Exam 1: Cardiac and Perfusion

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Left sided HF S/S
\
think LUNGS

\-paroxysmal nocturnal dyspnea

\-cough

\-crackles

\-wheezes

\-blood tinged sputum

\-tachypnea

\-tachycardia

\-exertional dyspnea

\-fatigue

\-cyanosis

\-restlessness

\-confusion

\-orthopnea
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Right sided HF S/S
Think REST of the body

\-enlarged liver and spleen

\-ascites

\-increased peripheral venous pressure

\-distended JVD

\-anorexia

\-complaints of GI distress

\-weight gain

\-dependent edema

\-fatigue
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__Acute Coronary Syndrome: primary cause__
Atherosclerosis

\-Angina occurs when the O2 demand is greater than the oxygen supply

·      The heart is working hard (high oxygen demand) but there is poor perfusion to the myocardium (low oxygen supply)

§  Lipids accumulate causing a fatty streak

§  The endothelial lining of the arteries is damaged
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Acute Coronary Syndrome: RF
§  Smoking

§  Hyperlipidemia

§  HTN

§  Toxins

§  Diabetes

§  Localized inflammatory process
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Acute Coronary Syndrome: S/S
§  Palpitations

§  Diaphoresis

§  Anxiety Nausea

§  Angina (chest pain)

·      Women confuse chest pain for indigestion

·      Men will describe it as an elephant on the chest

·      Both genders will complain of arm pain
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  __Non-ST Elevated Myocardial Infarction (NSTEMI):__
  __Non-ST Elevated Myocardial Infarction (NSTEMI):__
§  This is considered Ischemia

·      Ischemia means it is lacking O2 NOT tissue death

§  It is reversible

§  Releases cardiac enzymes if damaged
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how will an NSTEMI strip look like?
__ST Depression and/or T wave inversion indicating ischemia__
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NSTEMI and STEMI- dx and labs
12 lead EKG

myoglobins

creatine kinase MB

Troponin I or T
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Myoglobins
* earliest marker of injury to cardiac/skeletal muscle

§  No longer evident after 24hrs
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creatine kinase - MB
§  Peaks around 24hrs after onset of chest pain

§  No longer evident after 3 days
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Troponin I or T
§  If there is any POSITIVE+ value, it means there is cardiac tissue damage and should be reported
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__Unstable Angina & NSTEMI MEDS:__
o   MONA – Morphine, O2, Nitroglycerine, Aspirin

o   give heparin to prevent clot formation of microemboli

o   DAPT (dual anti platelet therapy) – ex. Aspirin, clopidogrel, ticagrelor

o   PCI (percutaneous coronary intervention) – within 12-72 hrs.

§  This refers to cardiac cath with stent placement

o   Notify PCP ASAP if there are any changes in ST segment
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o   __ST-Elevated Myocardial Infarction (STEMI):__
o   __ST-Elevated Myocardial Infarction (STEMI):__
§  Infarction – Classic heart attack

§  ST segment is elevated = pt is dying

§  Extensive heart damage

§  This is the only one with an ST elevation

·       Tissue is dead and more tissue is continuing to die
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§  __STEMI MEDS:__
·      PCI (percutaneous coronary intervention) – within 90 mins.

o   This refers to cardiac cath with stent placement

·      TPA if PCI is not available

o   TPA = tissue plasminogen activator = thrombolytic therapy = breaks up existing clots
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o   __PRIORITY NURSING INTERVENTIONS FOR ALL CLIENTS WITH ANGINA:__

§  FOR UA, NSTEMI, STEMI
·      12-LEAD ECG

·      Serial cardiac biomarkers

·      Vitals and O2 monitoring HOURLY

·      Continuous ECG monitoring

·      MONA

·      Monitor UOP

·      Maintain bed rest

·      Limit activity for 12-24hrs.

·      Monitor and treat Anxiety
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when do STEMI pts go for stent placement
§  goes to cardiac cath lab for stent placement right away; these interventions are happening during transport and procedure preparation
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when do NSTEMI and UA pts go for stent placement
will go to cardiac cath within 72h; these interventions are happening until they go to the cath lab
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o   __ACS Procedures:__ Angiography/Cardiac Catheterization:
·      This is an invasive procedure

·      Evaluates presence & degree of coronary artery blockage

·      Threads a catheter through a peripheral artery into the heart to visualize coronary arteries

·      Contrast is used to see blockage
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use of contrast nursing care
o   Assess for allergies: especially contrast dye \n o Perform baseline assessment \n o Withhold food/fluids 6-12 hrs before \n o Assess baseline lab values: cardiac biomarkers & creatinine

o Teach about procedure \n o Give sedative & other drugs
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§  Post Angiography Site Care:
·      Monitor vitals

·      Assess for bleeding

·      Assess for hematomas

·      Assess neurovascular checks (5 P’s – Pain, Paresthesia, Pallor, Pulse, Paralysis)

o   Check every 15 min for the 1st hour (4 times)

o   Check every 30 min for the 2nd hour (2 times)

o   Check every hour for the next 4 hours (4 times)

o   Check every 4 hours

·      Bed Rest

o   Pt must lay flat, supine

o   Extremity must be straight for the prescribed time

o   Pt cannot walk

o   Pt cannot sit up to eat
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ACS MEDS - drug action - *Vasodilators – Nitroglycerin -*
o   Prevents coronary artery vasospasm

o   Reduces preload and afterload, decreasing myocardial oxygen demand

o   Decreases BP
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ACS MEDS - nursing action - *Vasodilators – Nitroglycerin -*
o   Monitor for orthostatic hypotension

o   Teach pt headaches are common

o   Withhold drug if pt is taking phosphodiesterase inhibitor for erectile dysfunction within the last 24-48hrs – can cause severe hypotension

o   Educate to take 1 tablet every 5 mins x 3

o   If chest pain continues after first dose and 5 mins have passed, take 2nd tablet and call 911

o   When taking this medication pt should be sitting down
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ACS MEDS - drug action - *Analgesic – Morphine*
o   Pain relief (chest pain)

o   Decreased O2 consumption (Reduces the demand for O2)

o   Calms anxiety
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ACS MEDS - nursing action - *Analgesic – Morphine*
o   Monitor for decreased RR

o   Monitor for hypotension

o   N/V
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ACS MEDS - drug action - *Betablockers – Metoprolol* (end in LOL)
o   Antidysrhythmic & antihypertensive

§  decrease O2 demand by reducing afterload and slowing HR

o   Acute MI:  decrease infarct size

§  improves short- and long-term outcomes
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ACS MEDS - nursing action - *Betablockers – Metoprolol* (end in LOL)
o   Monitor for bradycardia and hypotension

o   Hold if apical pulse < 60

o   Monitor asthma & heart failure pts

o   Monitor for decreased LOC, crackles, chest discomfort

o   Check heart rate before admin

§  60 or less hold med call pcp
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ACS MEDS - drug action - *Thrombolytic Agent – Alteplase*
o   Breaks up clots in the blood
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ACS MEDS - nursing action - *Thrombolytic Agent – Alteplase*
o   Monitor for bleeding

o   Monitor labs – PTT and PT

o   Not indicated for pts with NSTEMI

o   Indicated for pts with STEMI and PCI is not an option
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ACS MEDS - drug action - *Antiplatelet Agents – Aspirin, Clopidogrel (Plavix)*

\
o   Prevent platelets from sticking together

o   Aspirin should be given with nitro on onset of symptoms due to its ability to prevent vasoconstriction
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ACS MEDS - nursing action -*Antiplatelet Agents – Aspirin, Clopidogrel (Plavix)*
o   Monitor for tinnitus (toxicity)

§  Ringing of the ears

o   Watch out for bleeding
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ACS MEDS - drug action - *Anticoagulants – Heparin and Enoxaparin*
o   Prevent clot growth

o   Prevent new clot formation
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ACS MEDS - nursing action - Anticoagulants – Heparin and Enoxaparin
o   Monitor for bleeding

o   PT/ INR, PTT, CBC

§  Platelet count comes from CBC

o   Thrombocytopenia & Anemia

o   Risk for bleeding and bruising
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ACS MEDS - drug action - *Lipid Lowering Statin – Atorvastatin (end in STATIN)*
o   Block synthesis of cholesterol and increase LDL receptors in liver

o   Decreases LDL

o   Decreases triglycerides

Increases HDL (in small amounts
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ACS MEDS - nursing action - *Lipid Lowering Statin – Atorvastatin (end in STATIN)*
o   Monitor liver enzymes and creatine kinase

§  Will be decreased

§  if muscle weakness or pain occurs

o   Give at night
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ACS – Nutrition
·      NPO except water until stable

·      Low sodium diet

·      Low saturated fat diet

·      Low cholesterol diet

·      No Fast food

·      No Canned food

·      No prepackaged food
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ACS - exercise
·      Low Impact activity
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ACS - nursing considerations
Administer stool softener

o   Prevent straining

o   Drink plenty of water

o   Include fiber in diet
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__Coronary Artery Bypass Graft (CABG)__
o   Surgical procedure to restore vascularization of the myocardium & improve client quality of life

o   Most effective when EF is less than 50%

o   Open chest procedure

o   ICU monitoring
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CABG - Pre-Op Nursing Considerations
o   Informed consent

o   Discontinue meds prior to sx (educate pt)

o   Meds to continue until morning of sx (educate pt)
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CABG - PRE-OP - Discontinue meds prior to sx
§  Diuretics - 2-3 days prior to sx

§  Aspirin and other anticoagulants – 1 week prior to sx
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CABG - PRE-OP - continue meds prior to sx
§  Potassium supplements

§  Antidysrhythmic

§  Antihypertensives

§  Insulin
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CABG - Post-Op Nursing Considerations:
o   ICU for 24-36 hours

o   Monitor hemodynamics – tight BP control

§  Arterial line for BP monitoring

·      Hypotension

o   Can be due to the graft collapsing

·      Hypertension

o   Can be due to bleeding at graft or suture sites

o   ECG for heart rhythms

o   Epicardial pacing wire for emergency pacing

o   Chest tube care

o   Endotracheal / Mechanical vent care

o   Foley cath

o   NGT for gastric decompression

o   Splinting for coughing and deep breathing

o   Early mobility
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CABG - Complications - Pulmonary
·      Atelectasis

·      Pneumonia

·      Pulmonary Edema
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CABG - Complications - Pulmonary - prevention
·      Early Ambulation

·      Turning

·      Deep breathing exercises
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CABG - Complications - Pulmonary - recognize cues
·      Abnormal lung sounds

·      Unequal lung sounds

·      Crackles
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CABG - Complications - Pulmonary - interventions
·      Administer O2

·      Notify PCP

·      Potentially prepare for chest tubes/ diuretics
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CABG - Complications - hypothermia
·      Vasoconstriction

·      Metabolic acidosis
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CABG - Complications - hypothermia - prevention
·      Monitor Temp

·      Keep pt warm
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CABG - Complications - hypothermia - recognizing cues
·      Decreased capillary refill

·      Cool extremities

·      HTN
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CABG - Complications - hypothermia - intervention
·      Check ABG’s

·      Bear hugger

·      Warming blanket

·      Warming fluids
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CABG - Complications - heart (decreased cardiac output)
·      Dysrhythmias – AFIB

·      Cardiac Tamponade (Causes restrictive pressure around heart which reduces its ability to pump = decreased cardiac output)

·      Hypovolemia

·      Left Ventricular Failure

·      Myocardial Infarction (MI)
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CABG - Complications - heart - Dysrhythmias – AFIB __Intervention__
§  Administer BB soon after sx
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CABG - Complications - heart - cardiac tamponade __Intervention__
§  Sternotomy or pericardiocentesis
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CABG - Complications - heart - hypovolemia __Intervention__
§  Carefully replace fluids, colloids
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CABG - Complications - heart - left ventricular failure __Intervention__
§  Vasopressors and positive inotropes
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CABG - Complications - heart - MI __Intervention__
§  Call MD

§  MONA
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CABG - Complications - *Electrolyte Disturbances*
·      K and Magnesium depletion
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CABG - Complications - *Electrolyte Disturbances - recognizing cues*
§  Fatigue

§  Muscle cramps

§  Tingle

§  Numbness

§  Heart palpitations
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CABG - Complications - *Electrolyte Disturbances - intervention*
o   give K + and Mag replacements

§  SAFETY for IV potassium- how fast can we give K+?

§  10 mEq/hr

§  Must use IV pump

§  Must be on cardiac monitor

§  NEVER PUSH IV
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CABG - Complications - neuro deficits
·      CVA (stroke) from transient HTN

·      hypotension

·      blood clot
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CABG - Complications - neuro deficits - recognizing cues
§  balance issues

§  eyesight issues

§  facial droop

§  arm weakness

§  speech difficulties
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CABG - Complications - neuro deficits - interventions
o   Protect airway

o   Call MD

o   Code stroke
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pacemakers indication
o   Help control abnormal heart rhythms with low-electrical pulses to prompt heart to beat at normal rate
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transcutaneous pacemaker


●Fully external



●Symptomatic bradycardia when pt is unresponsive to atropine



●Painful d/t large amount of electricity



●Temporary

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epicardial pacemaker


●Pulse generator outside of body



●Leads threaded through chest directly to heart



●Common after open-heart surgery



●Temporary

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endocardial (transvenous) pacemaker


●Pulse generator implanted under skin/muscle



●Wires threaded through a large vein and lodged into the wall of the heart



●Permanent (pulse generator will be changed as needed)



●\*Some also function as a defibrillator

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  Implantable Cardioverter/Defibrillator (ICD):
o   CONTAINS AN INTERNAL GENERATOR TO DELIVER SHOCK IF NEEDED

§  For pt’s with ventricular dysrhythmias who are at risk of needing D-FIB

§  Ventricular Tachydysrhythmias

§  MI with left ventricular dysfunction

§  For pts who survive sudden cardiac death / ventricular dysrhythmias

§  Stronger shock – will feel like a blow to the chest
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pacemaker on demand
 pacemaker will deliver electricity when the HR falls below a predetermined rate
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fixed pacemaker
the pacemaker will deliver electricity at a fixed rate (less common)
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reasons to put a pacemaker in
§  Symptomatic bradycardia

§  Complete heart block

§  Sick sinus syndrome

§  Cardiac arrest

§  Atrial tachydysrhythmias
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pacemaker spikes
expected

\
§  shows when electricity is being sent to the heart
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pacemaker - ECG Monitoring For Malfunction - failure to sense
\
·      Doesn’t sense pt HR

·      Causes inappropriate/random firing
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pacemaker - ECG Monitoring For Malfunction - failure to capture
§  due to leads not connected appropriately

§  Electricity is not caught by the heart

§  Leads to bradycardia or asystole
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pacemaker - ECG Monitoring For Malfunction - failure to pace
§  battery issue

§  Pacemaker is not sending electricity
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Pacemaker Complications
o   Infection- Endocarditis

o   Hematoma Formation

o   Pneumothorax

o   Atrial Or Ventricular Septum Perforation

o   Lead Misplacement

o   Hiccups
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Pacemaker Complications - why do hiccups occur?
**§  Pacemaker is sitting low in the heart – near the diaphragm (tickling the diaphragm)**
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Pacemaker FACTS - pt education
\-Regular pacemaker function checks

\-Report any signs of infection at incision site

\-Keep incision dry for 4 days after implantation, or as ordered.

\- AVOID LIFTING arm on pacemaker side above shoulder until approved by cardiologist.

\-Avoid close proximity to high-output electric generators

\-Monitor pulse and tell your HCP if heart rate drops below predetermined rate.

\-Always wear a Medic Alert ID device

\-Always carry your pacemaker information card and a current list of drugs.
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Pacemaker MYTHS - pt education


Okay to resume boxing / bar fights

All pacemakers are MRI safe

Microwave ovens interfere with pacemaker function.

Travel is restricted
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Aneurysm definition
o   Weakness in a section of a dilated artery that causes a widening or balloon in the wall of the blood vessel
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aneurysm RF
o   Male

o   Atherosclerosis (most common cause)

o   Hypertension

o   Smoking

o   Hyperlipidemia

o   Genetics

o   Age (loss of elastin in artery walls causes stiffening/thickening, & progressive fibrosis; more prone to aneurysms & higher mortality rate), etc.
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aneurysm types
saccular

fusiform
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aneurysm types - saccular
affect only one side of the artery
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aneurysm types - fusiform
Affect the complete circumference of the artery
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aneurysm - recognizing cues for thoracic aortic aneurism
§  Severe back pain (most common)

§  Hoarseness

§  Cough

§  SOB

§  Difficulty swallowing

§  Decrease in urinary output d/t hypovolemic shock
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aneurysm - recognizing cues for __Abdominal Aortic Aneurism:__
§  Constant gnawing

§   abdominal pain

§  flank or back pain

§  pulsating abdominal mass (do not palpate)
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aneurysm - recognizing cues for __Iliac Aortic Dissection:__ (EMERGENCY)
§  Sudden tearing, ripping, stabbing abdominal or back pain

§  Hypovolemic shock

·      Decreased BP

·      Tachycardia
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__Aneurism Nursing Care: (PRIORITY)__
o   Assess ABC - circulation!!

o   Vitals Q15 min

o   Decrease SBP to 100 to 120mm Hg with b-blockers or CCB

o   Monitor UOP

o   Prepare for emergency surgery for rupturing aneurysm
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__Aneurism Complication: rupture__
§  Can result in massive hemorrhage, shock & death

§  Treatment is resuscitation & immediate surgical repair

§   Older clients with > 6 cm aneurysm & hypertension have greater risk of death
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__Aneurism Complication: thrombus__
§  Can form inside aneurysm, emboli can dislodge causing ischemia

§  Assess circulation distal to aneurysm (pulses, color, & temperature)
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__Aortic Aneurysm Repair__
o    Graft

§  Report graft rupture or occlusion:

·      Absent pulses, coolness of extremities, signs of hypovolemia (hypotension, decreased UOP)

§  Implement general post op nursing care – ex. turning, deep breathing, splinting