Aortic Dissection Nursing Care Plan

Quick Overview & Assessment Checklist

Aortic dissection is a tear in the inner wall of the aorta, causing life-threatening internal bleeding. Patients often describe sudden, severe chest or back pain (tearing or ripping). Key assessment findings include unequal blood pressures (>20 mmHg difference between arms), weak pulses on one side, and signs of shock (hypotension, rapid heartbeat, cold clammy skin). Other red flags are neurologic changes (faintness, vision loss) if arteries to the brain are involved.

Nursing Care Plans

Nursing Care Plan #1: Acute Pain

Nursing Diagnosis Statement: Acute pain related to aortic wall tear, as evidenced by patient report of 10/10 tearing chest pain.
Related factors: Aortic wall stretching, inflammation, high blood pressure.
Nursing Interventions and Rationales:

  • Provide IV pain medication (e.g., opioids) and reassess frequently. Rationale: Controls pain, which reduces blood pressure and heart rate, decreasing stress on the aorta.

  • Position patient with head elevated and encourage stillness. Rationale: Reduces aortic pressure and prevents pain from movement.

  • Create a calm environment and reassure the patient. Rationale: Reducing anxiety helps lower vital signs and pain perception.
    Desired Outcomes: Patient reports decreased pain (e.g., ≤ 3/10) and remains calm with stable vital signs.

Nursing Care Plan #2: Decreased Cardiac Output

Nursing Diagnosis Statement: Decreased cardiac output related to impaired aortic flow, as evidenced by hypotension and tachycardia.
Related factors: Aortic obstruction, high afterload, possible aortic valve involvement.
Nursing Interventions and Rationales:

  • Monitor blood pressure and heart rate continuously. Rationale: Detects changes that require immediate treatment.

  • Administer IV beta-blockers or vasodilators as ordered. Rationale: Slows heart rate and lowers BP to protect the aorta and improve heart efficiency.

  • Track intake and output and maintain IV access. Rationale: Ensures proper fluid balance and prepares for emergency IV fluids if needed.
    Desired Outcomes: Blood pressure stabilizes in target range (e.g., systolic ~100 mmHg) and patient maintains warm extremities with good urine output.

Nursing Care Plan #3: Risk for Ineffective Tissue Perfusion

Nursing Diagnosis Statement: Risk for ineffective tissue perfusion related to obstructed aortic branches, as evidenced by (potential) weak pulses and cool extremities.
Related factors: Dissection flap blocking blood flow to organs, low cardiac output.
Nursing Interventions and Rationales:

  • Check pulses and capillary refill in all extremities every hour. Rationale: Early detection of decreased perfusion prevents complications like limb ischemia.

  • Monitor urine output and organ function. Rationale: Helps identify if organs (kidneys, brain) are losing adequate blood flow.

  • Keep extremities at heart level. Rationale: Optimizes perfusion (avoid raising above heart or dropping below).
    Desired Outcomes: Patient maintains strong pulses and normal capillary refill; no signs of organ ischemia (e.g., normal mental status, adequate urine output).

Nursing Care Plan #4: Anxiety

Nursing Diagnosis Statement: Anxiety related to fear of a life-threatening condition, as evidenced by restlessness and verbalized worry.
Related factors: Sudden emergency diagnosis, unknown outcome.
Nursing Interventions and Rationales:

  • Explain procedures and treatments in simple terms. Rationale: Understanding helps reduce fear of the unknown.

  • Encourage questions and provide emotional support. Rationale: Sharing concerns can alleviate anxiety and build trust.

  • Offer relaxation techniques (calm breathing). Rationale: Helps lower heart rate and stress on the body.
    Desired Outcomes: Patient reports reduced anxiety and uses at least one relaxation method successfully.

Study Tip / Printable Resource

Looking for practice materials? Download our printable Aortic Dissection nursing care plan as part of the Cardiac Bundle Care Plans. These study guides help reinforce key concepts and save you time!

FAQ

  • What are the main symptoms of aortic dissection? Sudden severe chest or back pain (tearing/ripping), unequal pulses or blood pressures, and signs of shock (low BP, rapid HR). Early recognition is crucial.

  • What is the priority nursing action? Manage pain and lower blood pressure quickly. For example, give IV opioids for pain and IV beta-blockers to slow heart rate. These steps protect the aorta.

  • Where can I get a printable care plan? Check our Cardiac Bundle Care Plans for a downloadable Aortic Dissection care plan PDF and other study resources.

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).

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