Aortic Dissection Nursing Diagnosis & Care Plan

Aortic dissection is a life-threatening condition characterized by a tear in the inner layer of the aorta, allowing blood to flow between the layers of the aortic wall, forcing the layers apart.

This nursing diagnosis requires immediate attention and care as it can lead to aortic rupture, organ ischemia, or cardiac tamponade if left untreated.

Causes (Related to)

Aortic dissection can result from various factors that weaken the aortic wall or increase stress on the aorta. Common causes include:

• Hypertension (chronic or acute)
• Genetic disorders affecting connective tissue (Marfan syndrome)
• Atherosclerosis
• Trauma (car accidents, falls)
• Pregnancy (especially in the third trimester)
• Cocaine use
• Weightlifting or other strenuous activities
• Pre-existing aortic aneurysm
• Bicuspid aortic valve
• Inflammatory diseases affecting blood vessels

Signs and Symptoms (As evidenced by)

Aortic dissection can manifest with a variety of signs and symptoms. In a physical assessment, a patient with aortic dissection may present with one or more of the following:

Subjective: (Patient reports)

• Sudden, severe chest or upper back pain, often described as tearing or ripping.
• Pain that radiates to the neck, jaw, or arms
• Shortness of breath
• Difficulty speaking or swallowing
• Weakness or paralysis on one side of the body

Objective: (Nurse assesses)

• Differences in blood pressure between arms (>20 mmHg)
• Weak or absent pulses in extremities
• Signs of shock (pale, cool, clammy skin)
• Neurological deficits (altered mental status, unequal pupils)
• Heart murmur
• Syncope or near-syncope
• Abnormal chest X-ray findings (widened mediastinum)
• Elevated cardiac enzymes (troponin)

Expected Outcomes

The following are the common nursing care planning goals and expected outcomes for aortic dissection:

• The patient will maintain stable vital signs within normal limits
• The patient will report decreased pain levels
• The patient will demonstrate improved tissue perfusion
• The patient will show no signs of complications (e.g., stroke, organ ischemia)
• The patient will verbalize understanding of the condition and treatment plan
• The patient will adhere to the prescribed medication regimen and lifestyle modifications

Nursing Assessment

The nursing assessment for aortic dissection is crucial for early detection and prompt intervention. Here are steps in the assessment process:

1. Obtain a thorough medical history
   Focus on risk factors such as hypertension, connective tissue disorders, and recent trauma.
2. Perform a comprehensive physical examination.
   Pay close attention to vital signs, pulse quality, symmetry, and neurological status.
3. Auscultate heart and lung sounds
   Listen for murmurs, rubs, or abnormal breath sounds that may indicate complications.
4. Assess pain characteristics
   Evaluate pain’s location, intensity, duration, and quality using a standardized scale.
5. Monitor blood pressure in both arms
   A difference of >20 mmHg between arms may indicate aortic dissection.
6. Evaluate peripheral pulses
   Check for symmetry and strength in all extremities.
7. Perform neurological assessment
   Look for signs of stroke or spinal cord ischemia.
8. Review diagnostic test results
   Analyze ECG, chest X-ray, CT angiography, and blood work findings.
9. Assess for signs of organ ischemia
   Monitor for signs of renal, mesenteric, or limb ischemia.
10. Evaluate the patient’s understanding of the condition.
    Assess the patient’s and family’s knowledge about aortic dissection and its management.

Nursing Interventions

Nursing interventions for aortic dissection focus on stabilizing the patient, managing symptoms, and preventing complications. Here are the interventions:

1. Maintain bed rest with the head of the bed elevated
   Reduces stress on the aorta and helps manage blood pressure.
2. Administer medications as prescribed.
   This may include beta-blockers, calcium channel blockers, or vasodilators to control blood pressure and heart rate.
3. Provide oxygen therapy as needed
   Ensures adequate oxygenation and reduces cardiac workload.
4. Monitor vital signs frequently
   It helps detect changes in condition and evaluate treatment effectiveness.
5. Perform frequent neurovascular checks
   Assesses for signs of organ or limb ischemia.
6. Manage pain
   Administer analgesics as ordered and use non-pharmacological pain management techniques.
7. Prepare for possible surgical intervention.
   Educate the patient about surgical procedures and assist with preoperative preparation if needed.
8. Provide emotional support
   Help the patient and family cope with the stress of the diagnosis and treatment.
9. Educate about lifestyle modifications.
   Teach about blood pressure control, smoking cessation, and avoiding strenuous activities.
10. Coordinate care with the healthcare team.
    Collaborate with physicians, surgeons, and other specialists for optimal patient outcomes.

Nursing Care Plans

Here are five nursing care plans for aortic dissection:

Care Plan 1: Acute Pain

Nursing Diagnosis: Acute Pain related to tissue damage and altered perfusion secondary to aortic dissection as evidenced by patient reporting severe chest pain rated 9/10 and facial grimacing.

Related factors/causes:

• Tissue damage from aortic wall dissection
• Altered blood flow to organs and tissues
• Pressure on surrounding structures

Nursing Interventions and Rationales:

1. Assess pain characteristics regularly using a standardized pain scale.
   Rationale: Provides a baseline for pain management effectiveness and helps detect changes in condition.
2. Administer prescribed analgesics and monitor their effectiveness.
   Rationale: Proper pain management reduces stress on the cardiovascular system and improves patient comfort.
3. Position the patient with the head of the bed elevated at 30-45 degrees.
   Rationale: This position helps reduce aortic wall stress and may alleviate pain.
4. Provide a calm, quiet environment and minimize unnecessary stimuli.
   Rationale: Reduces external stressors that may exacerbate pain and anxiety.
5. Teach and encourage relaxation techniques such as deep breathing.
   Rationale: Non-pharmacological interventions can complement medication in pain management.

Desired Outcomes:

• The patient will report pain level reduced to 3/10 or less within 2 hours of intervention.
• The patient will demonstrate the use of non-pharmacological pain management techniques.
• The patient will maintain stable vital signs during pain episodes.

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Care Plan 2: Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to altered myocardial perfusion secondary to aortic dissection as evidenced by tachycardia (HR 110 bpm), hypotension (BP 90/60 mmHg), and cool, pale extremities.

Related factors/causes:

• Compromised blood flow through the aorta
• Possible aortic valve insufficiency
• Myocardial ischemia due to coronary artery involvement

Nursing Interventions and Rationales:

1. Monitor vital signs, including blood pressure in both arms, every 15 minutes or as ordered.
   Rationale: Frequent monitoring helps detect changes in cardiac output and perfusion status.
2. Administer prescribed medications (e.g., beta-blockers, vasodilators) as ordered.
   Rationale: These medications help control blood pressure and heart rate, reducing stress on the aorta.
3. Maintain strict intake and output records.
   Rationale: Helps assess fluid balance and renal perfusion.
4. Position the patient in a comfortable, semi-Fowler’s position.
   Rationale: This position optimizes cardiac output and reduces the workload on the heart.
5. Prepare for possible emergency interventions (e.g., intubation, cardiac tamponade treatment).
   Rationale: Rapid response to complications can be life-saving in aortic dissection.

Desired Outcomes:

• The patient will maintain blood pressure within the target range (typically systolic BP between 100-120 mmHg).
• The patient will demonstrate improved peripheral perfusion with warm extremities and capillary refill <3 seconds.
• The patient will maintain urine output >30 mL/hour.

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Care Plan 3: Risk for Ineffective Peripheral Tissue Perfusion

Nursing Diagnosis: Risk for Ineffective Peripheral Tissue Perfusion related to altered blood flow secondary to aortic dissection.

Related factors/causes:

• Obstruction of branch vessels by the dissection
• Reduced cardiac output
• Potential for thrombus formation

Nursing Interventions and Rationales:

1. Assess peripheral pulses and capillary refill in all extremities every 2 hours.
   Rationale: Early detection of changes in peripheral perfusion allows for prompt intervention.
2. Monitor skin temperature, color, and sensation in extremities.
   Rationale: Changes in these parameters may indicate worsening tissue perfusion.
3. Encourage a passive range of motion exercises for bedridden patients.
   Rationale: Promotes circulation and prevents complications of immobility.
4. Elevate extremities slightly if not contraindicated.
   Rationale: It may improve venous return and reduce edema.
5. Administer anticoagulants as prescribed and monitor for bleeding.
   Rationale: Prevents thrombus formation while balancing the risk of bleeding.

Desired Outcomes:

• The patient will maintain palpable peripheral pulses of equal strength bilaterally.
• The patient will demonstrate capillary refill <3 seconds in all extremities.
• The patient will report no numbness, tingling, or coldness in extremities.

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Care Plan 4: Anxiety

Nursing Diagnosis: Anxiety related to acute life-threatening condition and uncertain prognosis secondary to aortic dissection as evidenced by expressed feelings of fear, restlessness, and increased heart rate.

Related factors/causes:

• Sudden onset of severe symptoms
• Fear of death or disability
• Lack of knowledge about the condition and its treatment

Nursing Interventions and Rationales:

1. Provide clear, concise information about the condition and treatment plan.
   Rationale: Knowledge can help reduce fear of the unknown and promote a sense of control.
2. Encourage the patient to express feelings and concerns.
   Rationale: Verbalization can help reduce anxiety and allow for addressing specific fears.
3. Maintain a calm and reassuring demeanor when interacting with the patient.
   Rationale: The nurse’s composure can help alleviate patient anxiety.
4. Teach and encourage the use of relaxation techniques such as deep breathing or guided imagery.
   Rationale: These techniques can help reduce anxiety and promote a sense of calm.
5. Administer anti-anxiety medications as prescribed.
   Rationale: Pharmacological intervention may be necessary to manage severe anxiety.

Desired Outcomes:

• The patient will verbalize decreased feelings of anxiety within 4 hours of interventions.
• The patient will demonstrate the use of at least one relaxation technique.
• The patient will maintain heart rate and blood pressure within target ranges.

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Care Plan 5: Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with aortic dissection and its management, as evidenced by the patient asking multiple questions and expressing uncertainty about future lifestyle changes.

Related factors/causes:

• Lack of exposure to information about aortic dissection
• The complexity of the condition and its treatment
• Stress and anxiety interfering with information retention

Nursing Interventions and Rationales:

1. Assess the patient’s current understanding of aortic dissection and its treatment.
   Rationale: Provides a baseline for education and helps identify specific knowledge gaps.
2. Provide education about aortic dissection, its causes, symptoms, and treatment options.
   Rationale: Increases the patient’s understanding of their condition and promotes informed decision-making.
3. Explain the importance of blood pressure control and medication adherence.
   Rationale: Emphasizes key aspects of long-term management to prevent complications.
4. Teach about lifestyle modifications (e.g., smoking cessation, stress management, diet).
   Rationale: Empower the patient to take an active role in their health management.
5. Provide written materials and recommend reliable resources for further information.
   Rationale: Reinforces verbal education and allows for later review.

Desired Outcomes:

• The patient will verbalize an understanding of aortic dissection and its management by the end of the educational session.
• The patient will correctly explain the purpose and side effects of prescribed medications.
• The patient will demonstrate the ability to monitor blood pressure and recognize warning signs requiring medical attention.

References

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3. Goldfinger, J. Z., Halperin, J. L., Marin, M. L., Stewart, A. S., Eagle, K. A., & Fuster, V. (2014). Thoracic aortic aneurysm and dissection. Journal of the American College of Cardiology, 64(16), 1725-1739.
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8. Zhan, S., Hong, J., Ding, Q., Wang, J., Zhang, X., Wu, B., & Han, Q. F. (2019). Risk factors for hospital mortality in patients with acute aortic dissection: A meta-analysis. Journal of Cardiovascular Nursing, 34(3), 219-227.