Aortic Dissection Nursing Diagnosis Interventions and Care Plans

Aortic Dissection NCLEX Review Care Plans

Nursing Study Guide on Aortic Dissection

An aortic dissection is a serious condition caused by tearing of the inner layer of the aorta, the largest artery branching off the heart.

The gushing of the blood through the tear causes the inner and middle layers of the aorta to break apart.

This condition can lead to death if the dissection ruptures outside the aortic wall.

However, early detection and management of this disorder increases the chance of survival.

Its symptoms can be similar to other cardiac conditions like stroke, which can lead to delay in performing the appropriate treatment.

Although it is uncommon, it is most likely to be seen in men in their 60s and 70s.

Signs and Symptoms of Aortic Dissection

  • Sudden severe chest or upper back pain, often described as a tearing, ripping or shearing sensation, radiating to the neck and lower back
  • Sudden severe abdominal pain
  • Loss of consciousness
  • Breathing difficulties
  • Stroke-like symptoms such as sudden difficulty in speaking, loss of vision, weakness or paralysis of one side of the body
  • Weaker pulse in one arm or thigh
  • Leg pain and paralysis
  • Difficulty walking

Causes and Risk Factors of Aortic Dissection

When there is constant stress and pressure in the aorta due to certain conditions, this will increase the force of blood throughout the system leading to the separation of the inner and middle layers of the aorta.

If it involves the ascending aorta, it is classified as Type A, the most common and dangerous type.

If it involves the descending aorta which extends into the abdomen, it is classified as Type B aortic dissection.

Aortic dissection happens when there is weakness in the aortic wall.

It is rarely caused by traumatic injuries but conditions such as having chronic high blood pressure, atherosclerosis, aortic valve defect, aortic aneurysm, can increase the likelihood of tearing due to the constant stress on the aortic tissue.

Genetic disorders like Marfan syndrome, a disease that poses damage to the aorta, Turner’s syndrome, and other rare conditions related to weakened or enlarged aorta can increase susceptibility to aortic dissection.

Complications of Aortic Dissection

If the aortic dissection progresses, the blood leak can block different arteries of the body which can cause:

  • Aortic valve damage such as aortic regurgitation (inability of the heart valves to close properly) and cardiac tamponade (accumulation of blood or fluid in the pericardial space)
  • Heart Attack – due to the blockage of coronary arteries
  • Organ damage
  • Life threatening damage to the intestines
  • Respiratory Failure and other lung infections
  • Kidney failure – due to the blockage of renal arteries
  • Severe internal bleeding
  • Stroke- due to the blockage of cerebral arteries
  • Nerve and or spinal cord damage – due to the blockage of spinal arteries
  • Paralysis
  • Death

Diagnosis of Aortic Dissection

1. Physical Examination – includes review of medical history and assessment of vital signs including the blood pressure on both arms.

2. Imaging tests such as:

  • Chest Xray – to check for widening of the aorta
  • Transesophageal echocardiogram (TEE) -a special type of echocardiogram
  • that uses an ultrasound probe to see the heart clearly
  • Computerized tomography (CT) scan-provides a cross section view
  • Magnetic resonance angiogram (MRA)

Treatment of Aortic Dissection

An aortic dissection is considered as a medical emergency that requires an immediate intervention. Treatment includes medication therapy and surgery, which depends on what area of the aorta is affected.

  1. Anti-hypertensive drugs such as beta blockers. These are given to control the blood pressure and lower the heart rate. These are prescribed for both Type A and Type B aortic dissection to stabilize the blood pressure prior to surgery. Once blood pressure is controlled, surgery is facilitated.
  2. Surgery. Surgical intervention for type A aortic dissection includes removal of the dissected aorta followed by closure of the torn aortic wall, after which a graft is used to reconstruct the area. In case a leak is noted in the aortic valve, replacement is necessary. However, if the affected area is the descending aorta (Type B) an endovascular stent graft is used. This involves the insertion of a small wire through the damaged part of the aorta, acting as a scaffolding. This is less invasive as compared to the removal of aortic dissection. Medication therapy is maintained after surgical procedure. Even if there is no indication for surgery, doctors still advise to continue drug therapy to prevent symptoms from aggravating. Regular imaging studies is also done to evaluate the effectiveness of treatment.

Prevention of Aortic Dissection

1. Engaging in a healthy lifestyle, including having a healthy diet, exercising regularly and cessation of smoking habits

2. Good blood pressure control
3. Use of seat belt to prevent trauma to chest area

4. Regular doctors visit, especially for those who are high risk and those who have family history of aortic dissection or stroke

Nursing Care Plans for Aortic Dissection

Nursing Care Plan 1

Decreased cardiac output secondary to progressive dissection of the aorta as evidenced by sudden and severe chest pain, difficulty of breathing, high blood pressure level of 170/89, and fatigue

Desired outcome: The patient will be able to maintain adequate cardiac output.

InterventionsRationale
Assess the patient’s vital signs and characteristics of heartbeat at least every 4 hours. Assess heart sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment.  The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.
Administer prescribed medications for aortic dissection.  Beta blockers – to decrease the cardiac demand for oxygen by means of lowering the heart rate and blood pressure levels
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value of at least 96%.
Educate patient on stress management, deep breathing exercises, and relaxation techniques.Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. Chronic stress may also cause an increase in adrenaline levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels. Reducing stress is also an important aspect of dealing with fatigue.

Nursing Care Plan 2

Nursing Diagnosis: Acute Pain related to decreased myocardial blood flow secondary to aortic dissection, as evidenced by  pain score of 10 out of 10, verbalization of sudden and severe chest pain, difficulty of breathing, respiratory rate of 29 breaths per minute, and restlessness

Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.

InterventionsRationale
Administer prescribed medications that alleviate the symptoms of chest pain.Aspirin may be given to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries. Nitrates may be given to relax the blood vessels. Other medications that help treat chest pain include anti-cholesterol drugs (e.g. statins), beta blockers, calcium channel blockers, and Ranolazine, if not contraindicated.
Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.  To monitor effectiveness of medical treatment for the relief of chest pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.  
Elevate the head of the bed if the patient is short of breath. Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value of at least 96%.
Place the patient in complete bed rest during chest pain attacks. Educate patient on stress management, deep breathing exercises, and relaxation techniques.Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. The effects of stress are likely to increase myocardial workload.

Nursing Care Plan 3

Nursing Diagnosis: Fatigue related to post surgical removal of aortic dissection, as evidenced by verbalization of lack of energy, verbalization of tiredness, and generalized weakness

Desired Outcome: Post surgery, the patient will verbalize improved energy levels and will demonstrate active participation in necessary and desired activities.

InterventionsRationales
Ask the patient to rate fatigue level (mild, moderate, or severe fatigue).     Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.To gradually increase the patient’s tolerance to physical activity. Sedentary lifestyle is a risk factor to develop aortic dissection related to chest pain.
Encourage the patient to follow a low cholesterol, high caloric diet. Refer to the dietitian as needed.To increase energy levels while promoting a lower risk for chest pain and aortic dissection.
Teach deep breathing exercises and relaxation techniques.   Provide adequate ventilation in the room.To allow the patient to relax while at rest. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity.

Other nursing diagnoses:

  • Powerlessness
  • Deficient Knowledge
  • Anxiety

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures. 

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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