MYOCARDIAL INFARCTION

LEARNING OBJECTIVES
At the end of the day the discussion, the students will be able to: a. Identify myocardial infarction b. Understand the etiology of MI c. Describe the sign and symptoms of MI d. Comprehend various nursing interventions and its stages. e. Explain nursing management f. List the medications use for MI g. Discuss nursing process h. Know the complications of MI

DEFINITION
Process by which myocardium tissue is destroyed due to reduced coronary blood flow and lack of oxygen; actual necrosis of heart muscle occurs.

ETIOLOGY
1. Insufficient myocardial blood supply is associated with a. Atherosclerosis b. Arteriosclerosis c. Vasospasm d. Myocardial hypertrophy e. Severe anemias f. Respiratory disease (oxygen deficit) g. Hyperthyroidism (increase force of contractions)

MANIFESTATIONS
A. CHEST PAIN 1. Heavy (viselike, crushing, squeezing) chest pain that may radiate down left arm, hand, jaw and neck. 2. Not relieved by rest often lasts longer than 15 minutes. 3. Women have a slightly different presentation: back pain, indigestion with nausea, cold sweating, weakness, pallor.

B. Nausea, vomiting due to stress reaction C. Diaphoresis, dizziness due to sympathetic reaction D. Drop in blood pressure E. ECG changes: inverted T wave and depressed ST segment indicate ischemic changes, elevated S segment and widened QRS indicate infarction F. Denial/anxiety G. Increased Troponin I and T, MB-CPK, LDH isoenzymes: done in serials of three to see trends.

NORMAL ECG

NURSING INTERVENTIONS

a. EARLY STAGE
1. Treat dysrhythmia properly: antiarrhythmics such as lidocaine (xylocaine) 2. Give analgesics: morphine

3. Maintain bed rest: Semi-Fowlers position to decrease venous return and rest myocardium. 4. Administer oxygen via cannula 5. Monitor vital signs 6. Administer aspirin and heparin to decrease thrombosis. 7. Administer propranolol HCL (Inderal): decreases heart rate and decreases work of myocardium.

8. Administer calcium channel blockers: decrease after load: vasodilators: increases oxygen to myocardium; decreases preload and after load 9. Provide emotional support 10. Administer streptokinase (kabikinase) or TPA (clot busters): if client arrives within first 6 hours; major side effect is bleeding.

LATE
1. Administer stool softeners to decrease myocardial workload. 2. Provide low-fat, low cholesterol, lowsodium diet, soft food. 3. Utilize bedside commode: cause less energy expenditure than using a bedpan. 4. Promote self-care to tolerance; stop at the onset of pain.

5. Plan for cardiac rehabilitation a. Exercise program: stop if fatigue or chest pain occurs b. Stress management c. Teach modifiable risk factors reduction 1. Obesity 2. Stress 3. Diet 4. Hypertension 5. Smoking 6. Lack of exercise

d. e. f. 1. 2.

Recognize non modifiable risk factors Heredity Race Age Sex Type A personality Psychological support Long-term drug therapy Antiarrhythmics: quinidine Anticoagulants: heparin, aspirin, warfarin (Coumadin), enoxaparin (Lovenox)

3. Antihypertensives: propranolol (Inderal), chlorothiazide (Diuril), and calcium channel blockers 4. Vasodilators nitroglycerin (nitro-bid) calcium channel blockers.

ASPIRIN
known as acetylsalicylic acid analgesic to relieve minor aches and pains, antipyretic to reduce fever, anti to help prevent heart attacks, strokes, and blood clot formation in people at high risk for developing blood clots. inflammatory medication.

NURSING MANAGEMENT
Pain management Morphine 5-10 mg Other medication- nitroglycerin, antiplatelet & thrombolytic Keep patient CRIB Monitor urine output. Relieve nausea and vomiting Stemetil 12.5 mg I/V Soft diet Avoid constipation give laxative Encourage light activities

HEPARIN
an anticoagulant (blood thinner) that prevents the formation of blood clots. It works by blocking reactions in the body that lead to blood clots. Do not use this medication if you are allergic to heparin, or if you have:

a. a severe lack of platelets in your blood; or

b. uncontrolled bleeding.

Calcium channel blockers

prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls.
1. 2. 3. 4. 5. 6. 7. 8. Examples of calcium channel blockers include: Amlodipine (Norvasc) Diltiazem (Cardizem LA, Dilacor XR, Tiazac) Felodipine (Plendil) Isradipine (DynaCirc CR) Nicardipine (Cardene, Cardene SR) Nifedipine (Procardia, Procardia XL, Adalat CC) Nisoldipine (Sular) Verapamil (Calan Verelan, Covera-HS)

THROMBOSIS
is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system.

NURSING DIAGNOSIS
Pain: chest pain/discomfort related to decreased coronary blood supply
Risk for decreased cardiac output Activity intolerance R/T fatigue/ shortness of breath Fear/Anxiety R/T hospitalization

Knowledge deficit regarding disease condition & treatment

Nursing process
1 Chest pain related to reduced coronary blood flow. Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus. Assess and record chest pain location, type, severity, aggravation/alleviation factors, duration, onset.

CONT
Obtain 12 lead ECG on admission & each time chest pain recurs Give pain relief medication Administer nitrates Inform physician about the pain & record patients response to medication. Give

oxygen therapy as ordered.

CRIB RIB gradually increase the level of physical activities as tolerated. Plan activities according to patients tolerance. Allow rest during and between activities. Discuss with patient about alternative therapy to relief pain such as music therapy, meditation. Educate patient on chest pain: To report any chest pain to the nurse.

2 Risk for decreased cardiac output

Assess pt level of consciousness/mental alertness Monitor vital sign-look for sign of hypotension Monitor urine output Monitor for pallor, sweating, cyanosis-sign of peripheral hypo perfusion Assess the effect of medication Monitor ABG

3 Activity intolerance related to fatigue / shortness of breath

Assess and record patients level of tolerance to activities of daily living. Encourage patient to verbalize activities that increase fatigue or shortness of breath. Provide rest period between and during activities Keep frequently used items within reach of patient. Give encouragement and promotes independence in activities within patients limit. Assist patient in activities of daily living.

MI -Complications
Heart failure when heart muscles dies, the ability
of heart to pump blood diminishes

Ventricular Fibrillations-due to injury to heart

Death Cardiogenic shock Recurrent MI

muscle, the electrical activity of the heart become chaotic

 Stress management Avoid strenuous activity, but can encourage mild exercises Advise patient on sign and symptom of recurrent MI Advise on medication and its side effect

Health education
Reduce weight

Low salt, cholesterol diet, avoid heavy meal Stop smoking Avoid alcohol

ANGINA PECTORIS

OBJECTIVES
At the end of this the students will be able to a. Define angina pectoris b. Understand the causes of angina pectoris c. Explain the precipitating cause d. Knowledgeable on the patterns of angina e. Know the sign and symptoms of angina pectoris f. Understand the different diagnostic procedure for angina pectoris g. Explain the rational on nursing interventions

ANGINA PECTORIS
Is a chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply. Caused by an imbalance between oxygen supply and demand. Causes include: a. Obstruction of coronary blood flow because of atherosclerosis b. Coronary artery spasm c. Conditions increasing myocardial oxygen consumption

1. ATHEROSCLEROSIS
Atherosclerosis (ath-er-o-skler-Osis) is a disease in which plaque (plak) builds up inside your arteries. Fatty deposits, called "Atheromas" or plaques, damage the lining of arteries causing them to narrow and harden.

 Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Plaque hardens and narrows your arteries, limiting the flow of oxygen-rich blood to your organs and other parts of your body. This can lead to serious problems, including heart attack, stroke, or even death

2. CORONARY SPASM

ETIOLOGY
1.

Exposure to cold

2.

Increased physical exertion

Vasoconstriction

Increased Blood pressure

Oxygen demand

Increased oxygen demand

Chest pain

Chest pain

Stress full event (death of family, break up of relationship)

Release of adrenaline

Increased blood pressure

Increase cardiac workload

Increase oxygen demand

Chest pain

Eating heavy meal

Increased blood flow to the mesenteric area for digestion Reduced blood flow to heart muscle

Chest pain

Goal of treatment:
To provide relief of an acute attack. Correct the imbalance between myocardial oxygen supply and demand

Prevent progression of the disease and

further attacks to reduce the risk of MI.

PRECIPITATION FACTORS CAUSE ANGINA

1. 2. 3. 4. Running upstairs, Getting angry Respiratory infection with fever Exposure to cold weather or eating a large meal.

PATTERNS OF ANGINA

1. STABLE ANGINA
a. Also called exertional angina. b. Occurs with activities that involve exertion or emotional stress and is relieved with rest or nitroglycerin. c. Usually has a stable pattern of onset, duration, severity and relieving factors.

2. UNSTABLE ANGINA
a. Also called preinfarction angina. b. Occurs with an unpredictable degree of exertion or emotion and increases in occurrence, duration, and severity over time. c. Pain may not be relieved by rest/nitroglycerin.

3. VARIANT ANGINA
a. Also called PRINZMETALS or vasospastic angina. b. Chest pain at rest with ECG changes due to coronary artery spasm c. Attacks may be associated with ST segment elevation noted on the electrocardiogram.

ASSESSMENT

1. PAIN
a. Pain can develop slowly or quickly. b. Pain usually is described as mild or moderate. c. Substernal, crushing, squeezing pain may occur. d. Pain may radiate to the shoulders, arms, jaw, neck and back. e. Pain usually last less than 5 minutes, however, pain can last up to 15-20 minutes. f. Pain is relieved by nitroglycerin or rest.

2. Dyspnea

3. Pallor
4. Sweating 5. Palpitations and tachycardia 6. Dizziness and faintness 7. Hypertension 8. Digestive disturbances.

DIAGNOSTIC STUDIES

1. ELECTROCARDIOGRAM (ECG)
Readings are normal during rest, with ST depression or elevation and/or T wave inversion during an episode of pain.

2. STRESS TEST
Chest pain or changes in the electrocardiogram or vital signs during testing may indicate ischemia. Helps show whether enough blood flows to your heart when it's working hard. Doctors usually use stress testing to help them diagnose coronary artery disease (CAD) or to see how serious this disease is in those who are known to have it.

3. CARDIAC ENZYMES AND TROPONINS

Findings are normal in angina.

4. CARDIAC CATHETERIZATION
Catheterization provides a definitive diagnosis by providing information about the patency of the coronary arteries.

NURSING INTERVENTIONS

A. ASSESS PAIN
1. Location: jaw and or arm as well as chest 2. Character 3. Duration: goes away with rest and/or

nitroglycerine (Nitro-bid)
4. Precipitating factors (once identified, eliminate or minimize to avoid attacks).

B. Educate the client to help client to adjust living style to prevent episode of angina
a. Avoid excessive activity in cold weather b. Avoid overeating c. Stop smoking

d. Avoid constipation
e. Rest after meals f. Exercise g. Decrease stress

C. Teach client that anything that decreases cardiac output or increases workload of

heart can cause chest pain.

D. Teach client how to cope with an attack: use of nitroglycerin peripheral vasodilation decreases myocardial oxygen demand; coronary artery

vasodilation increases supply of oxygen

to myocardium.

NITROGLYCERIN
Nitroglycerin : vasodilators. It works by relaxing the blood vessels so the heart does not need to work as hard and therefore does not need as much oxygen. When to take: daily to prevent and/or as needed at onset of chest pain; if lcient knows an activity can cause pain, should take before (e.g. Sexual intercourse). How often: if at onset of attack, every 5 minutes x 3; if client chest pain still not relieved call 911

 Storage: Dark, dry, only good for 3 months. Side effects: Headache, hypotension Types: tablet, ointment, patch and spray a. If given daily for prevention, client must be nitroglycerin free daily for 12 hours to prevent tolerance b. If patch user: on upon waking, off at bedtime c. Never take nitroglycerin with out sitting down and stopping activity.

CONTRAINDICATIONS FOR NITRATES

Hypotension Increased intracranial pressure Severe anemia

SIDE EFFECTS OF NITRATES

Headache Orthostatic hypotension Dizziness, weakness Faintness Nausea, vomiting Flushing or pallor Confusion Rash Dry mouth Reflex tachycardia Paradoxical bradycardia

NURSING ACTIONS WHEN GIVING SUBLINGUAL MEDICATIONS

Monitor vital signs Offer sips of water before giving because dryness my inhibit medication absorption Instruct the client to place under the tongue and leave until fully dissolved. Instruct the client to tale one tablet for pain and repeat every 5 minutes for a total of three doses. Inform the client that a stinging or burning sensation may indicate that the tablet is fresh.

CONT....
Instruct the client to store medications in a dark, tightly closed bottle Instruct the client to check the expiration date on the medication bottle because expiration may occur within 6 months of obtaining medication Instruct the client to take acetaminophen for a headache.

Collateral circulation
is a network of tiny blood vessels, and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

CONGESTIVE HEART FAILURE

Definition: Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump enough blood to the body's other organs. Can be one sided or both sided failure

ETIOLOGY
A. Narrowed arteries that supply blood to the heart muscle coronary artery disease B. Past heart attack, or myocardial infarction, with scar tissue that interferes with the heart muscle's normal work C. High blood pressure

ETIOLOGY
D. Heart valve disease due to past rheumatic fever or other causes E. Primary disease of the heart muscle itself, called cardiomyopathy. F. Heart defects present at birth congenital heart defects.

G. Infection of the heart valves and/or heart muscle itself endocarditis and/or myocarditis

CCF-PATHOPHYSIOLOGY
As heart's pumping power is weaker than normal, blood moves through the heart and body at a slower rate, and pressure in the heart increases.

The chambers of the heart respond by stretching to hold more blood to pump through the body. In time, the heart muscle walls weaken and are unable to pump as strongly.

As a result, the kidneys often respond by causing the body to retain fluid (water) and sodium thus the body becomes congested.

LEFT SIDED HEART FAILURE (LVF)

When Left ventricle muscle is damaged- it fails to contract/pump with sufficient force When ventricular fails to circulate blood, the blood will back up in the lung

Increase pressure in the pulmonary circulation

Fluid moves into pulmonary tissue and alveoli

PULMONARY EDEMA

Pulmonary Edema
The most severe manifestation of Left Heart Failure Fluid leak into the pulmonary interstitial spaces (Pulmonary congestion/edema) Hypoxia and poor 02 exchange

CLINICAL MANIFESTATIONS (LVF)

LEFT VENTRICULAR FAILURE

Dyspnea Orthopnea difficulty in breathing at rest or when lying flat in bed (supine position causes the fluid to back up in the lung) Cough or wheezing Frothy pink sputum Crackles can be heard in the lungs Paroxysmal Nocturnal Dyspnea waking up at night short of breath.

CLINICAL MANIFESTATIONS (LVF)

Cerebral hypoxia- result of decreased cardiac output causes: Anxiety Irritability Restlessness Confusion Impaired memory Insomnia NocturiaOliguria-late manifestation

RIGHT SIDED HEART FAILURE (RVF)

When Right ventricular fails ,it cannot accept all the blood returning to the heart

The blood backs up to the tissue, causing congestion of viscera and peripheral tissue

Edema of the leg, ankles, liver, abdominal cavity

CLINICAL MANIFESTATIONS (RVF)

Shortness of breath Swelling of feet and ankles Urinating more frequently at night Pronounced neck veins Palpitations (sensation of feeling the heart beat) Irregular fast heartbeat Fatigue Weakness Fainting Hepatomegaly - liver congestion Ascites due to liver congestion

Jugular venous distention S3 Rales Pleural effusion Edema Hepatomegaly Ascites

Heart Failure Clinical manifestations : Pulmonary Congestion (L) and Systemic Congestion (R)
Right Heart Failure Left Heart Failure

Peripheral fluid overload

Pulmonary fluid overload

83

CCF- INVESTIGATIONS
A. Serum electrolytes ,urea & nitrogen B. Liver function test C. Arterial blood gases to evaluate gas exchange D. Kidney functions test E. Chest X-Ray may show pulmonary vascular congestion, cardiomegaly F. ECG Ventricular enlargement G. Echocardiography to evaluate left ventricular function

CCF-MEDICATIONS
to reduce cardiac work and improve cardiac function a. Diuretics b. Beta blockers. c. Digitalis Digoxin d. Inotropes-Dopamine, Dobutamine e. Angiotensin converting enzyme inhibitors

NURSING INTERVENTION FOR HEART FAILURE

Assess cardiovascular status, vital sign and hemodynamic variable to detect signs of reduced cardiac output. Assess respiratory status to detect increasing fluid in the lungs and respiratory failure. Keep the client in semi-fowler's position to increase chest expansion and improve ventilation.

 Administer medication as prescribed, to enhance cardiac performance and reduce excess fluids. Administer oxygen to enhance arterial oxygenation. Measure and record intake and output, Intake greater than output may indicated fluid retention.

 Monitor laboratory test result to detect electrolyte imbalances, renal failure, and impaired cardiac circulation. Provide suctioning, if necessary assist with turning and encourage coughing and deep breathing to prevent pulmonary complication. Restrict oral fluid to avoid worsening the client's condition.

 Weigh the client daily to detect fluid retention. A weight gain of 2lb (0,9 kg) in 1 day or 5 lb (2,3 kg) in 1 week indicates fluid gain. Measure and record the client's abdominal girth. An increased in abdominal girth suggests worsening fluid retention and right-sided heart failure. Make sure the client maintains a low-sodium diet to reduce fluid accumulation. Encourage the client to express feelings, such as a fear of dying to reduce anxiety.

SURGICAL MANAGEMENT Heart Transplantation A heart transplant removes a damaged or diseased heart and replaces it with a healthy one. The healthy heart comes from a donor who has died. It is the last resort for people with heart failure when all other treatments have failed. The most common procedure is to take a working heart from a recently deceased organ donor (allograft) and implant it into the patient. The patient's own heart may either be removed (orthotopic procedure) or, less commonly, left in to support the donor heart (heterotopic procedure).

 HEART TRANSPLANTATION

 Heart Transplantation

Cardiomyoplasty
This is a procedure in which skeletal muscles are taken from a patient's back or abdomen. Then they're wrapped around an ailing heart. This added muscle, aided by ongoing stimulation from a device similar to a pacemaker, may boost the heart's pumping motion.

CCF-Nursing Management
Assessment of patient- general condition & vital sign Spo2 monitoring O2 support-to relieve hypoxia & dyspnea Position client-high fowler or chair to reduce pulmonary venous congestion Position of leg dependant Limit sodium & H2O intake- for severe CCF patient ,limit H2O to 1L/day RIB

a. Decreased cardiac output b. Impaired gas exchange c. fluid and electrolyte imbalance related to fluid volume excess d. Imbalanced nutrition: less than body requirements e. Risk for impaired tissue integrity f. Activity intolerance g. Sleep pattern disturbance h. Fear/Anxiety

NURSING DIAGNOSIS

Breathlessness related to impaired Pulmonary gas exchange / impaired gas exchange related to pulmonary congestion Assess and record respiratory pattern include rate depth and rhythm. Observe color of patient lips and nails. Reassure patient during distress episodes. Put patient in upright position supported with by pillowsencourage lung expansion.

Promote rest reduces oxygen demand. Administer Oxygen therapy Give medication as prescribed to reduce pulmonary edema.- Diuretics Strict intake and output chart

DECREASED CARDIAC OUTPUT

Assess patient for sign of decreased cardiac output-e.g. confusion, dizziness, irritability Vital sign BP,PR & Spo2 monitoring ECG monitoring-monitor for sign of dysrhythmias Monitor lung sound-sign of crackles & coughing

DECREASED CARDIAC OUTPUT

Monitor IO -detect sign of reduced renal perfusion Medication as prescribed to increase myocardial contractility- e.g Dopamine, Digoxin Promotes rest to reduce myocardial workload & oxygen demand

SELF CARE DEFICIT RELATED TO FATIGUE / SHORTNESS OF BREATH

Assess and record patients level of tolerance to activities of daily living. Encourage patient to verbalize activities that increase fatigue or shortness of breath. Provide rest period between and during activities Keep frequently used items within reach of patient. Give encouragement and promotes independence in activities within patients limit. Assist patient in activities of daily living.

IMPAIRED SKIN INTEGRITY RELATED PHYSICAL IMMOBILITY.

Assess and record skin integrity. Lift correctly to avoid dragging on the patients skin. Use pressure relieving mattress as necessary. Encourage patient to move position frequently If she/ he is unable to do so, assist patient in changing position every 4 hourly and gently massage pressure area to promote blood circulation.

Impaired skin integrity related physical immobility.

Ensure bedclothes are smooth and free from crumbs. Change pampers or bed sheet when soiled. Keep skin clean and dry at all time.

INADEQUATE NUTRITIONAL INTAKE RELATED TO LOSS OF APPETITE

Assess nutritional status. Record all intake and output chart strictly. Observe and record for nausea and vomiting. Note vomitus for frequency, amount and color. Refer to dietitian Advise on dietary supplements Avoid process and canned food.

INADEQUATE NUTRITIONAL INTAKE RELATED TO LOSS OF APPETITE

Offer small and frequent diet. Plan meals with patient and dietitian. Assist patient with meals as needed. Ensure pleasant environment during meals. Soft diet as tolerated.

ANEURYSM

 An aneurysm (AN-u-rism) is described as a permanent bulging and stretching of an artery, in which the dilation is two times or greater the size of the artery. This balloon-like bulge abnormality develops a weakness in the arterial wall and puts the patient at risk for serious complications.

PATHOPHYSIOLOGY
Degenerative changes in the muscular layer of the aorta create a focal weakness, allowing the inner and outer layer to stretch outward. Blood pressure within the aorta progressively weakens the vessel walls and enlarges the aneurysm

Types of aneurysm
1. Aortic aneurysms 2. Cerebral aneurysms 3. Peripheral aneurysms.

The two types of aortic aneurysm area. a. Thoracic aortic aneurysm (TAA) b. Abdominal aortic aneurysm (AAA).

Factors that increase the risk for aneurysm include:

1. Atherosclerosis, a buildup of fatty deposits in the arteries. 2. Smoking. People who smoke are eight times more likely to develop an aneurysm. 3. Overweight or obesity: A family history of aortic aneurysm, heart disease, or other diseases of the arteries. Certain diseases that can weaken the wall of the aorta, such as: a. Marfan syndrome (an inherited disease in which tissues don't develop normally) b. Untreated syphilis (a very rare cause today) c. Tuberculosis (also a very rare cause today) 4. Trauma such as a blow to the chest in a car accident. 5. Severe and persistent high blood pressure between the ages of 35 and 60. This increases the risk for a cerebral aneurysm. 6. Use of stimulant drugs such as cocaine.

I. Abdominal Aortic Aneurysms

Abdominal Aortic Aneurysm

An abnormal dilation in the arterial wall, most commonly occurs in the aorta between the renal arteries and iliac branches.

TYPES
1. FUSIFORM: Diffuse dilation that involves the entire circumference of the arterial segment 2. SACCULAR: Distinct localized out pouching of the artery wall 3. DISSECTING: Created when blood separates the layers of the artery wall, forming a cavity between them 4. FALSE (pseudoaneurysm): a. Pseudoaneurysm occurs when the clot and connective tissue are outside the arterial wall b. Pseudoaneurysm occurs as a result of vessel injury or trauma to all three layers of the arterial wall.

Most abdominal aortic aneurysms (AAAs) develop slowly over years. They often don't have signs or symptoms unless they rupture. If you have an AAA, your doctor may feel a throbbing mass while checking your abdomen. When symptoms are present, they can include: a. A throbbing feeling in the abdomen b. Deep penetrating pain in your back or the side of your abdomen c. Steady, gnawing pain in your abdomen that lasts for hours or days d. Coldness, numbness, or tingling in the feet due to blocked blood flow in the legs

If an AAA ruptures, symptoms can include sudden, severe pain in your lower abdomen and back a. nausea (feeling sick to your stomach) and vomiting b. clammy, sweaty skin; lightheadedness; c. a rapid heart rate when standing up. d. Internal bleeding from a ruptured AAA can send you into shock. This is a life-threatening situation that requires emergency treatment.

II. Thoracic Aortic Aneurysms

II. Thoracic Aortic Aneurysms

Thoracic aortic aneurysm (TAA) may not cause symptoms until it dissects or grows large. Then, symptoms may include: a.Pain in your jaw, neck, back, or chest b.Coughing, hoarseness, or trouble breathing or swallowing.

III. Cerebral Aneurysm

If a cerebral (brain) aneurysm presses on nerves in the brain, it can cause signs and symptoms. These can include:

A droopy eyelid Double vision or other changes in vision Pain above or behind the eye A dilated pupil Numbness or weakness on one side of the face or body

 If a cerebral aneurysm ruptures, symptoms can include: a. a sudden, severe headache b. nausea and vomiting c. stiff neck d. loss of consciousness e. signs of a stroke. Signs of a stroke are similar to those listed for cerebral aneurysm, but they usually come on suddenly and are more severe. Any of these symptoms require immediate medical attention.

IV. Peripheral Aneurysm

Signs and symptoms of peripheral aneurysm may include:

A pulsating lump that can be felt in the neck, arm, or leg. Leg or arm pain, or cramping with exercise Painful sores on toes or fingers. Gangrene (tissue death) from severely blocked blood flow in the limbs.

An aneurysm in the popliteal artery (behind the knee) can compress nerves and cause pain, weakness, and numbness in the knee and leg.

DIAGNOSTIC PROCEDURE
1. Abdominal or chest X-rays may show calcification that outlines the aneurysm. 2. CT scan and ultrasonography are used to detect and monitor size of aneurysm. 3. MRI or magnetic resonance angiography further evaluate circulation. 4. Arteriography allows visualization of aneurysm and vessel.

Surgical Interventions:
Surgery may be required to remove the aneurysm and restore vascular continuity with a bypass graft. Complications of surgery include arterial occlusion, graft hemorrhage, infection, ischemic colon, and impotence. Endovascular grafting using stent inserted via catheter through the femoral artery may be warranted.

NURSING INTERVENTIONS
1. Monitor for signs and symptoms of spinal cord ischemia such as pain, numbness, paresthesia, and weakness caused by dissection. 2. Monitor for signs of stroke or cardiac tamponade caused by dissection. 3. Postoperatively, monitor vital signs continuously. 4. Check extremities for sensation, temperature, pulses, color, capillary refill, and petechiae. 5. Monitor for bleeding from the wound and for signs of hemorrhage, hypotension, tachycardia, pallor, and diaphoresis.

6. Monitor temperature and incision for signs of infection. 7. Monitor urinary output hourly. 8. Administer antibiotics, if ordered, to prevent infection. 9. Administer pain medication, as ordered, or monitor patient-controlled analgesia. 10.Elevate the head of the bed no more than 45 degrees for first 3 days postoperatively to prevent pressure on the repair graft site.

7. Warn patient not to cross legs or sit for long periods to prevent thrombus formation. 8. Teach the patient about blood pressure medications and the importance of taking them as prescribed. 9. Teach the patient to recognize and report signs and symptoms of an expanding aneurysm or rupture. 10.Encourage adequate nutritional intake to enhance wound healing. 11.Teach the patient to maintain a postoperative exercise regimen.