# A nurse is caring for a 45-year-old female client with suspected thoracic aortic aneurysm who presents to the emergency department with sudden onset of severe chest pain radiating to her back, blood pressure of 180/100 mmHg in the right arm and 140/80 mmHg in the left arm, anxiety, and a report of feeling like something is "tearing" inside her chest. Which assessment finding should be the nurse's immediate priority?

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> subject: Adult Health

## 문제

A nurse is caring for a 45-year-old female client with suspected thoracic aortic aneurysm who presents to the emergency department with sudden onset of severe chest pain radiating to her back, blood pressure of 180/100 mmHg in the right arm and 140/80 mmHg in the left arm, anxiety, and a report of feeling like something is "tearing" inside her chest. Which assessment finding should be the nurse's immediate priority?

## 보기

1. Monitor for changes in peripheral pulses
2. Assess for blood pressure differences between arms **✔ 정답**
3. Evaluate for presence of heart murmur
4. Check for jugular venous distension

**정답: 2**

## 해설

Blood pressure differences between arms is a critical sign of aortic dissection requiring immediate intervention. Other findings are important but less urgent in this emergency context.

## 심화 해설

Clinical Priority in Suspected Thoracic Aortic Aneurysm

The client’s presentation—sudden, severe chest pain radiating to the back with a “tearing” sensation, extreme anxiety, and a markedly asymmetric blood pressure reading (180/100 mmHg right arm vs. 140/80 mmHg left arm)—is a classic clinical picture for an acute aortic syndrome, such as a dissecting thoracic aortic aneurysm. In this high-stakes scenario, the nurse’s immediate priority is to further quantify and document the finding that most directly supports the suspected vascular catastrophe and guides emergency intervention.

Why Assessing Blood Pressure Differences Between Arms Is the Priority

A significant interarm blood pressure difference is a critical, readily obtainable bedside cue that can signal involvement of the aortic arch and its major branches in the pathological process. In a dissection, a propagating hematoma within the aortic media can compress or shear off the origin of a subclavian artery, leading to a unilateral pressure drop. The provided evidence underscores this principle: a case of an occluded aberrant left subclavian artery was first suspected due to the coincidental finding of an interarm blood pressure difference [1]. While that specific case involved a congenital arch anomaly and an asymptomatic chronic occlusion, the underlying physiological mechanism—unilateral subclavian flow obstruction causing a pressure differential—is identical to what can occur acutely in a thoracic aortic dissection. Confirming and precisely documenting the magnitude of this asymmetry in both arms (and ideally in a lower extremity) provides immediate, objective data that can confirm the suspicion of arch vessel involvement, stratify the urgency of the situation, and directly inform the medical team’s decision to proceed with emergent blood pressure control and definitive imaging, such as a CT angiogram. The other options represent important, but secondary, assessments. Monitoring peripheral pulses and evaluating for a new aortic regurgitation murmur or jugular venous distension (a late sign of tamponade) are all part of the comprehensive examination for a dissection, but they do not take precedence over the immediate, focused clarification of the interarm blood pressure differential, which is the most direct and rapidly interpretable sign of the suspected pathology at the bedside.References (research sources)

- [1]Interarm Blood Pressure Difference Revealing a Right-Sided Aortic Arch and Occluded Aberrant Left Subclavian Artery.Research articleVanreusel I, De Wolf D, Van der Zijden T, Van Berendoncks A. (2024) · DOI: 10.1016/j.jaccas.2024.102246

## 임상 시나리오

Suspected Aortic Dissection: Immediate Nursing ActionPrioritizing the interarm blood pressure difference
In a patient with sudden tearing chest pain and asymmetric arm pressures, the immediate priority is to accurately measure and document the blood pressure in both arms. A difference of >15-20 mmHg systolic is a critical bedside cue for aortic dissection involving the subclavian artery.

This finding directly supports the suspected diagnosis and guides emergency interventions, such as initiating blood pressure control and preparing for urgent imaging. Do not delay this assessment to evaluate for secondary signs like heart murmurs or jugular venous distension.

CautionA single normal blood pressure reading in one arm can be falsely reassuring. Always check both arms and use the higher reading for monitoring and treatment decisions.

## 핵심 개념

- **Aortic Dissection** — A life-threatening condition where a tear in the aortic intima allows blood to surge into the media, creating a false lumen that can obstruct branch arteries or rupture.
- **Interarm Blood Pressure Difference** — A systolic pressure difference of >15-20 mmHg between arms, suggesting subclavian artery compression or occlusion from an aortic arch pathology like dissection.
- **Thoracic Aortic Aneurysm** — A localized dilation of the thoracic aorta; a dissecting aneurysm involves a tear in the vessel wall layers, often presenting with severe tearing chest pain.
- **Subclavian Artery** — A major artery branching from the aortic arch that supplies blood to the arms; its involvement in a dissection causes unilateral arm pressure reduction.
- **Tearing Sensation** — A classic subjective descriptor for the pain of an acute aortic dissection, reflecting the propagating separation of the aortic wall layers.

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