Cardiovascular: Valvular,
Cardiomyopathy, Aneurysm and Cardiac
Surgery
Click here- Heart valves at work!
Review of Heart Valve sounds (etc)
A&P Heart Valves- Click here
Valvular Heart Disease
(Access to Helpful Interactive Sites)
HeartPoint: HeartPoint Gallery
Valvular Disease
(great introductory video!)
Valvular Heart Disease:
Heart Valves at Work *UTube
Flashcards
(many resources here!)
(Test your knowledge!)
Pathophysiology
Stenosisnarrowed valve, sloews forward blood flow
increases afterload, dec. CO
Regurgitation (insufficiency)
increases preload
heart pumps same blood again
blood volume and pressures reduced in front of affected
valve; increased behind affected valve
results in heart failure
*All valvular diseases have characteristic
murmurs (click to hear!)
•Damaged valve disrupts blood flow=turbulence & sound!
Caused by
Rheumatic Heart Disease
Acute conditions (infective endocarditis)
Acute MI
Congenital Heart Defects
Aging, etc
Mitral Valve Stenosis
Mitral Valve Stenosis
Etiology/Pathophysiology:
Most cases due to rheumatic fever
Contractures and adhesions of valve leaflets- “fish
mouth”
Dec. flow into LV>LA hypertrophy>inc. pulmonary
pressures> pulmonary hypertension
Dec. CO-lead to Rt. Heart failure
Mitral Valve Stenosis
Clinical Manifestations:
Early symptom-dyspnea on exertion (DOE)
Cough, hemopysis, etc.
Late- Signs Rt. Heart failure (dec. CO)
Atrial fib. (enlarged atrium)
Murmur- loud S1, low pitched diastolic murmur
Hoarseness, seizures, stroke (emboli risk)
Management Mitral Valve Stenosis
Treatment for Mitral Stenosis (non-surgical) Balloon Valvuloplasty
Valvular Surgery
Access site to see and hear the
newest information!
Heart Surgery Innovations 11:22 valves
20 beating heart
20 aortic valve
(27 min)
Mitral Regurgitation
Etiology/Pathophysiology/Manfesations
Valve does not close fully
Regurgitation of blood into LA during systole
Dev. LA dilation and hypertrophy > pulmonary congestion >
RV failure
LV dilation and hypertropy-accommodate increased preload
(from regurgitation)
Dec. CO
Acute and chronic MR
Acute-poorly tolerated-fulminating pulmonary edema
Chronic- Lt. ventricular failure, S3 sound, pansystolic murmur
Mitral Regurgitation
Treatment of Mitral Valve
Regurgitation
Innovations (Percutaneous) MitraClip Repair
MitraClip 3D Animation
View video -procedure to correct
mitral valve regurgitation! Non-invasive
Mitral Valve Prolapse
Etiology/Pathophysiology/Manifestations
Mitral valve cusps “billow’ into atrium during
ventricular systole
Most common form valvular disease,
associated with Marfan’s syndrome (Michael
Phelps…does he have it?)
Usually benign-complications- MR, infective
endocarditis (IE) , SCD
Usually asymptomatic- mid systolic click, and
last holosystolic murmur
Chest pain (atypical)-does not respond to
antianginals
Dysrhythmia risk
?Need for prophylactic antibiotics (IE risk)
Mitral Valve Prolapse
Midsytolic click & late systolic murmur (Click
here to hear characteristic sounds of MVP)
UTube- Mitral Valve Prolapse (brief lectureinformative)
UTube- Mitral Valve Prolapse (current research-re
prophylactic antibiotics)
Endocarditis and MVP
Aortic Stenosis
Etiology/Pathophysiology/Manifestations
Congenital or due to rheumatic fever or aging
May be asymptomatic for years
Obstruction LV to aorta > inc afterload > L. ventricular
hypertrophy > dec. CO
Eventual pulmonary hypertension, myocardial ischemia
and later right heart failure
*DOE, angina, syncopy (SAD)- Classic Symptoms
*Poor prognosis-if symptoms and obstruction not
relieved
*Nitroglycerin contraindicated
Normal to soft S1; absent S2; harsh systolic
crescendo-decrescendo murmur, loud S4 (click for sound)
Classic Symptoms
Syncope
Angina
Dyspnea
Aortic Stenosis
*Normal aortic valve has 3 leaflets-not 2
(bicuspid) (Arnold Schwarzenegger- lead to
aortic stenosis and require valve replacement)
Aortic valve
Aortic Valve animation
Aortic Stenosis
Access these sites to learn about procedures to treat/replace damaged aortic valves
Aortic Stenosis
Minimally Invasive Aortic Heart Valve Replacement
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… Research at Cleveland Clinic is evaluating a percutaneous
technique for implanting a prosthetic valve inside diseased calcific aortic valve. The procedure is
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.
Heart Valve
replacement
(Aortic valve, patient
resource,
mechanical,
biological)
Aortic Regurgitation
Etiology/Pathophysiology/Manifestations
Congenital valvular defect
Acute causes- trauma, aortic dissection (life threatening)
Chronic- rheumatic heart disease, bicuspid valvular disease
Retrograde blood flow (inc. preload) from ascending aorta > L
ventricle dilation, hypertrophy
Eventual dec. myocardial contractility > dec. CO
Develop pulmonary hypertension, Rt. Ventricular failure (*inc. L.
ventricular end diastolic pressure=LVED)
If severe- characteristic “*water hammer pulse” (Corrigan’s pulse),
wide pulse pressure, and Musset’s sign
Soft or absent S1, presence of S3, S4; soft, high pitched diastolic
murmur, systolic ejection click; Austin Flint murmur
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 triphammer pulse. (Click to view video)
Aortic Regurgitation
Echocardiography
Tricuspid and Pulmonic Valve Disorders
Etiology/Pathophysiology/Manifestations
Tricuspid stenosis (more common than regurgitation)
Result in R. atrial enlargement > inc. systemic venous pressure
> atrial fibrillation, peripheral edema, ascites, etc.
Found mostly in rheumatic heart disease, IV drug users
Pulmonic stenosis
Result in R. ventricular hypertension and hypertrophy
Fatigue , loud midsystolic murmur
Uncommon valve disorders
Collaborative Care
Keys
Prevent recurrent rheumatic fever, infective endocarditis
Identify by characteristic murmur
Aware of effect of stenosis, regurgitation on cardiac
hemodynamics (preload, afterload)
Appropriate prophylactic therapy (antibiotics before
invasive procedures-at risk patients)
Manage heart failure if present
Manage complications-ie dysrhythmias, risk for emboli (afib) etc.
*Treatment depends upon valve involved
Adequate follow-up care.
Medications/Diet
Manage complications (ie heart failure, dysrhythmias)
ACE,
Dig
Diuretics
Vasodilators
Beta blockers
Anticoagulants *a-fib common
*Prophylactic antibiotics
Treatment specific for disease (ie no *nitroglycerin if
aortic stenosis)
Diet
Low sodium-if risk for heart failure
Diagnostic Tests
Echo- assess valve motion and chamber size
TEE
CXR
EKG
Cardiac cath- measure pressure gradients
(hemodynamic function)
Transesophageal
echocardiogram
Surgical Intervention
*Not all types valve disease require surgical intervention
Valvuloplasty-general term valve repair, invasive/non-invasive
methods
Percutaneous balloon valvuloplasty (non-invasive)
Surgery
Open commissurotomy- open stenotic valves
Annuloplasty- repair of valve’s outer ring-used for stenosis,
regurgitant valve
Valve Replacement
Mechanical-need anticoagulant
Biologic-only last about 15 years
Ross Procedure-transfer pulmonic valve for aortic
Valve Replacement Surgery
Patient Teaching-Heart Valve Replacement Surgery (click here)
Ross Procedure
Mechanical valve prosthesis- modern tilting disk
variety (for mitral valve); last indefinitely from
structural standpoint; patient requires continuing
anticoagulation due exposed non-biologic surfaces.
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.)
Important-teaching needs for
valve replacement
Nursing Diagnoses
Decreased Cardiac Output
Activity Intolerance
Excess Fluid Volume
Ineffective therapeutic regimen
Risk for Infection
Ineffective Protection
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 is which a ventricle has become
enlarged, thickened or stiffened.
As a result heart’s ability as pump is reduced
3 Types
Dilated
Hypertropic
Restrictive
Cardiomyopathy
Primary-idiopathic
Secondary
Ischemia- from CAD
Infectious/viral disease
Exposure to toxins
Metabolic disorders
Nutritional deficiencies
Genetic
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!
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
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
Surgical/resynchronizationization therapy
VAD or LVAD
CRT
(cardiac resynchronization therapy)
Dilated Cardiomyopathy
Collaborative Care
Heart transplant
Hypertrophic Cardiomyopathy (HCM)
Genetic; IHSS
(idiopathic hypertrophic subaortie stenosis
), HOCM
(hypertrophic obstuctive cardiomyopathy)
Hypertrophy of ventricular mass; impaired
ventricular filling (diastole); dec. CO > inc
pulmonary & venous pressures
Forceful ventricular contraction
*Obstruction aortic outflow (not all cases)
S&S: syncopy, angina, dyspnea (SAD); S4
develop during or after physical activity
*Sudden cardiac death (dysrhythmia)
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
Note obstruction-aortic
outflow (HCM)
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
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
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)
Biopsy of heart (EMB)
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
Heart Transplant
Heart transplant
(slide show)
Virtual transplant
(try it!)
Click here-YouTube-
Lung machine
Heart-
A new heart!
Cardiomyopathy
Nursing Diagnoses
Decreased Cardiac Output
Fatigue
Ineffective Breathing Pattern
Fear
Ineffective Role Performance
Anticipatory grieving
Case study
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
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
of digoxin toxicity)
(dysrhythmias, visual disturbances, common side effects
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
Abdominal Aortic Aneurysm
Click Here for an excellent lecture on AAAAbdominal Aortic Aneurysms!! (You Tube)
Quickly tells you all the essentials!
Aortic Aneurysms
Aortic Aneurysm – go to page 5
Aneurysms (video)
Aneurysms = Time Bombs
•Outpouchings or dilations of arterial wall
•May involve aortid arch, thoracic aorta and/or
abdominal aorta
•*1/2 all aneurysms larger than 6 cm rupture
within one year.
•*Thrombi form on dilated arterial wall lead to
emboli
•Male and smoking great risk factor,
Classifications Aneurysms
True- Fusiform, Saccular
False- (a pseudoaneurysm)- have disruption all layers arterial wall,
from trauma, etc.
C.Aortic dissection; D. “False” aneurysm
Saccular- true aneursym, pouchlike, narrow neck
connecting buldge to one side of arterial wall
Fusiform- most are fusiform; 98% are
below renal artery, circumferential, relatively
unifrom in shape
Thoracic Aortic Aneurysm
Frequently asymptomatic
May have substernal, neck or back pain
Coughing, due to pressure placed on
the windpipe (trachea)
Hoarseness
Dysphagia
Swelling (edema) in neck or arms
Myocardial infarction, or stroke due to
dissection or rupture involving
branches of the aorta
Abdominal Aortic Aneursysm
Pain intensity correlates to size and severity
Pulsating mass in mid and upper abdomen; bruit
over the mass
May have thrombi
Can rupture causing shock and death in 50% of
rupture cases
Mimic pain associated with abdominal or back
disorders
“Blue toe syndrome” due to emboli
Complications-Rupture!
Anterior
Posterior (better chance for survival)
Aortic Dissection - blood invades or dissects the layers
of the vessel wall (not really an aneurysm)
Dissecting aneurysms-unique and life threatening. A break or tear in tunica intima and
media allows blood to invade or dissect layers of vessel wall. Blood is usually contained
by 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
Life threatening emergency
Intima tears, causes hemorrhage into media
Hypertension- main cause
With contraction of heart, inc. pressure, further
damage
Cause uncertain- hypertension- *primary,
Marfan’s syndrome, blunt trauma, inc age
symptom- excruciating pain-tearing, ripping
sensation
90% mortality if untreated
Manifes tations of Aortic D is s ection
Aneurys m *
Symptoms depend upon location
 Abrupt, s evere, ripping or
tearing pain in area of
aneurys m
 Mild or marked
hypertens ion early
 Weak or abs ent puls es and
blood pres s ure in upper
extremities
 S yncope
C omplications : hemorrhage,
is chemic kidneys (renal
failure), MI, heart failure,
cardiac tamponade, s eps is ,
weaknes s or paralys is of
lower extremities .
Collaborative Care
Goal-*identify and prevent rupture
Diagnostic Tests
Most dx on routine work-up
If identified, tests specific to determine size, location
CXR, CT or MRI, Abd ultrasound, TEE, ECHO,
angiography, Abd. Ultrasound
EKG
Recognize “Terrible Triad” impending rupture
Pulsating hematoma, back pain, hypotension
Collaborative Care-Medications
Anti-hypertensives
Beta blockers,
Vasodilators
Calcium channel blockers
Nipride
*Avoid direct arterial vasodilators (as hydralazine)
Sedatives
Niacin, mevocor, statins
Post-op anti-coagulants
Collaborative Care/Surgery, Other Options
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- (when to call Dr.)
Endovascular stents- placed through femoral
artery
Surgical repair of an abdominal aortic aneurysm. A, Incising the
aneurysmal sac. B, Insertion of synthetic graft. C, Suturing native aortic
wall over synthetic graft.
Bifurcated (two branched) endovascular stent grafting of an aneurysm. A, Insertion of a woven polyester tube
(graft) covered by a tubular metal web (stent). B, Stent graft is inserted through large blood vessel (e.g., femoral
artery) using a delivery catheter. Catheter is positioned below renal arteries in area of aneurysm. C, Stent graft is
slowly released (deployed) into blood vessel. When stent comes in contact with blood vessel, it expands to preset
size. D, A second stent graft can be inserted in contralateral (opposite) vessel if necessary. E, Fully deployed
bifurcated stent graft
Aneurysm repair
Live Search Videos: aneurysm
Live Search Videos: aortic
aneurysm-percutaneous approach
to abdominal aneurysm repair
Nursing Diagnoses
Risk for Ineffective Tissue Perfusion
Risk for Injury
Anxiety
Pain
Knowledge Deficit
Prevention
Ultrasound-extremely effective at detecting AAAs.
U.S. Preventive Services Task Force (USPSTF)
recommends-anyone aged 65 to 75 who has ever
smoked undergo a one-time ultrasound screening
for AAA
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-can grow 0.5cm/yr
Key Complications
Rupture- signs of ecchymosis
Back pain
Hypotension
Pulsating mass
Live Search Videos: aortic aneurysm (See rupture)
Thrombi
Renal Failure
Priority Question # 1, #2
1. During initial post-operative assessment of a patient who has just transferred
to post-anesthesia care unit after repair of an abdominal aortic aneurysm all of
these data are obtained. Which has most immediate implications for client’s
care?
A. Arterial line indicates a blood pressure of 190/112.
B. Monitor shows sinus rhythm with frequent PAC’s.
C. Client does not respond to verbal stimulation.
D. Client’s urine output is 100ml of amber urine.
2. It is the manager of a cardiac surgery unit’s job to develop a standardized
care plan for post-operative care of client having cardiac surgery. Which of
these nursing activities included in care plan must 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 analgesic medications as needed prior to assisting patient
out of bed on first post-operative day.
Priority Question # 1, #2
1. During initial post-operative assessment of a patient who has just transferred
to post-anesthesia care unit after repair of an abdominal aortic aneurysm all of
these data are obtained. Which has most immediate implications for client’s
care?
A. Arterial line indicates a blood pressure of 190/112.
(HIGH RISK OF RUPTURE)
B. Monitor shows sinus rhythm with frequent PAC’s.
C. Client does not respond to verbal stimulation.
D. Client’s urine output is 100ml of amber urine.
2. It is the manager of a cardiac surgery unit’s job to develop a standardized
care plan for post-operative care of client having cardiac surgery. Which of
these nursing activities included in care plan must 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. (RN develops individual teaching plan)
D. Administer oral analgesic medications as needed prior to assisting patient
out of bed on first post-operative day.
Case study from Hospital
Patient History
27 year old male
African American
L ives alone in apartment
F amily hx D M
Morbid obesity (314.6 lbs )
Height: 5’11
Ambulates with walker
F ull C ode
Medical His tory:
E T O H abuse
S moker
Hypertens ion
DOE
S leep apnea
T rach (8/30)
E jection F raction 50%
Hemodialys is (M-W-F )
Mitral insufficiency, Mild regurgitation(mitrial, tricuspid)
P ress ure ulcer on coccyx
R espiratory failure with trach , pneumonia, delirium
 (8/13) P t appeared in E R
w c/o flank and abd pain
 B /P 270/159
(C ardene drip which decreas ed pres sure to 185/73)
Na 138 K 4.4 C h108 B UN 24 C reat 3.0
G lucos e 147 C a 8.5 H gb 12.5
Admis s ion diagnos is :
Malignant hypertens ion
T ype B Aortic D is s ection
R enal ins ufficiency
Morbid obes ity
P t teaching:
S moking ces s ation
C ontrol H TN
L ifes tyle changes
D iet control
Us e of s tool s ofteners (increase fluid and fiber in diet)
• E X T R A D X D E VE L O P E D
D UR ING HO S P IT AL
S T AY :
• Myopathy
• Acute res piratory failure
• C hronic kidney dis eas e
• P neumonia due to S taph
and Hemophilus
Influenze
• HT N encephalopathy
acute renal dis eas e with
les ion of tubular necros is
• D elirium
• Uns pec d/o of kidney and
ureter
Labs
Diagnostic Test
C hes t X -ray to vis ualize thoracic
aortic aneurys ms : C ardiac
s ilhouette remains enlarged.
P os ition of endotrachial tube
opacity. P ulmonary vas cular
conges tion pers ist. Aortic arch
enlarged; mild perihilar interstitial
pulmonary edema. Atelectas is or
edema adjacent to left ventricular
border improved. L ungs
underinflated with evidence of
pulmonary edema.
C T to allow precis e meas urement
of aneurys m: S tanford B thoracic
aortic dis s ection distal to origin of
L eft s ubclavian to above iliac
arteries . C ompromis ed flow of left
renal artery. L eft ventricular
hypertrophy and left renal s tone.
Vital S igns :
B /P - 109/53 P -88
100.8
R - 18 T -
WB C 12.9 ?
R B C 3.13 ?
Hgb 8.9 ?
Hct 26 ?
P lt 200
Na 129
K 3.6
C hl 90 ?
B un 120 ?
AG AP 16 ?
Mg 2.3
C reat 10 ?
G lucos e 115 ?
P hos 8 ?
S urgery
•
S urgery is done when an
aneurys m is 6 cm in diameter,
expanding fas t or s ymptomatic.
T ype B dis s ections are
s urgically repaired depending
on extent of involvement and
ris k for rupture.
• Aneurys m excis ed and
replaced with s ynthetic fabric
graft.
Ns g D x:
• R is k for Ineffective tis s ue
perfus ion.
• Anxiety
Medications
Allergy:PCN
T reated with long term beta blocker therapy and antihypertens ive drugs as needed to control heart
rate and blood pres s ure. Initially treated with I.V beta blockers s uch as propranolol (Inderal),
metoprolol (L opres s or), Normodyne or B revibloc to reduce heart rate to 60 bpm. Nipride
infus ion to reduce s ys tolic to 120mmHg. C alcium channel blockers may als o be us ed. D irect
vas odilators are avoided becaus e they may wors en the dis s ection. After s urgery anticoagulants
may be initiated; us ed indefinitely and maybe even lifelong.
P t meds : Albuterol 2.5mg IH q8h
H eparin 5000u S Q q8h
F lonas e nas al s pray 2 s prays each nos e q12h
Amphojel 1020mg q8h
C atapres s 0.2mg q4h
Minoxidil 10mg P O q12h
E ns ure s upp 240ml P O T ID
P rotonix 40mg po d
Multivitamin 1 tab P O d
L exapro 20mg P O d
R enal D iet
P rocrit 10000u S Q MWF
R P ermacath, R AC , S L
D is charge Ins tructions








P t dis charged to C orners tone at S t
D avid’s for R ehab with trach
P s ychiatry cons ult for behavioral
problems
C ardiology s eeing pt for B /P control
(ranging from 110-130 s ys tolic upon
dis charge)
R egular diet American Heart
As s ociation
P hys ical therapy being used but s till
needs lots of rehab
P lan is to medically manage aortic
dis s ection for now and once s table
he’ll follow up w vas cular s urgery for
definitive treatment.
F /U w vas cular s urgery and
C ardiothoracic M.D when d/c from
C orners tone, nephrology, internal
medicine, infectious dis eas eps ychiatry
D is charged 09-26
Dis charge
Medications :
F lonas e daily
Heparin 5000 u q 8h
Albuterol MD I p.r.n
Amphojel 30cc q8h
Atenolol 50mg q 12h
C lonidine 0.2 p.r.n
Minoxidil 10mg B .I.D
E ns ure T .I.D w meals
P rotonix 40mg d
Multivitamin d
L exapro 20mg d
P rocrit q M-W-F s ubcu
10,000u
Ativan p.r.n
OPEN HEART SURGERY
Diagnostic Tests
EKG
exercise stress test
CXR
cardiac cathechocardiogram
thallium scan
PRE-OP TEACHING
Open Heart Surgery
Open Heart Surgery-What to Expect!
Intra-op
Events
hypotension
cardioplegia
cross clamping aorta
cardiopulmonary bypass
heparinized
CP Bypass
Heart Lung Machine (video)
Post-op Appearance
mechanical ventilator-SIMV mode
hemodynamic monitoring- dec. CO
cardiac monitoring-SVT and Afib common
mediastinal tube-100cc first hour to 500/24
multiple IV sites and lines
pacer wires
foley-hourly output
Assessment
vital signs
PAP
PCWP
CO
urine output
bleeding
fluid balance and neuro
Complications
decreased cardiac output
cardiac tamponade
hypokalemia
Hemorrhage-replace cc for cc . 100 first hr.
then 55/24 hours
neuro changes
resp insufficiency
infection and pain-demoral, splint incision.
Offer pain med: percoset or vicodin q 4hr.
Cardiac tamponade
Paradoxical pulse is a pulse that markedly decreases in amplitude during
inspiration. On inspiration, more blood is pooled in the lungs and so decreases the
return to the left side of the heart; this affects the consequent stroke volume.
•Cardiac tamponade (influenced by volume and rate of
accumulation)
•Beck triad (jugular venous distention, hypotension, and
muffled heart sounds)
•Pulsus paradoxus is measured by careful auscultation with
a blood pressure cuff. The first sphygmomanometer
reading is recorded at the point when beats are audible
during expiration and disappear with inspiration. The
second reading is taken when each beat is audible during
the respiratory cycle. A difference of more than 10 mm Hg
defines pulsus paradoxus.
•Cyanosis
• No drainage from mediastinal tube
Decreased Cardiac Output
decreased preload-need fluid
inc. afterload- need to dec. B/P
(Nipride)
dec. contractility- need dobutamine
Arrhythmias- SVT and Afib common
Post-op Care Goals
Promote CV function, tissue perfusion
and stablization of VS
cont.
Promote respiratory function and sufficient
oxygenation by promoting chest drainage and use of
IS
Goals
Promote fluid and electrolyte balance
Promote renal function
Promote rest, comfort, and relief of pain
Promote neurological function
Promote psych adjustment
Promote early movement and
ambulation