Aortic Aneurysm and Aortic Dissection

The nurse plays a key role in helping manage the care of the patient with aortic aneurysm and aortic dissection.
Assessment and education is needed to closely monitor for complications associated with the conditions. Early
recognition of complications is essential as they are often severe and deadly.

Upon completion of this lesson, the learner will be able to:

Manage the care of the patient with aortic aneurysm and aortic dissection.

Etiology and Pathophysiology

The aorta is the largest artery and supplies oxygen (O2), nutrients, and blood to all vital organs. One of the most
common problems affecting the aorta is an aneurysm, which is a permanent, localized outpouching or dilation of the
vessel wall.

Aortic aneurysms may involve the aortic arch, thoracic aorta, or abdominal aorta. Three-fourths of aortic aneurysms
occur in the abdominal aorta, known as abdominal aortic aneurysm (AAA) and most occur below the renal arteries.

abdominal aortic aneurysm

abnormal dilatation of the abdominal aorta, usually in an area of severe atherosclerosis.

Risk factors for aortic aneurysms include:

• Age (increased risk with aging)

• Male gender
• Tobacco use
• High cholesterol
• Obesity
• Hypertension
• Coronary artery disease
• Lower extremity artery disease
• Family history
Primary causes of aneurysms:

• Degenerative
• Congenital
• Mechanical (e.g., penetrating or blunt trauma)
• Inflammatory (e.g., aortitis [Takayasu’s arteritis])
• Infectious (e.g., aortitis [Chlamydia pneumoniae, human immunodeficiency virus])

There are two types of aneurysms, true and false aneurysms.

A true aneurysm is one in which the wall of the artery forms the aneurysm with at least one vessel layer still intact. True
aneurysms are further subdivided into fusiform and saccular dilations. A fusiform aneurysm is circumferential and
relatively uniform in shape. A saccular aneurysm is pouch-like with a narrow neck connecting the bulge to one side of
the arterial wall

A false aneurysm, or pseudoaneurysm, is not an aneurysm but a disruption of all arterial wall layers with bleeding that is
contained by surrounding anatomic structures. False aneurysms may result from:

• Trauma
• Infection
• Peripheral artery bypass graft surgery
• Clinical manifestations and complications are dependent on the location of the aneurysm.

Thoracic Aortic Aneurysms (TAAs)

TAAs are often asymptomatic. When present, symptoms include deep, diffuse chest pain that may extend to the
interscapular area.

Ascending Aorta and Aortic Arch Aneurysms manifestations include:

Decreased blood flow to the coronary and carotid arteries resulting in:

• Angina
• Transient ischemic attacks
Pressure on the laryngeal nerve resulting in:

• Coughing
• Dyspnea
• Hoarseness
• Dysphagia

Decreased venous return resulting in:

• Jugular venous distention

• Edema of the face and arms

Abdominal Aortic Aneurysm (AAA) manifestations include:

• Back pain
• Epigastric discomfort
• Altered bowel elimination
• Intermittent claudication
• Pulsatile mass in the periumbilical area slightly to the left of the midline
• Bruits (vascular murmurs) heard over the aneurysm
• “Blue toe syndrome” (patchy mottling of the feet and toes in the presence of palpable pedal pulses) caused by
the aneurysm spontaneously embolizing plaque
• Physical findings may be more difficult to detect in obese individuals.

Complications

The larger the aneurysm, the greater the risk of rupture, which is the most serious complication. If rupture occurs into
the retroperitoneal space, the patient often has severe back pain and may have back or flank ecchymosis (Grey Turner
sign). If rupture occurs into the thoracic or abdominal cavity, patients can die from massive hemorrhage. The patient
who has a rupture outside the hospital will be in hypovolemic shock upon reaching the hospital.

Diagnostic Studies

• Chest x-rays reveal abnormal widening of the thoracic aorta. Abdominal x-rays may show calcification within the
aortic wall.
• Echocardiography assesses the function of the aortic valve.
• Abdominal ultrasound is useful for aneurysm screening and to monitor aneurysm size.
• Computerized tomography (CT) scan of thorax and abdomen is the most accurate test to determine the length
and cross-sectional diameter and the presence of thrombus in the aneurysm.
• Magnetic resonance imaging (MRI) of thorax and abdomen may be useful to diagnose and assess the location
and severity of aneurysms.
•
• Nursing Care Pearl
• Small aneurysms, regardless of location, are typically asymptomatic. Many times they are found accidentally
during an x-ray or CT scan for some other reason. Educate your patient–good management now may prevent
invasive surgery later.

Aortic Dissection: Etiology

Aortic dissection. (From Klatt EC: Robbins and Cotran Atlas of Pathology, ed 3, Philadelphia, 2015, Saunders.)
dissecting aneurysm - a localized dilation of an artery, most commonly the aorta, characterized by a longitudinal
separation of the outer and middle layers of the vascular wall. Blood entering a tear in the intimal lining of the vessel
causes a separation of weakened elastic and fibromuscular elements in the medial layer and leads to the formation of
cystic spaces filled with matrix. Rupture of a dissecting aneurysm may be fatal in less than 1 hour.

Aortic dissection results from the creation of a false lumen between the intima (inner lining) and the media (middle
layer) of arterial wall.

• Type A dissection: affects ascending aorta and arch

• Type B dissection: begins in the descending aorta

Predisposing factors:

• Male gender
• Age (occurs sixth and seventh decades of life)
• Aortic diseases
• Atherosclerosis
• Trauma
• Tobacco use
• Cocaine or methamphetamine use
• Congenital heart disease
• Family history
• History of heart surgery
• Pregnancy
• Poorly controlled hypertension
• Marfan syndrome: Nearly half of all acute aortic dissections in patients <40 years of age occur in patients with
Marfan syndrome.

View the flowchart to learn about the pathophysiology of aortic dissection.

Aortic Dissection >> dissection is caused by degenerated elastic fibers in arterial wall >> a tear develops in the inner
layer of the aorta >> blood surges through this tear causing the inner and middle layers to separate (dissect). If the
blood-filled channel ruptures through the outside aortic wall, aortic dissection is often fatal.

A patient with an aortic dissection may be asymptomatic initially. Symptoms can be neurologic in nature, but often
involve pain. The older adult population can have differences in symptom manifestation.
Description of Pain

If there is pain, it is frequently described as “sharp” and “worst ever,” or as “tearing,” “ripping,” or “stabbing.”

• Acute Type A Dissection: abrupt onset of excruciating anterior chest pain

• Acute Type B Dissection: pain in the back, abdomen, or legs

Neurologic Symptoms

If the aortic arch is involved, the patient may exhibit neurologic deficits including:

• Altered level of consciousness

• Weakened or absent carotid and temporal pulses
• Dizziness or syncope

Geriatric Symptom Variations

Older patients are less likely to have abrupt onset of chest or back pain and more likely to have hypotension and vague
symptoms.

Complications

There can be serious complications of aortic dissection.

• Cardiac tamponade occurs when blood from the dissection leaks into the pericardial sac. Symptoms include
jugular vein distention, sharp chest pain worse with deep breathing and relieved by leaning forward, muffled
heart sounds, narrowed pulse pressure
• Hemorrhage may occur into the mediastinal, pleural, or abdominal cavities
• Spinal cord ischemia leads to weakness and decreased sensation
• Renal ischemia leads to renal failure
• Mesenteric ischemia causes abdominal pain, decreased bowel sounds, altered bowel function, and bowel
necrosis. mesenteric ischemia: ischemia in an area of the intestine supplied by a mesenteric artery. It may be
either occlusive or nonocclusive and may progress to a mesenteric infarction.
• Aortic rupture typically results in exsanguination and death

Diagnostic Studies

Diagnostic studies to evaluate aortic dissection include:

• Chest x-ray: indicates widening of the mediastinum and pleural effusion

• Three-dimensional (3-D) CT scanning, transesophageal echocardiography (TEE), or MRI: used to diagnose acute
aortic dissection. transesophageal echocardiography: an endoscopic/ultrasound test that provides ultrasonic
imaging of the heart from a retrocardiac vantage point, thus preventing the interposed subcutaneous tissue,
bony thorax, and lungs from interfering with the ultrasound. It is performed to better visualize the mitral valve
or atrial septum, to differentiate intracardiac from extracardiac masses and tumors, to diagnose thoracic aortic
dissection, to detect valvular vegetation as seen with endocarditis, to determine cardiac sources of arterial
embolism, to detect coronary artery disease, and to monitor high-risk patients for ischemia intraoperatively.
Key Points

• Aortic aneurysms are described as a localized outpouching or dilation of the vessel wall.
• Risk factors of developing an aortic aneurysm include aging, male gender, tobacco use, obesity, hypertension,
and family history.
• Causes of aortic aneurysm can be due to degenerative, congenital, mechanical/trauma, inflammatory, or
infectious process.
• Many aneurysms are located in the abdominal aorta and below renal arteries.
• Clinical manifestations depend on location of the aneurysm.
• Often thoracic aortic aneurysms (TAAs) are asymptomatic.
• Aneurysms in the ascending aorta and aortic arch may cause angina and transient ischemic attacks from
decreased blood flow.
• Abdominal aortic aneurysms (AAA) may cause back pain and epigastric discomfort.
• Aortic dissections result from the creation of a false lumen between the inner and middle layer of the arterial
fall; risk factors are similar to that of aortic aneurysms with the addition of Marfan syndrome.
• Clinical manifestations of dissection include a ripping or tearing sensation with severe pain; patients that do not
have pain with aortic dissection often present with severe hypotension.
• X-ray, CT, ultrasound, TEE, and MRI imaging is used to diagnose and monitor the status of an aneurysm and
aortic dissection.

QUIZ ME NOW

Which patient is at highest risk of developing an aortic aneurysm?

a. 47 y/o male with BMI 23
b. 59 y/o female with LDL of 98 mg/dl
c. 67 y/o female w/ arterial LE ulcer
d. 73 y/o male smokes 4 packs a day last 25 years. 73 y/o male with history of smoke is at highest risk for developing
an aneurysm due to his increasing age and his long term tobacco use.

The patient with a chronic aneurysm presents to the clinic with back pain. What objective assessment finding is MOST
concerning to the nurse?
a. diffuse pain extending to the interscapular area
b. a palpable mass is located in the periumbilical area
c. BLE are mottled, dusky & cool. BLE that are gray & cool would be most concerning because this indicates
inadequate blood flow. Occasionally, aneurysms spontaneously embolize plaque, causing "blue toe syndrome"
(patchy mottling of the feet & toes in the presence of palpate pedal pulses).
d. bruit heard on auscultation over the anterior midline chest

Place the pathophysiology of an aortic dissection in order

1. blood-filled channel ruptures through the outside aortic wall
2. elastic fibers in the arterial wall degenerate
3. a tear develops in the inner later of the aorta
4. blood surges causing the inner and middle layers to separate.
Order: 2-3-4-1 type A affects ascending aorta/arch; type B begins in the descending aorta

The patient presents to the emergency department with a BP of 76/52 mmHG. What subjective symptoms from the
patient would be MOST concerning to the nurse?
a. painful urination.
b. decreased sensation of feet
c. chills & sweating during the night
d. tearing & ripping sensation in the anterior chest. Tearing & ripping sensation in the anterior chest would be the
most concerning because it may indicate aortic dissection. Other symptoms may include altered level of
consciousness, weak uses, & dizziness from internal hemorrhage.
Aortic Aneurysm: Conservative Treatment

The primary goal of interprofessional care is to prevent the rupture of an aneurysm. Early detection and prompt
treatment are essential.

Conservative medical therapy of small, asymptomatic AAAs (4.0 to 5.4 cm) is the best practice and consists of risk factor
modification:

• Ceasing tobacco use

• Optimizing lipid profile results
• Gradually increasing physical activity
• Heart rate (HR) control
o Reduces aortic wall stress by decreasing heart rate to 60 beats/minute or less with IV β-blocker
• BP control:
o Reduces aortic wall stress by managing systolic BP between 100 and 110 mm Hg and myocardial activity
with IV β-blocker or a calcium channel blocker (e.g., diltiazem) can be used if a beta-blocker (β-blocker)
is contraindicated; IV angiotensin-converting-enzyme (ACE) inhibitor (e.g. enalapril) may also be used

The aneurysm should be monitored using ultrasound or CT every 6-12 months. However, monitoring by ultrasound
every 2-3 years is recommended for patients with smaller AAAs.

Aortic Aneurysm: Drug Therapy

Growth rates of aneurysms may be lowered with:

• β-blockers (e.g., propranolol)

• ACE inhibitors (e.g., captopril)
• Angiotensin II receptor blockers (e.g., losartan)
• Statins (e.g., simvastatin)
• Antibiotics (e.g., doxycycline)

Aortic Aneurysm: Surgical Repair

Surgical repair is recommended in patients with asymptomatic aneurysms ≥5.5 cm in diameter. Correction of existing
carotid or coronary artery blockages may be needed before repair. If the aneurysm has ruptured, emergent surgical
intervention is required.

OPEN: 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.
 • An incision is cut through the abdomen and into the diseased aortic segment.
• The thrombus or plaque is then removed.
• A synthetic graft to the aorta proximal and distal to the aneurysm is placed.
• The native aortic wall around the graft is sutured in place to act as a protective cover.

ENDOVASCULAR: 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, The stent graft is inserted through a large blood vessel
(e.g., femoral artery) using a delivery catheter. The catheter is positioned below the renal arteries in the area of the
aneurysm. C, The stent graft is slowly released (deployed) into the blood vessel. When the stent comes in contact with
the blood vessel, it expands to a preset size. D, A second stent graft can be inserted in the contralateral (opposite) vessel
if necessary. E, Fully deployed bifurcated stent graft.

• Minimally invasive endovascular aneurysm repair (EVAR) is an alternative to OAR for select patients.
• The procedure involves the placement of a sutureless aortic graft into the abdominal aorta inside the aneurysm
via the femoral artery.
• The main section of the graft is bifurcated and delivered through a femoral artery catheter.
• The second part of the graft is inserted through opposite femoral artery.
• When all graft components are in place, they are released (deployed) against the vessel wall by balloon inflation-
blood flows through the endovascular graft, preventing further expansion of the aneurysm.

Postsurgical Complications

The aorta is fragile after dissection. Even with prompt surgical intervention, the risk of in-hospital mortality and many
potential complications is high. The nurse should work with the care team to monitor for surgical complications and
prevent fatalities. Causes of death include aortic rupture, mesenteric ischemia, myocardial infarction (MI), sepsis, stroke,
and multiorgan failure.
Complications include:

Intraabdominal hypertension (IAH) with associated abdominal compartment syndrome

• Persistent IAH reduces blood flow to the viscera

• Abdominal compartment syndrome refers to the impaired organ perfusion resulting in multisystem organ failure

Endoleak

• The seepage of blood backs into the old aneurysm from an inadequate seal at either graft end, a tear through
the graft fabric, or leakage between overlapping graft segments
• Ischemia below the aneurysm graft site
• Aneurysm growth above or below the graft
• Aneurysm rupture
• Aortic dissection and bleeding
• Renal artery occlusion - This is caused by stent migration and graft thrombosis, which may lead to kidney failure
• Incisional site hematoma
• Incisional infection
• Myocardial ischemia or infarction - Occurs due to decreased myocardial O2 supply or increased myocardial
O2 demands. Adequate blood pressure is needed to maintain graft patency. Cardiac dysrhythmias occur because
of electrolyte imbalances, hypoxemia, hypothermia, or myocardial ischemia

Key Points

• Conservative treatment is the best practice for aneurysms that are asymptomatic and <5.4 cm.
• Heart rate and blood pressure control is essential to prevent hemorrhage from aneurysms and dissections.
• Antihypertensive drug therapy can be used to slow growth rate of an aneurysm.
• Patients with aneurysms ≥5.5 cm require surgical intervention.
• Aortic dissections require immediate surgical treatment; mortality rate is high.
• Goals of surgery include normal tissue perfusion and no surgical complications.

QUIZ ME NOW

The patient newly diagnosed with a 4.1 cm aortic aneurysm states, "my provider said that the aneurysm with be treated
conservatively. What does this mean? What is the nurses BEST response?
a. the clinic will call you this week to schedule your aneurysm repair surgery. '
b. lifestyle changes & medications will be used to help control your heart rate and blood pressure. Conservative
medical therapy of small asymptomatic AAA's (4.0-5.4cm) is the best practice and consists of risk factor modifications:
stop smoking, optimize lipid profile agents, increase exercise, HR control, reduce aorta wall stress by decreasing HR to
close to 60bpm with an IV beta blocker
c. a medication called a beta-blocker will be prescribed for you to help decreased the size of th aneurysm.
d. you will need to increase your physical activity and take your prescribed HTN medication to fix the aneurysm.

The nurse is caring for a patient after an open aneurysm repair - OAR. What laboratory finding would cause the nurse to
contact the health care provider?
a. creatinine 4.1 mg/dL. An increased creatinine level such as 4.1 mg/dL may indicate a kidney issue. There is a risk of
post renal complications such as AKI above level of renal arteries – communicate this to surgeon.
b. hemoglobin 10.8 grams/L
c. WBC count 7500 mcL
d. partial pressure of carbon dioxide (PaCO2) 41. mmHg
The nurse is caring for a patient with aortic dissection preoperatively in the ICU. The family member states, "Usually his
heart rate is in the 80s. Why is it 53?" What is the nurse's best response?
a. "It is common for patients with aortic dissection to experience a lower heart rate. His heart rate should return to
baseline after the surgery."
b. "I will call the provider immediately. We may need to give a medication to increase his heart rate so that he is
sufficiently perfusing throughout his body."
c. "A beta-blocker was administered to decrease his heart rate. A slower heart rate is needed so that there will be less
blood leaking from the aortic dissection." "A beta-blocker was administered to decrease his heart rate. A slower
heart rate is needed so that there will be less blood leaking from the aortic dissection."
Heart rate control reduces aortic wall stress. The goal should be to decrease heart rate to ≥60 beats/minute with IV β-
blocker BP control. This also reduces aortic wall stress by managing systolic BP between 100 and 110 mm Hg and
myocardial activity.
d. "This may be due to the stress or his feelings of anxiety from being in the hospital. I will go look at his chart to see
what his heart rate has been during hospitalization."

Aortic Aneurysm: Preoperative Care

The overall nursing goals for a patient undergoing aortic surgery include:

• Normal tissue perfusion

• Intact motor and sensory function
• No complications related to surgical repair, such as thrombosis, infection, or rupture

Nursing actions for preoperative care include monitoring the patient, establishing baseline data, and preparing the
patient during the preoperative period.

Monitor the patient for signs of aneurysm rupture and intraabdominal hypertension (IAH) that could lead to abdominal
compartment syndrome (ACS). These signs include diaphoresis, pallor, weakness, tachycardia, hypotension, abdominal,
back, groin, or periumbilical pain, changes in level of consciousness, or a pulsating abdominal mass.

Establishing baseline data is critical for comparison with later postoperative assessments. Pay special attention to the
character and quality of the patient’s peripheral pulses and renal and neurologic status. Before surgery, mark pedal
pulse sites (dorsalis pedis and posterior tibial) with a single-use marker and document any skin lesions on the lower
extremities.

In general, the nurse should check the aortic surgery patient’s orders for:

• Bowel preparation (e.g., laxatives, enemas)

• Skin cleansing with an antimicrobial agent prior to surgery and appropriate hair removal per TJC SCIP core
measures
• Nothing by mouth (NPO) after midnight the day before surgery
• IV antibiotics to be administered per TJC within 1 hour prior to cutting time; prophylactic antibiotics need to be
discontinued within 48 hours after surgery per SCIP core measures
• β-blocker (e.g., metoprolol [Lopressor]) to be administered preoperatively for patients with a history of
cardiovascular disease

Provide emotional support and teaching to the patient and the caregiver

Preoperative teaching includes a brief explanation of the disease process, the planned surgical procedure(s),
preoperative routines, what to expect immediately after surgery, and usual postoperative timelines
Aortic Aneurysm: Postoperative Nursing Care

Postoperative nursing assessments and interventions are system based. Infection prevention is the main priority.

Infection Prevention

• A prosthetic vascular graft infection is a relatively rare but potentially life-threatening complication.
• Give a broad-spectrum antibiotic as prescribed for infection
• Assess temperature regularly
• Monitor laboratory data for an elevated white blood cell (WBC) count
• Assess the surgical incision for signs of infection (e.g., redness, inflammation, drainage)

Cardiovascular System

• The location of the aneurysm determines what type of peripheral perfusion assessment is done.
• Check and record all peripheral pulses hourly for several hours and then routinely (based on agency policy)
• A decreased or absent pulse together with a cool, pale, mottled, or painful extremity may indicate embolization
or graft occlusion. Report these findings to the health care provider immediately
• Nursing interventions: continuous ECG monitoring; intraarterial blood pressure monitoring; frequent electrolyte
and arterial blood gas determinations; administration of O2, IV antidysrhythmic and antihypertensive drugs, and
electrolytes as needed; adequate pain control; and resumption of cardiac drug

Gastrointestinal System

• After OAR, postoperative ileus may develop as a result of anesthesia and the handling of the bowel during
surgery.
• An NG tube may be placed during surgery. Record the amount and character of the NG output. While the
patient is NPO, provide oral care frequently
• Ice chips or lozenges can help soothe a dry or irritated throat
• Assess for bowel sounds every 4 hours. The passing of flatus signals returning bowel function and should be
noted
• Encourage early ambulation as this can help the return of bowel function
• If the blood supply to the bowel is disrupted during surgery, temporary ischemia or infarction (death) of
intestinal tissue may result. Observe for absent bowel sounds, fever, abdominal distention, bloating, pain,
diarrhea, and bloody stools
• The patient will need a H2 blocker or proton-pump-inhibitor (PPI) for NPO status

Neurologic System

• When the ascending aorta and aortic arch are involved, assess the patient’s level of consciousness, pupil size
and response to light, facial symmetry, tongue position, speech, upper extremity movement, and quality of hand
grasps
• When the descending aorta is involved, perform a neurovascular assessment of the lower extremities
• Report changes from baseline to the HCP immediately

Renal System

• Provide catheter care for the patient’s indwelling urinary catheter

• Per catheter-associated urinary tract infection (CAUTI) core measure, the urinary catheter should be removed
within 48 hours of surgery or documentation is needed to indicate need for catheter
• In the immediate postoperative period, record hourly urine output
• Monitor daily blood urea nitrogen (BUN) and serum creatinine levels
 • Maintain accurate fluid intake and output records and record daily weights
• Observe for signs of hypotension which can result from dehydration, prolonged aortic clamping during surgery,
blood loss, or embolism

Aortic Aneurysm: Patient and Caregiver Education

Conservative Treatment Education

• Patients must understand that they need to take antihypertensive drugs daily for the rest of their lives to control
blood pressure and heart rate.
• It is important that patients understand the drug regimen and potential side effects (e.g., dizziness, depression,
fatigue, erectile dysfunction).
• Tell the patient to discuss any side effects with the HCP before stopping the drug.
• Follow-up with regularly scheduled MRIs or CTs is essential. The most common cause of death in long-term
survivors is aortic rupture from redissection or aneurysm formation.
• Tell patients that if the pain or other symptoms return, they should activate emergency response system for
immediate care.
• Utilize the teach-back method; the teach-back method ensures the patient’s understanding of education.

Postoperative Teaching

• Instruct the patient and caregiver to gradually increase activities once home.
• Educate patients that fatigue, poor appetite, and irregular bowel habits are common.
• Teach the patient to avoid heavy lifting after surgery according to the health care provider’s recommendations.
• Any redness, inflammation, increased pain, drainage from incisions, or fever >100° F (37.8° C) should be
reported to a HCP.
• Teach the patient and caregiver to look for changes in color or warmth of the extremities and to assess
peripheral pulses.
• Sexual dysfunction in male patients is common after aortic surgery. A referral to a urologist may be useful if
erectile dysfunction occurs.

Key Points

• In the preoperative period, the nurse should administer medications as ordered, prepare the patient to be NPO
and provide education as needed.
• In the postoperative period, the nurse should assess the patient frequently to monitor for infection and
complications.
• The patient should gradually increase activity after discharge.
• The nurse should provide postoperative education on how to assess for infection and when to call the clinic.
• If any symptoms of aortic aneurysm or dissection occur, the patient should immediately activate the emergency
response system.
• Drug therapy education is essential in the treatment plan.
• The patient should understand drug side effects and should have a discussion with the provider prior to stopping
any medication.
QUIZ ME NOW

The nurse is prepping the patient with a history of cardiovascular disease (CVD) for aortic aneurysm surgical repair. What
medication order would cause the nurse to contact the health care provider for further clarification?
a. Aspirin 325 mg PO hold
b. Metoprolol 50 mg PO after surgery. Metoprolol 50 mg PO after surgery
Patients undergoing an aneurysm repair with a history of CVD should be given a beta-blocker preoperatively, not
postoperatively. This ordering provider should be contacted to clarify the order. A beta-blocker should be given prior
to surgery to slow the heart rate and reduce aortic wall distress.
c. Cefazolin 1 gm IV 30 minutes prior to surgery
d. Hibiclens skin cleanse the day prior to surgery

The nurse is caring for a postoperative aneurysm repair patient. What assessment finding would cause the nurse to
contact the provider?
a.Blood pressure 86/54. Blood pressure 86/54
A BP of 86/54 needs to be communicated to the provider. An adequate BP is important to maintain graft patency.
Prolonged hypotension may result in graft thrombosis.
b.Urine output 40 mL/hr
c.Bilateral pedal pulses 3+
d.Hypoactive bowel sounds

The nurse is providing patient discharge education postoperative open aortic aneurysm repair on the ascending aorta.
What patient statement would indicate to the nurse further education is needed?
a."I should contact my provider if I notice any weakness in my hands."
b."It is most important for me to feel for pulses on my feet and notice if they are cool."
"It is most important for me to feel for pulses on my feet and notice if they are cool."
The patient should feel the pulses on the feet if they have undergone a descending, not ascending, aortic repair.
When the ascending aorta and aortic arch are involved, the carotid, radial, and temporal artery pulses should be
assessed.
c."Heavy lifting, like vacuuming or carrying groceries, should be avoided for 6 weeks."
d."I will contact my provider if I notice any redness, swelling, or drainage coming from the incision."

Summary

Aortic aneurysm can be caused by several conditions: degenerative, congenital, mechanical, inflammatory, or infectious
processes. Risk factors like aging, hypertension, and peripheral artery disease may increase the risk of development. An
aortic aneurysm is described as a localized outpouching or dilation of the vessel wall. Most aneurysms are abdominal
aortic aneurysms (AAA) and are located below the renal arteries. Radiology imaging is used to diagnose and monitor the
status of an aneurysm and aortic dissection. Clinical manifestations depend on the location of the aneurysm but can be
asymptomatic. If clinical manifestations are present, they may include: angina and transient ischemic attacks and pain. A
pulsatile mass may be seen and bruit may be heard over the AAA location. Risk of rupture increases as the aneurysm
increases in size. If rupture occurs, massive hemorrhage can lead to hypovolemic shock or death. Aortic dissections
result from the creation of a false lumen between the inner and middle layer of the arterial wall. Risk factors are similar
to that of aortic aneurysms. Aortic dissection may be asymptomatic. If pain is present, it is described as tearing or
ripping.

Aortic dissection can cause serious complications and death and hospital mortality rates are high. The goal of
collaborative care is to prevent rupture of an aneurysm. Heart rate and blood pressure control is essential for aneurysms
and dissections to prevent hemorrhage. Drug therapy can be used to slow the growth rate of an aneurysm. If surgery is
needed, goals include normal tissue perfusion and prevention of surgical complications. In the preoperative period, the
nurse should provide preoperative care as ordered. The nurse should assess the patient frequently in the postoperative
period to monitor for infection and other complications. The nurse should provide education on activity
recommendations and how to assess for infection. If any symptoms return, the patient should immediately activate the
emergency response system.

• Aortic aneurysms are described as a localized outpouching or dilation of the vessel wall.
• Risk factors of developing an aortic aneurysm include aging, male gender, tobacco use, obesity, hypertension,
and family history.
• Causes of aortic aneurysm can be due to degenerative, congenital, mechanical/trauma, inflammatory, or
infectious process.
• Many aneurysms are located in the abdominal aorta and below renal arteries.
• Clinical manifestations depend on location of the aneurysm.
• Often thoracic aortic aneurysms (TAAs) are asymptomatic.
• Aneurysms in the ascending aorta and aortic arch may cause angina and transient ischemic attacks from
decreased blood flow.
• Abdominal aortic aneurysms (AAA) may cause back pain and epigastric discomfort.
• Aortic dissections result from the creation of a false lumen between the inner and middle layer of the arterial
fall; risk factors are similar to that of aortic aneurysms with the addition of Marfan syndrome.
• Clinical manifestations of dissection include a ripping or tearing sensation with severe pain; patients that do not
have pain with aortic dissection often present with severe hypotension.
• X-ray, CT, ultrasound, TEE, and MRI imaging is used to diagnose and monitor the status of an aneurysm and
aortic dissection.
• Conservative treatment is the best practice for aneurysms that are asymptomatic and <5.4 cm.
• Heart rate and blood pressure control is essential to prevent hemorrhage from aneurysms and dissections.
• Antihypertensive drug therapy can be used to slow growth rate of an aneurysm.
• Patients with aneurysms ≥5.5 cm require surgical intervention.
• Aortic dissections require immediate surgical treatment; mortality rate is high.
• Goals of surgery include normal tissue perfusion and no surgical complications.
• In the preoperative period, the nurse should administer medications as ordered, prepare the patient to be NPO
and provide education as needed.
• In the postoperative period, the nurse should assess the patient frequently to monitor for infection and
complications.
• The patient should gradually increase activity after discharge.
• The nurse should provide postoperative education on how to assess for infection and when to call the clinic.
• If any symptoms of aortic aneurysm or dissection occur, the patient should immediately activate the emergency
response system.
• Drug therapy education is essential in the treatment plan.
• The patient should understand drug side effects and should have a discussion with the provider prior to stopping
any medication.
TEST

1. Label the image

2. Which statement best describes a fusiform aneurysm?

a. The pouch-like bulge is on one side of the arterial wall.
A true aneurysm is one in which the wall of the artery forms the aneurysm, but there is at least one vessel layer still
intact. A true saccular aneurysm is pouchlike with a narrow neck connecting the bulge to one side of the arterial wall.
b. The shape is comparatively uniform and circumferential.
A true aneurysm is one in which the wall of the artery forms the aneurysm, but there is at least one vessel layer still
intact. A fusiform aneurysm is circumferential and relatively uniform in shape.
c. The tear between the inner and middle layers of the arterial wall has caused a false lumen.
A tear between the inner and middle layers of the arterial wall that causes a false lumen best describes aortic or
arterial dissection. Aortic dissection results from the creation of a false lumen between the intima (inner lining) and
the media (middle layer) of arterial wall.
d. The arterial wall layers are disrupted and bleeding is contained by surrounding anatomic structure.
Disrupted arterial walls and bleeding contained by anatomic structure best describes a false aneurysm or
pseudoaneurysm. A false aneurysm, or pseudoaneurysm, is not an aneurysm but a disruption of all arterial wall layers
with bleeding that is contained by surrounding anatomic structures.

3. The patient presents to the emergency department with a suspected aortic dissection. What assessment finding
would be most concerning to the nurse?
a. Pulse 96 beats/min, creatinine level 1.3 mg/dL, low urine output
A pulse of 96 beats/min is considered normal. While an elevated creatinine level and low urine output may indicate a
renal issue, these are not the most concerning findings at this time. Aortic dissection can cause renal ischemia due to the
lack of blood flow. Low urine output may be expected if the patient is hemorrhaging.
b. Respirations 24, lower extremity weakness, tingling in fingers
An increased respiratory rate may indicate pain, hemorrhage, or anxiety. Aortic dissection can cause spinal cord
ischemia. While these findings do need further assessment and treatment, this is not the priority at this time.
c. BP 86/64, positive jugular vein distention, muffled heart sounds
These clinical manifestations would be most concerning because they indicate cardiac tamponade. The patient is
hypotensive and has a narrowed pulse pressure (22). Jugular vein distention and muffled heart sounds are also signs
of cardiac tamponade.
d. Temperature 99.1 degrees Fahrenheit, decreased bowel sounds, abdominal pain
Aortic dissection can lead to mesenteric ischemia that would cause abdominal pain and decreased bowel sounds. While
this needs further assessment and treatment, it is not the highest priority at this time. A temperature of 99.1 is not
concerning.
4. The nurse is caring for a patient recovering from endovascular graft aortic repair. The family states, "I think he's lying
on a tube under his back. I'll move it from underneath him so he's more comfortable." What is the nurse's best
response?
a. "The tube needs to be in that position in order to function correctly. Please do not move it."
This is not the best response as it does not address the patient's comfort level or the family's concern. Additionally, the
nurse should work with the patient and family to improve comfort.
b. "The tube needs to be handled by nurses only because of the risk of infection. I will put on gloves and reposition
the tube."
A temporary lumbar drain may be inserted for cerebrospinal fluid removal to reduce spinal cord edema and help
prevent paralysis. If a lumbar drain is used, strict aseptic techniques are essential to avoid introducing infection.
c. "The nursing assistant and I will help you move the tube to a more comfortable position as more people are needed to
move it safely."
This is not the best response because it does not state the reason why the family should not move the tube and does not
instruct the family to not touch the tube.
d. "Please be sure to wash your hands and put on gloves before you move the tube. He can turn on his side and then you
can move it."
Families should not be moving lines and drains due to the high risk of infection and fragility of the patient and monitors.

5. The nurse is caring for a patient with aortic dissection preoperatively. The patient rates his pain 7/10 on a numeric
scale. The patient's blood pressure is 137/82, heart rate 92 beats per minute, respirations 18 per minute, oxygen
saturation 98%, and oral temperature 98.4°. What is the nurse's priority action?
a. Administer IV morphine
The morphine will help decrease the patient's pain. Morphine is a vasodilator that will also help decrease the
patient's blood pressure.
b. Administer IV beta-blocker
While beta-blockers may decrease the patient's blood pressure, which is important with aortic dissection, they do
nothing to address the patient's complaint of pain. Beta-blockers decrease pulse as well.
c. Contact the surgeon immediately
Pain is expected with an aortic dissection and the patient's vital signs are stable. The patient's pain should be addressed
by the nurse.
d. Use nonpharmacologic techniques to decrease pain
The patient with aortic dissection can have significant pain that can be relieved most efficiently through use of
medications. The goal of managing an aortic dissection prior to surgery is to maintain blood pressure and control pain
and anxiety, which can increase blood pressure.

6. The nurse is preparing the patient with EVAR for discharge. The patient states, "I am glad this procedure is done and I
won't have to keep seeing doctors and having scans." What is the nurse's best response?
a. "It must be relieving not to worry about your aneurysm any more. You should schedule one more follow-up
appointment to check for infection around your incision."
While the patient should have a postsurgical follow-up visit, this does not address that the patient will need more
frequent follow-up visits.
b. "Be sure to gradually increase your physical activity at home, refrain from smoking, and monitor your blood pressure.
Call the clinic if you notice any side effects from your medications."
While the information provided is appropriate, the nurse needs to address the patient's comment about never going to
the hospital again.
Correct
c. "With the aneurysm repair surgery you had, there will always be a risk of developing a leak. You will need to have
imaging done periodically throughout your life to monitor for this complication."
Patients undergoing EVAR require periodic imaging for the rest of their lives to monitor for an endoleak, document
stability of the aneurysm sac, and determine the need for surgical intervention.
d. "You should return to the hospital immediately if you notice any dizziness, pain where the aneurysm was located, or
shortness of breath. You should also return if you notice any foul-smelling discharge or redness and warmth to the
incision site."
This response gives the patient appropriate education about at-home care but does not address the need for follow-up
care. The symptoms described could indicate a leak or infection, and the patient should return to the hospital
immediately.

7. The nurse is caring for the patient with aortic dissection postoperatively. What assessment finding would cause the
nurse to contact the provider immediately?
a. Absent bowel sounds
While absent bowel sounds are concerning, they would not cause the nurse to contact the provider. After surgery,
postoperative ileus may develop as a result of anesthesia and the handling of the bowel during surgery. If the blood
supply to the bowel is disrupted during surgery, temporary ischemia or infarction (death) of intestinal tissue may result.
b. NG in place with green-brown output
Green-brown NG output is considered normal and indicates draining of the stomach contents.
c. Pain near incision site with ambulation
This assessment finding is normal and would not be communicated to the provider. Pain is expected at the incision site
after an aortic dissection surgery. There is no indication that there is a complication occurring from the surgery.
d. Decreased response to physical stimulation
A decreased level of consciousness likely indicates decreased perfusion and complication from the aortic dissection
repair; further assessment and treatment are needed.

8.The patient has a history of aortic dissection repair 1 month ago. The patient calls the clinic and states he started
having discomfort in his chest 30 minutes ago. What is the nurse's best response?
a. "Call 911 immediately."
For patients with a history of aortic dissection, they should activate emergency response system (ERS) for immediate
care if symptoms reoccur. This could indicate further dissection, which is a medical emergency.
b. "You should drive to your primary care office to be examined."
Chest discomfort could indicate dissection. The patient should not drive himself because of the complications associated
with aortic dissection; if he is bleeding internally and loses blood volume, he could lose consciousness while driving.
c. "Be sure to make a follow-up appointment with your surgeon this week."
The patient will need care immediately, not later in the week, due to the risks associated with aortic dissection repair.
d. "It is common to have chest discomfort after an aortic dissection repair."
The patient is indicating that chest discomfort is a new symptom, which is concerning after an aortic dissection repair.
Further assessment and care is needed immediately.

9. The nurse is caring for a postoperative open aortic aneurysm repair. The patient complains of feeling "bloated." What
should be the nurse's priority assessment?
a. Assess lung sounds
While a lung assessment should be completed on a patient that has undergone an OAR, it is not the priority assessment
related to the patient's complaint. The nurse should listen to lung sounds and monitor for any changes with breathing.
b. Assess urine output
While a urine output assessment should be completed on a patient that has undergone an OAR, it is not the priority
assessment related to the patient's complaint.
c. Assess for bowel sounds
After an OAR, postoperative ileus may develop due to anesthesia and handling of the bowel during surgery. If the
blood supply to the bowel is disrupted during surgery, temporary ischemia or infarction (death) of intestinal tissue
may result. Observe for absent bowel sounds, fever, abdominal distention and pain, diarrhea, and bloody stools.
d. Assess for incisional infection
Assessing for incisional infection is not the priority assessment. However, this should be assessed at a later point and the
nurse should assess for redness, inflammation, and warmth surrounding the incision site.

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