Aortic Dissection Nursing Diagnosis & Care Plans

Assessment Cues and Diagnostics:
Nursing assessment focuses on rapidly identifying signs of dissection. Watch for sudden, intense chest or upper back pain often described by the patient as tearing or ripping; the pain may radiate to the neck, jaw, or arms.

Check for differences in blood pressure between arms (a gap >20 mmHg is concerning) and compare pulses in all extremities. Note any neurological symptoms (weakness, vision changes) that may indicate branch vessel involvement. Observe for signs of shock or poor perfusion (hypotension, rapid pulse, cold clammy skin).

Definite diagnosis is confirmed by imaging. Nurses assist with obtaining a CT angiogram or transesophageal echocardiogram (TEE) to visualize the dissection. A chest X-ray may show a widened mediastinum. Baseline labs (cardiac enzymes, D-dimer) and continuous ECG monitoring help rule out myocardial infarction and guide treatment.

Pathophysiology (Brief):
An aortic dissection begins when high blood pressure or a weakened aortic wall causes an intimal tear, allowing blood to enter and split the middle layer (tunica media) of the aorta.

This creates a false lumen that can extend along the vessel. According to the Stanford system, Type A dissections involve the ascending aorta (often requiring emergency surgery), while Type B involve only the descending aorta (sometimes managed medically).

The dissection can obstruct branch arteries, causing organ ischemia (for example, stroke or kidney failure) if cerebral or renal arteries become involved.

Nursing Care Plans

Nursing Care Plan #1: Acute Pain

Nursing Diagnosis Statement: Acute pain related to aortic wall disruption and ischemia secondary to dissection, as evidenced by patient report of severe tearing chest/back pain and restlessness.

Related factors/causes:

Tearing of the aortic wall layers activates nociceptors.
Increased pressure on adjacent tissues and nerves.
Anxiety and sympathetic surge increasing heart rate and pain perception.

Nursing Interventions and Rationales:

Assess pain frequently using a standardized scale. Rationale: Establishes baseline and treatment effectiveness; worsening pain may signal progression.
Administer prescribed IV analgesics (e.g., opioids) promptly. Rationale: Adequate pain control decreases sympathetic activity, reducing heart rate and aortic stress.
Keep the patient still and in semi-Fowler’s position (head elevated). Rationale: Reduces arterial pressure on the aorta and prevents worsening of the dissection.
Provide a calm, quiet environment and reassure the patient. Rationale: Decreasing stress and anxiety helps lower blood pressure and pain perception.
Teach relaxation techniques (deep breathing) if possible. Rationale: Helps alleviate pain by relaxing muscles and decreasing anxiety.

Desired Outcomes:

Patient reports pain reduced to mild (≤ 3/10) and uses comfort measures.
Vital signs remain stable (heart rate and BP controlled) during pain episodes.
Patient remains as calm and motionless as possible, indicating effective pain management.

Nursing Care Plan #2: Decreased Cardiac Output

Nursing Diagnosis Statement: Decreased cardiac output related to impaired aortic blood flow secondary to dissection, as evidenced by hypotension, tachycardia, and cool, pale extremities.

Related factors/causes:

The dissection flap obstructs normal aortic flow and reduces preload.
Possible acute aortic valve regurgitation if the tear extends to the valve.
Increased myocardial workload as the heart compensates (high heart rate increases oxygen demand).

Nursing Interventions and Rationales:

Monitor blood pressure and heart rate continuously. Rationale: Detects rapid changes in hemodynamics; early intervention (adjusting medications) can prevent shock.
Administer IV beta-blockers (e.g., esmolol) or other antihypertensives as ordered. Rationale: Slowing heart rate and lowering BP decreases shear force on the aortic wall, improving cardiac output efficiency.
Maintain strict intake and output records. Rationale: Ensures adequate circulating volume and renal perfusion without fluid overload.
Position the patient in semi-Fowler’s. Rationale: Optimizes cardiac filling pressure while reducing workload on the heart.
Prepare for emergency interventions (IV fluids, vasopressors, or surgery) if the patient deteriorates. Rationale: Quick response can maintain perfusion and prevent organ failure.

Desired Outcomes:

Patient maintains BP in the target range (e.g., systolic ~100–120 mmHg) and heart rate within prescribed limits.
Strong peripheral pulses and warm extremities return, indicating improved perfusion.
Urine output remains ≥ 30 mL/hr, indicating adequate renal perfusion.

Nursing Care Plan #3: Risk for Ineffective Tissue Perfusion

Nursing Diagnosis Statement: Risk for ineffective tissue perfusion related to compromised aortic blood flow and thrombus risk secondary to dissection.

Related factors/causes:

Obstruction of branch vessels by the dissection flap or clot (e.g., carotid, mesenteric arteries).
Decreased cardiac output reduces the overall blood supply.
Hypotension exacerbates poor perfusion of organs and limbs.

Nursing Interventions and Rationales:

Perform frequent neurovascular checks on extremities (monitor color, temperature, pulses, capillary refill) every 1–2 hours. Rationale: Early detection of cold or pale extremities or delayed capillary refill indicates reduced perfusion.
Check urine output hourly and assess renal function markers. Rationale: Low output may indicate renal artery compromise; early intervention can prevent kidney damage.
Monitor neurologic status (orientation, speech, vision) regularly. Rationale: Changes could signal cerebral ischemia; prompt intervention can protect brain function.
Keep extremities at the level of the heart. Rationale: Promotes optimal arterial perfusion; excessive elevation or dependency can worsen blood flow issues.
Administer anticoagulation (e.g., IV heparin) as ordered and monitor for bleeding. Rationale: Helps prevent clot formation in the false lumen, reducing embolism risk while carefully watching for bleeding complications.

Desired Outcomes:

Peripheral pulses are equal and strong bilaterally; capillary refill < 3 seconds.
No new neurologic deficits develop; patient remains alert and oriented.
Urine output remains adequate (≥ 30 mL/hr), indicating sufficient renal perfusion.

Nursing Care Plan #4: Anxiety

Nursing Diagnosis Statement: Anxiety related to fear of death or disability and unfamiliar treatments secondary to aortic dissection, as evidenced by restlessness and expressed concerns.

Related factors/causes:

Sudden diagnosis of a life-threatening condition requiring emergency treatment.
Uncertainty about surgical outcomes and health status.
Physiological stress response from pain and potential complications.

Nursing Interventions and Rationales:

Provide simple, honest explanations about the condition and care plan. Rationale: Understanding reduces fear of the unknown and improves cooperation.
Encourage expression of feelings and allow questions. Rationale: Ventilating fears can relieve anxiety and helps the nurse address specific patient concerns.
Maintain a calm, reassuring approach and comfortable environment. Rationale: The nurse’s demeanor and a soothing setting can lower stress hormones.
Teach and coach deep breathing or relaxation exercises. Rationale: These techniques lower heart rate and blood pressure, counteracting anxiety.
Administer prescribed anti-anxiety medication if needed. Rationale: Medication may be necessary to control severe anxiety symptoms and stabilize vital signs.

Desired Outcomes:

Patient reports feeling calmer and demonstrates at least one relaxation technique.
Patient’s vital signs remain within normal limits while at rest.
Patient actively participates in care discussions, showing reduced fear and understanding.

Patient Education & Safety: (Exam-focused)
Educate the patient and family on the importance of strict blood pressure control after aortic dissection. Explain medication adherence (especially beta-blockers) and lifestyle changes (low-sodium diet, smoking cessation, stress reduction).

Demonstrate home blood pressure monitoring. Instruct on warning signs that require immediate attention (e.g., sudden chest/back pain, dizziness, limb weakness) and when to call 911. Emphasize the need for regular follow-up with cardiology and compliance with the treatment plan.

FAQ:

What is aortic dissection? Aortic dissection is a tear in the lining of the aorta that allows blood to split the vessel wall. It is a medical emergency that can cause organ damage or death if not treated immediately.
What are common nursing diagnoses for aortic dissection? Priority diagnoses include Acute Pain, Decreased Cardiac Output, Ineffective Tissue Perfusion, and Anxiety. Care plans address pain management, hemodynamic stability, tissue perfusion, and emotional support.
What are priority nursing interventions? Key interventions are pain relief (usually with IV opioids), tight blood pressure and heart rate control (with IV beta-blockers and vasodilators), continuous monitoring of vital signs and perfusion, and preparing for possible surgical intervention.
How is aortic dissection treated? Immediate treatment focuses on stabilizing the patient: IV antihypertensives (e.g., labetalol, nitroprusside) to lower blood pressure, aggressive pain control, and rapid consultation for surgical repair (especially for Type A dissection).

Peer-Reviewed References:

Carpenito, L. J. (2022). Handbook of Nursing Diagnosis (16th ed.). Wolters Kluwer.
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2021). Medical-Surgical Nursing (11th ed.). Elsevier.
Brunner, L. S., & Suddarth, D. S. (2018). Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer.
Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2021). Fundamentals of Nursing (10th ed.). Elsevier.
Isselbacher, E. M., Preventza, O., Hamilton Black, J., Augoustides, J. G., Beck, A. W., Bolen, M. A., et al. (2022). 2022 ACC/AHA guideline for the diagnosis and management of aortic disease. Circulation, 146(e334–e482).