restrictive cardiomyopathy? Often the cause is never found. But we do know that there are a number of diseases or problems that can lead to restrictive cardiomyopathy. These include: Cardiac amyloidosis, a buildup of an abnormal protein in the heart muscle. Hemochromatosis, a buildup of iron in the heart muscle. Sarcoidosis, a rare type of heart inflammation. Radiation therapy and chemotherapy, used to treat cancer. Carcinoid syndrome, a rare disease that causes certain chemicals to be released into the blood stream. These chemicals can stiffen heart muscle. Löeffler’s syndrome and endomyocardial fibrosis, conditions that can cause scar tissue in the heart. Genetic factors. You can inherit diseases, including Gaucher disease and Fabry''s disease, that can lead to restrictive cardiomyopathy. But these diseases can be treated to prevent restrictive cardiomyopathy. Restrictive cardiomyopathy

Restrictive Cardiomyopathy Collaborative Care Dx Test Chest X-ray (cardiomegaly?, show R. and L atrial enlargement) EKG (tachycardia), supraventricular dysrhythmias, AV block ECHO wall motion, EMB, CT nuclear imaging Medications *No specific treatment Meds to improve diastolic filling, manage heart failure, dysrhythmia Surgical/Other Treatment Poor prognosis Transplant maybe (depends underlying cause) The test, endomyocardial biopsy, or EMB, involves inserting a catheter into a vein in the neck and threading it into the heart, so that a tiny amount of the heart muscle can be sampled for analysis. Now, a quick, easy-to-administer blood test is rapidly replacing EMB as the gold standard for diagnosing rejection of the donor heart.

Biopsy of heart (EMB)

Restrictive Cardiomyopathy Treatment Surgery Vad-bridge to transplant Heart Transplant Myoplasty ICD- antiarrhythmics are negative inotropes Dual chamber pacemaker Hypertrophic excision of ventricular septum-myotomy, inject denatured alcohol in coronary artery that feeds the top portion of septum.

Restrictive Cardiomyopathy Treatment No specific Treatment- goal to improve diastolic filling Medications HF and dysrhythmias Teaching Avoid strenuous activity, dehydration, increases in SVR High risk for IE

Review-Management Cardiomyopathy Vad-bridge to transplant Heart Transplant Myloplasty ICD- antiarrhythmics are negative inotropes Dual chamber pacemaker *Hypertrophic- excision of ventricular septum-myotomy, inject denatured alcohol in coronary artery that feeds top portion of septum. *Transplant

Cardiomyopathy Nursing Diagnoses Decreased Cardiac Output Fatigue Ineffective Breathing Pattern Fear Ineffective Role Performance Anticipatory grieving

Nursing Relieve symptoms Prevent complications Provide pysch and emotional support Teaching- Avoid strenuous exercise and dehydration Avoid anything increasing the SVR (afterload) makes obstruction worse Chest pain Rest and elevation of feet for venous return NO vasodilators like nitroglycerine

Aortic Aneurysms Aorta Aneurysm- Largest artery Responsible for supplying oxygenated blood to essentially all vital organs Aneurysm- Abnormal dilation of a blood vessel at a site of weakness or a tear in the vessel wall. Usually secondary to atherosclerosis Most commonly affect the aorta

Aortic Aneurysms Atherosclerotic plaques deposit beneath the intima Plaque formation is thought to cause degenerative changes in the media Leading to loss of elasticity, weakening, and aortic dilation

May have aneurysm in more than one location Growth rate unpredictable Larger the aneurysm greater risk of rupture May also involve the aortic arch or the thoracic aorta, Most (3/4) are found in abdominal aorta below renal arteries ¼ are found in the thoracic area

Dilated aortic wall becomes lined with thrombi than can embolize Leads to acute ischemic symptoms in distal branches Important to assess peripheral pulses

Aortic Aneurysms Male>female Risk increases with age Studies suggest strong genetic predisposition *Male gender and smoking stronger risk factors than hypertension and diabetes Atherosclerosis Risks: Age>60 Male White Family Hx AAA Smoking HTN CAD

Aortic Aneurysms Usually atherosclerosis May also result from Genetic Trauma Infection Surgery Inflammation Genetic Marfan’s

Types of Aneursyms 2 basic classifications- True and False True aneurysm Wall of artery forms the aneurysm At least one vessel layer still intact Fusiform-Circumferential, relatively uniform in shape Saccular-Pouchlike with narrow neck connecting bulge to one side of arterial wall Types of Aneursyms

Types of Aneurysms Saccular Fusiform-most are fusiform and 98% are below the renal artery

Types of aneursyms False aneurysm (also called pseudoaneurysm) Not an aneurysm Disruption of all layers of arterial wall Results in bleeding contained by surrounding structures

Ascending Aortic Aneurysm Aortic Arch Clinical Manifestations ASH Angina Swelling Hoarseness If presses on superior vena cava decreased venous return can cause distended neck veins edema of head and arms

Thoracic Aortic Aneurysm Clinical Manifestations Frequently asymptomatic Coughing Hoarseness Difficulty swallowing May have substernal, neck, back pain Swelling (edema) in the neck or arms Myocardial infarction Stroke

Abdominal Aortic Aneurysm Clinical Manifestations Abdominal aortic aneurysms (AAA) Often asymptomatic Frequently detected On physical exam Pulsatile mass in periumbilical area Bruit may be auscultated Often found when patient examined for unrelated problem (i.e., CT scan, abdominal x-ray)

Aortic Aneurysm Clinical Manifestations AAA May mimic pain associated with abdominal or back disorders Pain correlates to the size May spontaneously embolize plaque Causing “blue toe syndrome” patchy mottling of feet/toes with presence of palpable pedal pulses It can rupture causing shock and death in 50% of rupture cases

Complications Rupture- signs of ecchymosis Thrombi Renal Failure Death Back pain Hypotension Pulsating mass (rupture triad) Thrombi Renal Failure Death

Aortic Aneurysm- Complications Rupture- serious complication related to untreated aneurysm Anterior rupture Massive hemorrhage Most do not survive long enough to get to the hospital Posterior rupture Bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death Severe pain May/may not have back/flank ecchymosis

Turner’s sign and Cullen’s Sign Live Search Videos: aortic aneurysm http://www.austincc.edu/adnlev4/rnsg2331online/module05/aneurysm_case_study.htm

Aortic Aneurysm Diagnostic Studies X-rays Chest - Abdomen - ECG -to rule out MI Echocardiography Ultrasound CT scan MRI Angiography

Medical Treatment Anti-hypertensives Sedatives Beta blockers, Vasodilators Calcium channel blockers Nipride Sedatives Niacin, mevocor, statins Post-op anti-coagulants

Surgery Usually repaired if >5cm Open procedure- abd incision, cross clamp aorta,aneuysm opened and plaque removed, then graft sutured in place Pre-op assess all peripheral pulses Post-op-check urine output and peripheral pulses hourly for 24 hours

Endovascular stents- placed through femoral artery

YouTube - Abdominal Aortic Aneurysm Graft Repair

Endovascular graft procedure New approach is percutaneous femoral access Advantages Shorter operative time Shorter anesthesia time Reduction in use of general anesthesia Reduced groin complications within first 6 months YouTube - Cook's modular AAA graft an "engineering achievement"

Aortic Dissection Blood invades or dissects the layers of the vessel wall

Dissecting aneurysms are unique and life threatening Dissecting aneurysms are unique and life threatening. A break or tear in the tunica intima and media allows blood to invade or dissect the layers of the vessel wall. The blood is usually contained by the adventitia, forming a saccular or longitudinal aneurysm.

Aortic dissection occurs when blood enters the wall of aorta, separating its layers, and creating a blood filled cavity.

Aortic Dissection Often misnamed “dissecting aneurysm” Not a type of aneurysm Occurs most commonly in thoracic aorta Result of a tear in the intimal lining of arterial wall Male>Female Occurs most frequently between 30’s-60’s Acute and life threatening Mortality rate 90% if not surgically treated

Aortic Dissection As heart contracts, each systolic pulsation ↑ pressure on damaged area Further ↑ dissection May occlude major branches of aorta Cutting off blood supply to brain, abdominal organs, kidneys, spinal cord, and extremities People with Marfan’s at risk

Aortic Dissection Manifestations Abrupt severe ripping or tearing pain Mild or marked HTN early Weak or absent pulses and BP in upper extremeties Syncope

Aortic Dissection Collaborative Care Initial goal ↓ BP and myocardial contractility to diminish pulsatile forces within aorta Conservative therapy If no symptoms Can be treated conservatively for a period of time Success of the treatment judged by relief of pain Emergency surgery is needed if involves ascending aorta

Aortic Dissection Collaborative Care Drug therapy IV Beta- adrenergic blocker Esmolol (Brevibloc) Other antihypertensive agents Calcium channel blockers Sodium Nitroprusside Angiotensin converting enzyme

Aortic Dissection Collaborative Care Surgical therapy When drug therapy is ineffective or When complications of aortic dissection are present Heart failure, leaking dissection, occlusion of an artery Surgery is delayed to allow edema to decrease and permit clotting of blood Even with prompt surgical intervention 30-day mortality of acute aortic dissections remains high (10%-28%)

Nursing Diagnoses Risk for Ineffective Tissue Perfusion Risk for Injury Anxiety Pain Knowledge Deficit

Nursing Management Acute Intervention- Post-op ICU monitoring Arterial line Central venous pressure (CVP) or pulmonary artery (PA) catheter Continuous ECG monitoring Oxygen administration/Mechanical ventilation Pulse oximetry/ Arterial blood gas monitoring Urinary catheter Nasogastric tube Electrolyte monitoring Antidysrhythmic/pain medications

Nursing Management Infection Neurologic Status Peripheral perfusion status Renal perfusion status Gastrointestinal status Ambulatory /Home care

Prevention 1.Ultrasound 2.Prevent atherosclerosis 3.Treat and control hypertension 4.Diet- low cholesterol, low sodium and no stimulants 5.Careful follow-up if less than 5cm.

Case study 1. What action should you take first? Ms. C. 81 y/o admitted to CCU with SOB; has a hx of mitral valve regurgitation with left ventricular enlargement. She received 100mg Lasix IV in ER and her dyspnea improved. She has O2 at 3L/min. She has crackles bibasilar and monitor is SR rate 94-96 with occ. PVC’s. The only med ordered is morphine 2-4mg IV as needed for chest pain or dyspnea. As you go to assess her, you find her in bed at 60 degree angle. She is pale, has circumoral cyanosis and respirations are rapid and labored. 1. What action should you take first? A. Listen to breath sounds B. Ask when the dyspnea started C. Increase her O2 to 6L minute D. Raise the HOB to 75-85 degrees

Case study 1. What action should you take first? Ms. C. 81 y/o admitted to CCU with SOB; has a hx of mitral valve regurgitation with left ventricular enlargement. She received 100mg Lasix IV in ER and her dyspnea improved. She has O2 at 3L/min. She has crackles bibasilar and monitor is SR rate 94-96 with occ. PVC’s. The only med ordered is morphine 2-4mg IV as needed for chest pain or dyspnea. As you go to assess her, you find her in bed at 60 degree angle. She is pale, has circumoral cyanosis and respirations are rapid and labored. 1. What action should you take first? A. Listen to breath sounds B. Ask when the dyspnea started C. Increase her O2 to 6L minute (symptoms indicate acute hypoxemia, need to inc O2 flow, HOB already elevated) D. Raise the HOB to 75-85 degrees

Case Study-Question 2, 3 2. Which of these complications are you most concerned about, based on your assessment? A. Pulmonary edema B. Cor pulmonale C. Myocardial infarction D. Pulmonary embolus 3. Which action will you take next? A. Call the physician about client’s condition. B. Place client on a non-rebreather mask with FiO2 at 95%. C. Assist client to cough and deep breathe. D. Administer ordered morphine sulfate 2mg IV.

Case Study-Question 2, 3 2. Which of these complications are you most concerned about, based on your assessment? A. Pulmonary edema- hx of inc SOB, mitral valve regurgitation, and sx hypoxemia, pink frothy sputum indicate L. ventricular failure….prioroity B. Cor pulmonale C. Myocardial infarction D. Pulmonary embolus 3. Which action will you take next? A. Call the physician about client’s condition. B. Place client on a non-rebreather mask with FiO2 at 95%. (in this case, priority is still oxygenation, give morphine and call physician still appropriate…) C. Assist client to cough and deep breathe. D. Administer ordered morphine sulfate 2mg IV.

Case Study questions #4, 5 4. What additional assessment data are most important to obtain at this time? A. Skin color and capillary refill B. Orientation and pupil reaction to light C. Heart sounds and PMI D. Blood pressure and apical pulse 5. B/P is 98/52, apical is 116, irregular at 110-120 with frequent multifocal PVC’s. Physician is called and these orders received. Which one should be done first? A. Obtain serum dig level B. Give furosemide 100mg. IV C. Check blood potassium level D. Insert #16 french foley catheter

Case Study questions #4, 5 4. What additional assessment data are most important to obtain at this time? A. Skin color and capillary refill B. Orientation and pupil reaction to light C. Heart sounds and PMI D. Blood pressure and apical pulse (Need VS to know changes in CO) 5. B/P is 98/52, apical is 116, irregular at 110-120 with frequent multifocal PVC’s. Physician is called and these orders received. Which one should be done first? A. Obtain serum dig level B. Give furosemide 100mg. IV C. Check blood potassium level (Must know serum K level, low level might be cause of PVC, know prior to Lasix) D. Insert #16 french foley catheter

Question #6, 7, 8 6. Which order could be assigned to an LVN? A. Obtain serum digoxin level G. Give furosemide 100mg. IV C Check blood potassium level D. Insert #16 french foley catheter 7. While waiting for potassium level, you give morphine sulfate IV to the patient. A new graduate asks why you are giving the morphine. What is the best response? It will: A. prevent chest pain. B. decrease respiratory rate. C. make her comfortable if intubation required. D. decrease venous return to heart 8. Her K is 3.1; physician orders KCL 20meq. IV. How this be given? A. Utilize a syringe pump to infuse KCL over 10 minutes. B. Dilute KCL in 100 ml of D5W and infuse over 1 hour. C. Use a 5ml syringe and push KCL over at least 5 minutes. D. Add KCL to 1 liter of D5W and give over 8 hours.

Question #6, 7, 8 6. Which order could be assigned to an LVN? A. Obtain serum digoxin level G. Give furosemide 100mg. IV C Check blood potassium level D. Insert #16 french foley catheter (All LVNs trained to insert Foleys) 7. While waiting for potassium level, you give morphine sulfate IV to the patient. A new graduate asks why you are giving the morphine. What is the best response? It will: A. prevent chest pain. B. decrease respiratory rate. C. make her comfortable if intubation required. D. decrease venous return to heart (Morphine dec. venous return, dec. ventricular preload) 8. Her K is 3.1; physician orders KCL 20meq. IV. How this be given? A. Utilize a syringe pump to infuse KCL over 10 minutes. B. Dilute KCL in 100 ml of D5W and infuse over 1 hour.(only safe way, too fast, > cardiac arrest; too slow may not correct problem rapidly enough) C. Use a 5ml syringe and push KCL over at least 5 minutes. D. Add KCL to 1 liter of D5W and give over 8 hours.

Questions #9, 10, 11 9. After infusing KCL, you give Lasix. Which of nursing action will be most useful in evaluating if lasix is having desired effect? A. Obtain the client’s daily weight B. Measure the hourly urine output C. Monitor blood pressure D. Assess the lung sounds 10. The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/ min. Which assessment data is most important to monitor during the infusion? A. Lung sounds B. Heart rate C. Blood pressure D. Peripheral edema 11. Which nurse should be assigned care for this client? A. Float RN who worked on CCU stepdown for 9 years and floated before to CCU B. RN from staffing agency, 5 years CCU experience and orienting to CCU today C. CCU RN, already assigned to a newly admitted client with chest trauma D. New graduate RN who needs experience in caring for client with left ventricular failure.

Questions #9, 10, 11 9. After infusing KCL, you give Lasix. Which of nursing action will be most useful in evaluating if lasix is having desired effect? A. Obtain the client’s daily weight B. Measure the hourly urine output C. Monitor blood pressure D. Assess the lung sounds (Major problem-pulmonary edema, lung sounds most important) 10. The physician orders a natrecor 100mcg IV bolus and an infusion of 0.5 mcg/ min. Which assessment data is most important to monitor during the infusion? A. Lung sounds B. Heart rate C. Blood pressure (natrecor causes vasodilation, diuresis, ck for hypotension) D. Peripheral edema 11. Which nurse should be assigned care for this client? A. Float RN who worked on CCU stepdown for 9 years and floated before to CCU (had experience with this type patient & on unit) B. RN from staffing agency, 5 years CCU experience and orienting to CCU today C. CCU RN, already assigned to a newly admitted client with chest trauma D. New graduate RN who needs experience in caring for client with left ventricular failure.

Question #12, 13 12.Which information would be important to report to the physician? A. Crackles and oxygen saturation B. Atrial fibrillation and fuzzy vision C. Apical murmur and pulse rate D. Peripheral edema and weight 13. All meds are scheduled for 9 AM. Which would you hold until you discuss it with the physician? A. Furosemide 40mg po bid B. Ecotrin 81mg po daily C. KCL 10meq three times a day D. Captopril 6.25mg po three times a day E. Lanoxin .125mg po every other day

Question #12, 13 12.Which information would be important to report to the physician? A. Crackles and oxygen saturation B. Atrial fibrillation and fuzzy vision (dysrhythmias, visual disturbances, common side effects of digoxin toxicity) C. Apical murmur and pulse rate D. Peripheral edema and weight 13. All meds are scheduled for 9 AM. Which ones would you hold until you discuss it with the physician? A. Furosemide 40mg po bid B. Ecotrin 81mg po daily C. KCL 10meq three times a day D. Captopril 6.25mg po three times a day E. Lanoxin .125mg po every other day **Hold Furosemide and Lanoxin- low potassium potentiates dig toxicity

Priority Question # 14 During the initial post-operative assessment of a patient who has just transferred to the post-anesthesia care unit after repair of an abdominal aortic aneruysm all of these data are obtained. Which has the most immediate implications for the client’s care? A. The arterial line indicates a blood pressure of 190/112. B. The monitor shows sinus rhythm with frequent PAC’s. C. The client does not respond to verbal stimulation. D. The client’s urine output is 100ml of amber urine.

Priority Question #17 It is the manager of a cardiac surgery unit’s job to develop a standardized care plan for the post-operative care of client having cardiac surgery. Which of these nursing activities included in the care plan will need to be done by an RN? A. Remove chest and leg dressings on the second post-operative day and clean the incisions with antibacterial swabs. B. Reinforce patient and family teaching about the need to deep breathe and cough at least every 2 hours while awake. C. Develop individual plan for discharge teaching based on discharge medications and needed lifestyle changes. D. Administer oral analgesisc medications as needed prior to assisting patient out of bed on first post-operative day.

Priority Question # 16 These clients present to the ER complaining of acute abdominal pain. Prioritize them in order of severity. A. A 35 year old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating. B. An 11 year old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days. C. A 40 year old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week. D. A 56 year old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour.

Priority Question # 25 These clients present to the ER complaining of acute abdominal pain. Prioritize them in order of severity. A. A 35 year old male complaining of severe, intermittent cramps with three episodes of watery diarrhea, 2 hours after eating. B. An 11 year old boy with a low-grade fever, left lower quadrant tenderness, nausea, and anorexia for the past 2 days. C. A 40 year old female with moderate left upper quadrant pain, vomiting small amounts of yellow bile, and worsening symptoms over the past week. D. A 56 year old male with a pulsating abdominal mass and sudden onset of pressure-like pain in the abdomen and flank within the past hour.