Aortic dissection typically presents with sudden, severe, tearing chest or back pain that may radiate to the neck or abdomen. Assessment may reveal unequal blood pressures or pulses between limbs and signs of shock such as hypotension and tachycardia.
According to the Stanford classification, Type A dissections (involving the ascending aorta) require emergency surgery, while Type B dissections (descending aorta) are often managed medically. Nursing priorities include rapid pain control, close hemodynamic monitoring, and strict blood pressure management to prevent further aortic injury.
Nursing Care Plans
Nursing Care Plan #1: Acute Pain
Nursing Diagnosis Statement: Acute pain related to aortic wall tearing, as evidenced by patient’s report of severe pain.
Related factors: Extreme chest/back pain, increased aortic pressure.
Nursing Interventions and Rationales:
- Give IV pain medication (e.g., opioids) and re-evaluate. Rationale: Controls pain and lowers stress on the aorta.
- Maintain patient on bedrest with head-of-bed elevated. Rationale: Reduces blood pressure on the aorta and prevents movement that could worsen the tear.
Desired Outcomes: Patient reports decreased pain and remains hemodynamically stable.
Nursing Care Plan #2: Decreased Cardiac Output
Nursing Diagnosis Statement: Decreased cardiac output related to impaired aortic flow, as evidenced by low BP and weak pulses.
Related factors: Aortic obstruction, high afterload.
Nursing Interventions and Rationales:
- Monitor vitals continuously, especially blood pressure. Rationale: Early detection of hypotension or tachycardia allows immediate treatment.
- Administer IV beta-blockers as ordered. Rationale: Reduces heart rate and BP to protect the aorta and improve cardiac output.
Desired Outcomes: Patient maintains target BP and heart rate; no signs of organ hypoperfusion.
Nursing Care Plan #3: Risk for Ineffective Tissue Perfusion
Nursing Diagnosis Statement: Risk for ineffective tissue perfusion related to compromised blood flow from the dissection.
Related factors: Potential obstruction of branches, decreased cardiac output.
Nursing Interventions and Rationales:
- Check peripheral pulses and capillary refill frequently. Rationale: Ensures early detection of reduced perfusion to limbs or organs.
- Monitor urine output and mental status. Rationale: Low urine or confusion could indicate renal or cerebral hypoperfusion.
Desired Outcomes: All pulses remain strong and equal; patient stays alert with adequate urine output.
FAQ
- What is the most common symptom of aortic dissection? Sudden, severe tearing chest or back pain that may radiate.
- What is the priority intervention? Control pain and blood pressure immediately (usually with IV opioids and beta-blockers) to prevent extension of the tear.
- How is hypertension managed? Rapid IV antihypertensives (like labetalol or nitroprusside) are given to quickly lower BP and protect the aorta.
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).