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MED SURG III
Exam #2 - Aneurysms & DIC
| Question | Answer |
|---|---|
| Disseminated Intravascular Coagulation (DIC) Pathophysiology | Systemic Syndrome that is characterized by micro thromboses and bleeding. Can be precipitated by sepsis, trauma, cancer, shock, abruptio placentae, allergic reactions, and other conditions. |
| Assessment of DIC | Progressive decrease in platelet counts. Signs of thrombosis in the organs involved. Followed by bleeding, starting as subtle and followed by frank hemorrhage. |
| Signs & Symptoms of DIC | Bleeding on multiple sites. Uncontrolled bleeding from puncture sites from injections or IV therapy. Blood Clots, Ecchymoses and Petechiae. Drop in BP. Sudden Bruising. Toes & fingers are pale, cyanotic or mottled and feel cold |
| Lab Results in DIC | Thrombocytopenia. Large Platelets on Blood Smear. Prolonged Prothrombin and Partial Thromboplastin Times. Markedly Low Serum Fibrinogen Levels. Elevated Fibrin Splits |
| Risk Factors for DIC | Cancer (especially leukemia), placental abruption, pre-eclampsia, amniotic fluid embolism, trauma and burns, extensive surgery. Infection in the blood, severe liver disease |
| Medical Management of DIC | IV administration of heparin. Blood transfusion for blood loss. Treating underlying cause |
| Anticoagulants (Heparin) in DIC | Given to prevent formation of new clots, and extension of existing clots |
| Thrombolytics (Alteplase, tPA) in DIC | Dissolve thrombi and limit tissue damage in selected thromboembolic disorders |
| BLACK BOX WARNING for Protamine Sulfate | Risk of severe hypotension, cardiovascular collapse, noncardiogenic pulmonary edema, catastrophic pulmonary vasoconstriction, and pulmonary hypertension |
| Cardiac Tamponade | Increased pressure in the pericardial sac (pericardial effusion) that compromises the hearts ability to fill and pump. Resulting in reduction of stroke volume, epicardial coronary artery compression with resultant myocardial ischemia. |
| Pericardial Effusion | Excessive fluid in the pericardial sac |
| Risk Factors for Cardiac Tamponade | Trauma, Punctures, Cancer & Cancer Treatments, Autoimmune Disorders, Hypothyroidism, Pericarditis, Ruptured Aortic Aneurysm, MI, Infections, Kidney Failure, Gunshot or Stab Wounds, Blunt Impact (motor vehicle accidents), Cardiac Surgery, Iatrogenic Causes (cardiac cath or pacemaker electrode perforation) |
| NORMAL fluid level in the pericardial sac | 20 mL |
| ABNORMAL fluid level in the pericardial sac in pleural effusion & cardiac tamponade | 1-2 L |
| Symptoms of Cardiac Tamponade | Dyspnea, Tachypnea, Hypotension, Paradoxical Pulse, Chest Pain, Tachycardia, JVD, Pericardial Compression. Restlessness, Agitation, Confusion, Weakness, Anorexia, Poor Tissue Perfusion, Muffled, Distant Heart Sounds. Cool, Pale Skin |
| Pulsus Paradoxus (Paradoxical Pulse) | A systolic BP that is markedly lower during inhalation. - An abnormal difference of at least 10 mm Hg in systolic pressure between the point it is heard during exhalation and the point heard during inhalation. |
| Echocardiogram in Cardiac Tamponade | Performed to confirm the diagnosis and quantify the amount of fluid in the pericardial sac |
| Chest X-Ray in Cardiac Tamponade | May show enlarged cardiac silhouette due to pericardial effusion |
| ECG in Cardiac Tamponade | Shows tachycardia, and may also show low voltage |
| Pericardiocentesis | Used when cardiac function is seriously impaired. It is the puncture of the pericardial sac to aspiration the fluid in cardiac tamponade & pericardial effusion |
| Pericardiotomy | Used for the treatment of recurrent pericardial effusions, usually associated with neoplastic disease. A portion of the pericardium is excised to permit the exudative pericardial fluid to drain into the lymphatic system in pericardial effusion and cardiac tamponade |
| Nursing Interventions in Cardiac Tamponade & Pericardial Effusion | Oxygen, 2 large-bore IV lines, medication administration, monitoring for dysrhythmias, coronary artery lacerations. |
| Thoracic Aortic Aneurysms | Caused by atherosclerosis. Most common in men between 50-70 years. Is the most common site for dissecting aneurysms |
| Thoracic Aortic Aneurysm Symptoms | Depend on how rapidly the aneurysm dilates and how the pulsating mass affects the intrathoracic structures. Some are asymptomatic. MOST CASES pain is the most prominent symptoms (occurring mainly when supine). Other symptoms include dyspnea, cough often in brassy quality, hoarseness, stridor, or vocal weakness or aphonia (complete loss of voice), dysphasia |
| Thoracic Aortic Aneurysm Assessment Findings | JVD, Edematous Areas on the Chest Wall & Cyanosis. Unequal Pupils from Pressure against cervical sympathetic chain |
| Thoracic Aortic Aneurysm Diagnostics | Chest X-Ray, CTA, MRA, TEE |
| Abdominal Aortic Aneurysm | Often caused by atherosclerosis. More common in MEN (more white men than black men). Most occur below the renal arteries. |
| Risk Factors for Abdominal Aortic Aneurysm | Genetics, Nicotine, Hypertension |
| Symptoms of Abdominal Aortic Aneurysm | Feeling heart beating when lying down. Feel an abdominal mass or abdominal throbbing. Cyanosis and mottling of toes |
| Signs of an Impending Rupture in an Abdominal Aortic Aneurysm | SEVERE back or abdominal pain (persistent or intermittent). Abdominal pain localized in the middle or lower abdomen, to the left of midline. |
| Signs of RUPTURE in an Abdominal Aortic Aneurysm | Constant, Intense Back Pain. Falling BP, Decreased Hematocrit |
| Abdominal Aortic Aneurysm Diagnostics & Assessment Findings | PULSATILE MASS IN THE MIDDLE AND UPPER ABDOMEN. Systolic Bruit may be heard over the mass. DUPLEX ULTRASONOGRAPHY OR CTA is used to determine the size, length, and location of the aneurysm |
| Aortic Dissection | Diseased by arteriosclerosis. Tear develops in the intima or media degenerates, resulting in dissection. Most commonly associated with poorly controlled hypertension, blunt chest trauma, and cocaine use. |
| Symptoms of an Aortic Dissection | Onset of symptoms is usually sudden. Severe and persistent pain described as tearing or ripping. Pain often is in the anterior chest or back and extends to the shoulders, epigastric area, or abdomen. Patient may appear pale. Sweating, tachycardia. BP may be elevated, or markedly different from one arm to the other |
| Assessment & Diagnostic Findings in an Aortic Dissection | Arteriography. Multidetector-computed Tomography Angiography (MDCTA). TEE. Duplex Ultrasonography. MRA |
| Treatment of an Aortic Aneurysm | Depends on the size (diameter) of the aneurysm. Low risk (less than 4 cm) does not require surgery. High risk = ENDOVASCULAR ANEURYSM REPAIR (EVAR) |
| Nursing Manage of an Endovascular Graft Repair (AAA) | Assessment every 15 minutes for the first hour. Then every 30 minutes for 4 hours. Then every hour. Monitor LOC, Pupillary Response, Facial Asymmetry, Tongue Position, Speech, Neurovascular Status, Vital Signs, Lab Values. |
| Postoperative Care of Endovascular Graft Repairs (AAA) | MUST BE SUPINE FOR ABOUT 6 HOURS. ---- BED REST until cleared by surgeon. -- MONITOR FOR POST IMPLANTATION SYNDROME which typically occurs within 24 hours Leukocytosis, Spontaneous Fever, Transient Thrombocytopenia) |
| Thoracic Aneurysm Medications | Beta-Blockers & Angiotensin Receptor Blockers (ARBs) to decrease BP or provide aortic dilation. IV vasodilators are administered in emergent situations |
| Abdominal Aneurysm Medications | Often managed with single or multiple antihypertensive agents including diuretics, beta-blockers, ACE inhibitors, ARBs, and CCBs. |
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