NUR2744

TEST 3 OUTLINE

• Aortic Aneurysm- outpuuching or dilations of the arterial wall and are o Physical exam: pulsating mass
common problems involving the aorta o CXR
• Pathophysiology of Aortic Aneurysms- o ECG
o most common cause atherosclerosis o Echocardiography
o trauma to intimal layer of the vessel causing thinning of the vessel wall o CT
o 2 classifications: o MRI
o Aortography
 True- @least 1 layer still intact
o Arteriography
• Fusiform- circumferential & relatively uniform in
o Doppler ultrasound/DSA
shape
o Ultrasonic scanning
• Saccular- pouch-like c narrow neck connecting the
bulge to one side of the arterial wall • Medical Mgmt:
 False- disruption of al layers resulting in bleeding contained by o Ultrasound test to document the size
surrounding structures o Pharmacology
o Risk factors o Physical checkups
 Anything causing increased BP • Surgical MGMT of AA
 Trauma o Graft (worry about perfusion everywhere)
 MI o Incision of diseased segment of aorta, removing thrombus or plaque,
 Cholesterol inserting graft, suturing aortic wall
 HTN • Preop nsg. Care or pt having aortic aneurysm repair-
• Clinical manifestation of AA- sharp stabbing pain radiating to the back o Hydrated and any abnormalities with electrolyte, coagulation, and
o Bp different on one arm= MI or AAA hematocrit are corrected
o Antibiotics
• Thoracic= o Antiseptic showers
o usually asymptomatic o Pt and family teaching
o Deep, diffuse chest pain o Providing support for pt and family
o Hoarseness o Careful assessment of all systems
o Dysphagia o Usually bowel prep
o Decrease venous drainage resulting in JVD o NPO p midnight
o Edema of head & arms
• Nsg Dx:
• Abdominal= o Alteration in peripheral tissue perfusion
o Mostly asymptomatic o Acute pain
o Pulsatile mass o Fear
o Bruits o Anxiety
o Mimic pain associated with any abdominal or back disorder o Risk for infection
o Back pain • Nsg interventions
o Deep, diffuse chest pain o H&P
o Epigastric discomfort c 0r s alteration in bowels o Monitor for sx’s of vascular problems
o Blue toe syndrome o Monitor for rupture: diaphoresis, paleness, weakness, tachycardia,
o Throbbing h/a at the beginning that disappears hypotension, abd, back, groin, or periumbilical pain, changes in
• Complications : RUPTURE (grey turners sign= retroperitoneal flank ecchymosis) sensorium, pulsating abd mass
• Dx studies: o Establish baseline data
 o Peripheral pulses o As it extends distally or proximally t may occlude major branches of the
o Prevent rupture “wait and see” aorta cutting off blood supply to other areas
o Prepare for preop eval • Clinical manifestations of aortic dissection
o Emotional support/ psychosocial support o Depends on location and extent of dissection
o Post op care o Sudden, severe pain anterior chest or intrascuplar pain radiating down
o Assure pt safety the spine into the abdomen or legs
o Prevent complications o Described as “tearing” or “ripping”
o Maintain nutritional status o Pain may mimic MI
o Pt. teaching and discharge planning o As dissection progresses, pain may be located both above and below the
o Acute interventions: diaphragm
 Large bore IV= NS (maintain graft patency) o CV, Resp., Neuro signs may also be present
 Monitor BP, CVP/PA or UOP hourly o If the arch is involved= neurological
 ECG monitoring • Collaborative care of aortic dissection-
 Electrolyte monitoring o Bed rest
 ABG’s o Initial goal s complication= decreased Bp & myocardial contractility to
 O2 and IV antiarrythmics diminish force
 Pain control  IV trimethaphan (Arfonad) Nitroprusside (Nipride) rapidly
 Infection reduce systolic blood pressure.
 VS  Beta blockers (lol) decrease force of contractility (propranolol
 CBC w dif (Inderal)
o Conservative therapy- without complications
 Nutrition
 NG tube care (flatus)  Pain relief, blood transfusion (if required), and mgmt of heart
failure(if indicated)
 Neuro status
o Surgical Therapy-
 Peripheral perfusion QH x several hours
 Indicated when drug therapy is ineffective or complications are
 Renal status
present
 I/O daily weight
 BUN Creatinine • Shock Syndrome- syndrome characterized by decreased tissue perfusion and
• Home care impaired cellular metabolism. Results in imbalance between supply and demand
of O2
o Gradual increase in activities
• Three major classifications-
o Fatigue, poor appetite, irregular bowels expected
o Cardiogenic Shock
o No heavy lifting 4-6 wks
o Hypovolemic Shock
o s/sx’x of infection
o Vasogenic
o perfusion of extremities
o sexual dysfunction common in men  Septic Shock
o Blood thinners  Anaphylactic Shock
o BP meds  Neurogenic Shock
o Routine checkups • Precipitating Factors-
o Diet- low fat, low cholesterol o Vascular tone/ vasodilation
• Pathophysiology or aortic dissection o Hypovolemia
o Tear in the intimal lining of the arterial wall that allows blood to enter o Pump failure
between the intima and media, thus creating a false lumen o Etiology of the shock
o As the heart contracts, each systolic pulsation causes increased pressure • Clinical manifestations:
on the damaged area o Decreased CO
o Further increasing the dissection o Hypotension
o Decreased perfusion (cardiac, renal, cerebral, and peripheral)
 o Decreased UOP  Blood cultures- organism growth
o Progressive multisystem, organ dysfunction • Select appropriate nursing diagnosis for a patient with shock syndrome.-
• Dx Studies- o Decreased CO RT shock
o CBC o Fear and Anxiety RT severity of condition
o BUN o Organ ischemia/ dysfunction
o Serum Creatinine o Decreased tissue perfusion
o Electrolytes o Potential for impaired gas exchange
o ABG’s
o Urine specific gravity
o Hemodynamic monitor
o Blood cultures
• Medical Mgmt-
o Airway mgmt
o Iv therapy including blood products
o Pharm
o Correction of acid/ base imbalance
o Pacemaker
o IABP
• Nsg. DX-
o Decreased CO
o Decreased tissue perfusion
o Potential for impaired gas exchange
• Nsg Interventions-
o Maintain patent airway
o Assess level of consciousness
o Maintain resp. status
o Correct acid/base disturbances
o Monitor hemodynamic parameters
o ECG
o Check for potential bleeding
o Prevent complications
o Maintain nutritional status
o Maintain fluids & electrolyte balance
o Provide emotional/psychological
o Pt teaching
• Assess patients with shock syndrome.-
o DX:
 CBC- different in diff forms
 BUN- increased
 Serum Creatinine- increased
 Electrolytes- increased
 ABG’s- Resp. alkalosis, Metabolic Acidosis
 Urine specific gravity- increased, fixed @ 1.010
 Hemodynamic monitor
 • Differentiate among the three major classifications of shock in relationship to cause and precipitating factors.-
Low Blood Flow Shock Misdistribution of Blood Flow Shock- Vasogenic
Cardiogenic Shock Hypovolemic Shock Neurogenic Shock Septic Shock Anaphylactic Shock

Either systolic or diastolic Loss of intravascular fluid Spinal Cord injury causing Presence of sepsis c Acute life-threatening
dysfunction of the volume. Inadequate to fill the massive vasodilation hypotension despite fluid hypersensitivity
myocardium results in vascular space. without compensation as a resuscitation along with the reaction to a sensitizing
compromised CO Absolute: consequence of the loss of presence of tissue perfusion substance. Immediate
• Systolic dysfunction: • Loss of whole blood SNS vasoconstrictor tone abnormalities reaction causing
inability of heart to (hemorrhage) • Hemodynamic • Infection (UTI, resp. massive vasodilation
pump (MI, • Loss of plasma (burns) consequence of tract, invasive (fluid shifts)
cardiomyopathy) • Loss of other body injury&/Or disease procedure, • Contrast media
• Diastolic fluids (V/D, diuresis, to the spinal cord @ indwelling lines and • Blood/blood
dysfunction: inability diaphoresis, diabetes T5 or above caths.) products
of the heart to fill insupdus, DM) • Spinal anesthesia • At risk pt’s: older • Drugs
(cardiac tamponade) • Vasomotor center adults, pt’s c chronic • Insect bits
• Arrhythmias (brady, Relative: depression (sever diseases (DM, • Anesthetic
tachy) • Poling of blood or pain, drugs, chronic RF, CHF) agents
• Structural factors: fluids (ascites, hypoglycemia, pt’s receiving
• Food/food
valvular abnormality peritonitis, bowel injury) immunosuppressive
additives
(stenosis or obstruction) therapy or who are
malnourished or • Vaccines
regurgitation) • Internal bleeding (fx of • Environmental
• Papillary muscle long bones, ruptured debilitated
• Gram-neg. bacteria agents
dysfunction spleen, hemothorax,
most common, also • latex
• Acute ventricular severe pancreatitis)
septal defect • Massive vasodilation gram-post, viruses,
(sepsis) fungi, and parasites
Shock SIRS (systemic inflammatory response MODS (Multiple Organ Dysfunction Syndrome)
syndrome)
DEF: Syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. Systemic response to a variety of Failure of more than one organ system in an acutely ill pt
insults, including infection, such that homeostasis cannot be maintained s intervention.
Cardiogenic Hypovolemic Neurogenic Septic Anaphylactic ischemia, infarct, and injury. MODS results from SIRS (represent a continuum and
Characterized by generalized does not occur in a clear-cut manner)
inflammation in orgasm remote
for the initial insult. (Norm
contained within confined
environment)

Manifested by 2 0r more: Sepsis- inflammatory body launched anti-inflammatory

• Temp > 38c or <36c When balance ceases the sequelae start
• HR < 90 Circulating volume—massive vasodilation
• RR > 20 or PaCO2 < O2 & perfusion—state of hypotension (MODS)
32 Usually resp 1st system to show!
• WBC > 12,000 or >
10% bands (immature
WBC’s)
Restore circulatory vol Treat or remove the • O2 Goal= prevent progression of SIRS—MODS
• Plasma cause& prevent CV • Remove Vigilant assessment & ongoing monitoring
expanders instability & Promote source • Assess all systems
Tissue perfusion optimal tissue perfusion • Bronchodilat • ???vent
Correct cause • Alpha or • Patent airway
• Control agonist • Airway • CV & renal status monitor
hemorrhage • Dopamine • IV Epi • Fluid & Meds
• Optimize O2 (alpha dose=
• Antihistamin • Prevent further sepsis
delivery >
10mcg/kg/mi
es, • No aspiration
• Vasoconstrictor diphehydra
n) • Labs
if BP still down mine
after volume • Ephedrine • Teaching
• Corticosteroi
loading. (12.5-25 mg
ds Prevention/tx:
IV Q3-4H)
• Immediate • Cultures
• Treat
withdrawal • Antibiotics
bradycardia
of antigen
c Atropine • Surgery to remove necrotic tissue
(0.5-1mg) • Prevention
• Pulmonary mgmt
• Temp pacer • Crystalloid
• Early AMB
(possible) admin. NSS,
LR • Strict asepsis
• Think Clots Maintance of tissue O2:
b/c blood • Vassopressor
Decrease O2 demand
pooling s to increase
perfusion • Sedation
• + inotropes • Mechanical vent
• Pt. edu • Analgesia
• Paralysis
• rest
Increase O2 supply
• Maintain norm Hgb (PRBC’s)
• Maintain norm PaO2 80-100 (PEEP)
• Increasing preload/ contractility= increase CO
• Reducing afterload = increase CO
Nutritional/metabolic support:
 • Preserve organ fxn
Support of Failing Organs: