nursing aneurysm

8/3/2019 Nursing Aneurysm

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AnAn-- Najah Najah National University National University

FacultyFaculty of Nursingof Nursing

Dr Dr Aidah Aidah Abu Abu Alsoud Alkaissi Alsoud Alkaissi

RN, BSc, MSc, PhD RN, BSc, MSc, PhD

Nursing Care Plan of

Aortic Aneurysm



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What is Aortic Aneurysm ?

Is a localized sac or

dilation at a weak point

of the aorta to a sizegreater than 1.5 times

its normal diameter



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What are the causes of Aortic Aneurysm ?

Most aneurysms arearteriosclerotic in origin

Syphilis

Infection

Inflammatory diseases

Trauma

Hypertension

Smoking

Aortic dissection



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What are the classifications of aneurysms according to

their shape ?

The first classificationis :

Fusiform Aneurysm :

dilation of the entire

circumference of theartery

Saccular Aneurysm :localized balloon-shaped outpouching

projects from one sideof the artery



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The second classification is :

True Aneurysm : involvethe entire vessel wall

False Aneurysm : is formedwhen blood leaks outside of the artery but is containedby the surrounding tissues

A pseudoaneurysm, or falseaneurysm, is an enlargementof only the outer layer of the

blood vessel wall

A false aneurysm may be the

result of a prior surgery or trauma



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Thoracic Aortic Aneurysm (TAA)

8 Occur most frequently in

men between the ages 40

and 70 years

8 About one third of

patients with (TAA) dieof rupture of the

aneurysm



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Thorasic Aorta Aneurysm- Clinical manifestations Back, neck or substernal pain

Dyspnea, stridor or brassy cough if pressing on trachea

Hoarseness

Edema of the face and neck

Distended neck vein

Aphonia

Disphagia

Complications: such as rupture and hemorrhage



What are the diagnostic tests for (TAA) ? Chest x-ray

Computedtomography (CT)

Transesophagialechocardiography



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Abdominal Aortic Aneurysm (AAA)

Affects men four times

more often than womenand is most prevalent inelderly patients

Most of these aneurysmsoccur below renal arteries(infrarenal aneurysm)

Untreated, the eventualoutcome may be ruptureand death



Clinical manifestations of (AAA)

Patients with (AAA) feel their heart beating in their abdomen when lying down

Client s awareness of a pulsating mass in the abdomen,with or without pain, followed by abdominal pain and back

pain

Flank pain or groin pain may be experienced because of

increasing pressure on other structures sometimes mottlingof the extrimities or distal emboli in the feet alert theclinician to a source in the abdomen

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Clinical manifestations of (AAA)

Aortic calcification noted on x-ray

Mild to severe midabdominal or lumbar back pain

Cool, cyanotic extrimities if iliac arteries are involved

Claudication (ischemic pain with exercise, relieved by

rest)

Complication: peripheral emboli to lower extrimities

Ru ture and hemorra e



Who’s at risk?

In 20% of patients, familial clustering of aortic aneurysmssuggests a hereditary tendency to develop aneurysms, aorticaneurysms also can be an individual aberration present at

birth

Pregnancy can hasten aneurysm development because of hormonal and hemodynamic changes

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Other risk factors include a history of

Smoking

Chronic obstructive pulmonary disease

Hyperlipidemia

Poorly controlled

diabetes

Connective tissue disorders,including Marfan syndrome(which is a geneticconnective tissue disorder that affects the skeleton,

eyes, and cardiovascular system)

Mycotic aneurysms,

develop from streptococcal,staphylococcal, or salmonella infections of theaorta



ndications ndications ndications ndications forforforfor urgical urgical urgical urgical epair epair epair epair ofofofof ortic neurysms ortic neurysms ortic neurysms ortic neurysms horacic horacic horacic horacic iameter 6 cm 5 cm in

patients with arfansyndrome

ymptoms suggestingexpansion orcompression of

surrounding structures

bdominal bdominal bdominal bdominal

iameter 5 cm or more iameter 4 cm or less

need regular follow up

iameter 4 5 cm



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Implement Interventions to Reduce the Risk of

Aneurysm Rupture

Maintain bed rest withlegs flat

Maintain a calm

environment,implementing measuresto reduce psychologicstress

Prevent straining duringdeafecation

Administer beta blockers

and antihypertensive as prescibed

Elevating or crossing thelegs restricts peripheral

blood flow and increases pressure in the aorta or iliac arteries



Abdominal Aortic Aneurysm- Open Repair

Open repair of an abdominal aortic aneurysm involves anincision of the abdomen to directly visualize the aorticaneurysm

The procedure is performed in an operating room under

general anesthesia

The surgeon will make an incision in the abdomen either lengthwise from below the breastbone to just below thenavel or across the abdomen and down the center

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rafts



Abdominal Aortic Aneurysm- Open Repair

The aneurysm is exposed, the aorta is clamped just above and below the aneurysm to stop the

flow of blood, the aneurysm is opened and a

Dacron graft is placed within the anuerysm

The aneurysm sac is then wrapped around thegraft to protect it

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Open Repair

The graft is sutured to theaorta connecting one end

of the aorta at the site of the aneurysm to the other end of the aorta

Open repair remains thestandard procedure for anabdominal aortic aneurysm

repair

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EndovascularAneurysm Repair

(EVAR )

EVAR is a minimally-invasive (without a large abdominal incision) procedure performed to repair an abdominal aortic aneurysm

EVAR may be performed in an operating room, radiologydepartment, or a catheterization laboratory

The physician may use general anesthesia or regional anesthesia(epidural or spinal anesthesia)

The physician will make a small incision in each groin to visualize

the femoral arteries in each leg



Endovascular

Aneurysm Repair(EVAR )

With the use of special endovascular instruments, alongwith x-ray images for guidance, a stent-graft will beinserted through the femoral artery and advanced up into

the aorta to the site of the aneurysm

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Endovascular Aneurysm Repair (EVAR)

A stent-graft is a long cylinder-like tube made of a thinmetal framework (stent). The stent helps to hold the graftin place

The stent-graft is inserted into the aorta in a collapsed position and placed at the aneurysm site

Once in place, the stent-graft will be expanded (in aspring-like fashion), attaching to the wall of the aorta tosupport the wall of the aorta

The aneurysm will eventually shrink down onto the stent-graft



Risks of the Procedure- open repair

Myocardial infarction

Irregular heart rhythms

Bleeding during or after surgery

Injury to the bowel

Limb ischemia

Embolus to other parts of the body

Infection of the graft

Lung problems

Kidney damage

Spinal cord injury

Damage to surrounding blood vessels, organs, or other structures byinstruments

Groin wound infection

Groin hematoma

Endoleak

Aller



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Nursing Care- Assessment

Focused assessment for the client with a suspectedaortic aneurysm includes:

Health history: complaints of chest, back, cough, difficultor painful swallowing, hoarseness, history of hypertension,

coronary heart diseas, heart failure, peripheral vascular

disease



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Physical examination: vital signs including blood pressure in upper and lower extrimities, peripheral

pulses, skin color and temperature, neck veins,

abdominal exam including gentle palpation for masses and auscultation for bruits, neurological exam

including level of consciousness, sensation and

movement extrimities




Attention to the character and quality of the

peripheral pulses and the neurologic status

Pedal pulse sites

(dorsalis pedis and posterial tibial)

and skin lesions on the lower

Extrimities should be marked and

documented before surgery27



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Nursing Care of the client having surgery of aorta

Postoperative care

Assess the surgical sites for swelling and pain

(hematoma) and bleeding Monitor peripheral perfusion closely, ambulation is

allowed the day after surgery

Clients may ask if they can feel the hooks in the aorta

They should be told that they will not be able to feel

the hooks because the aorta can not sense the hooks

Before dismissal, the location of the graft may be

confirmed with CT scan, ultrasound, or x ray study



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Postoperative care

Monitor for and report manifestations of graftleakage: Ecchymoses of the scrotum, perinium, or penis; a new

expanding hematoma

Increased abdominal girth

Weak or absent peripheral pulses, tachycardia,hypotension

Decreased motor function or sensation in theextrimities

Fall in Hb and HT Increasing abdominal, pelvic, back or groin pain

Decreasing urinary out put (less than 30 ml/ hr)



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Postoperative care

Decreasing CVP , pulmonary artery pressure, or

pulmonary artery wedge pressure These manifestation may signal graft leakage and

possible hemorrhage

Pain may be due to pressure from an expandinghematoma or bowel ischemia

Decreased renal perfusion causes the glomerular

filtration rate and urine output to fall



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Postoperative care

Maintain fluid replacement and blood or volume expanders asordered

Promptly report changes in vital signs, level of consciousnessand urine outpit

Hypovolemic shock may develop due to blood loss duringsurgery, third spacing, inadequate fluid replacement and/or

hemorrhage if graft separation or leakage occurs Report manifestations of lower extrimity embolism: pain and

numbness in lower extrimities, decreasing pulses, and pale,cool, or cyanotic skin

Pulses may be absent for 4-12 hr postoperatively due tovasospasm; however absent pules with pain, changes insensation, and a pale, cool extrimity are indicative of arterialocclusion



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Postoperative care

Report manifestations of bowel ischemia or gangrene:

abdominal pain and distention, occult or fresh blood instools, and diarrhea

Bowel ischemia may result from an embolism or ocur as

a complication of surgery

Report manifestations of impaired renal function: urine

output less than 30 ml per hour, fixed specific gravity,

increasing BUN and serum creatinine levels

Hypovolemia or clamping of the aorta during surgery

may impair renal perfusion, leading to acute renal failure



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Postoperative care

Report manifestations of spinal cord ischemia: lower

extremity weakness or paraplegia

Impaired spinal cord perfusion may lead to ischemia

and impaired function



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Planning

The overall goals for a patient undergoing aortic surgery

include:

Normal tissue perfusion

Intact motor and sensory function

No complications related to surgical repair such as

thrombosis or infection



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Nursing Implementation- Graft Patency

Maintain adequate blood pressure to promote graft patency.Prolonged hypotention may result in graft thrombosis dueto decreased blood flow

Administration of of i.v. fluids and blood components as

indicated is essential to maintaining adequate blood flow tothe graft

Central venous pressure readings or pulmonary artery pressures and urinary output should be monitored hourly inthe immediate postoperative period to help assess the

patient s state of hydration



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Nursing Implementation- Graft Patency

Severe hypertention may cause undue stress on the arterialanastomosis resulting in leakage blood or rupture at the

suture lines

Drug therapy with duiretics or i.v antihypertensive agents

may be indicated if severe hypertension persists



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Nursing Implementation- Cardiovascular

Status

In individuals with preexisting coronary artery disease,myocardial ischemia or infarction may occur in the

perioperative period due to decreased oxygen supply to theheart or increased oxygen demands on the heart. Cardiacrhythmias also may occur due to electrolyte imbalances,

hypoxemia, hypothermia or myocardial ischemia

Nursing interventions include continous ECG monitoring,frequent electrolyte and blood gas (ABG) determinations,

administrations of oxygen and antiarrhythmic medicationsas needed

Replacement of electrolytes as indicated, adequate paincontrol and resumption of preoperative cardiac medications



Infection

Diagnosis

Risk for infection related to presence of a prostheticvascular graft and invasive lines

Outcome

Normal body temperature

No signs of infection

Wound is well approximated



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Nursing Implementation- Infection

Nursing prevention to prevent infection shouldinclude ensuring that the patients receives a broad

spectrum antibiotic as prescribed

Monitor for signs of infetion

The nurse should ensure adequate nutrition andobserve the surgical incision for any evidence of

delaying healing or prolonged drainage

N i I l t ti I f ti



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Nursing Implementation- Infection

All i.v., arterial and central venous catheter insertion sites

should be carried for carefully with the use of sterile

technique because they are frequently a portal of entry for bacteria

Meticulous perianial care for the patient with an

indwelling urinary catheter is essential to minimize the

risk of urinary tract infection

Surgical incisions should be kept clean and dry



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Nursing Implementation- Gastrointestinal Status

Paralytc ileus may develop as a result of anesthesia and themanual manipulation and displacement of the bowel for

long periods during surgery

The intestine may become swollen and bruised and pristalsis ceases for variable intervals

A nasogastric tube is inserted during surgery and connectedto low, intermittent suction

This decompreses the stomach and duodenum, preventaspiration of stomch contents, and decrease pressure onsuture lines



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Nursing Implementation- Gastrointestinal Status

The nasogastric tube should be irrigated with normal salinesolution as needed and the amount and character of the

drainage should be recorded

The nurse should auscultate for the return of bowel sounds

The passing of the flatus is a key sign of returning bowelfunction and shoud be noted

Early ambulation will assist with the resumption of bowelfunctioning

It is unusual for paralytic ileus to persist beyond the fourth

postoperative day

Di risk for ischemia



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Diagnose: risk for ischemiaof the bowel

If the client undergoes extensiveaortic procedures that involveclamping the mesenteric vessels,

ischemic colitis can develop

Inferior mesenteric artery canembolize

The lack of blood supply canlead to ischemia and ileus

Outcomes

The nurse will monitor the clientfor abdominal distention,diarrhea, severe abdominal pain,

sudden elevation in white bloodcell count and bowel sound

Intervention



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Intervention

Assess bowel sounds

every 4 hours

Keep the client NPO and provide oral care every 2-4 hr

Provide routine nasogastric

tube care and assess naresfor tissue impairment

Perform guaiag test (Testfor blood in stool) of NGdrainage every 4 hours or if

bleeding is suspected (i.e.,

drainage has dark, coffee-ground appearance or is bright red)

Nursing Implementation- Neurologic Status



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Nursing Implementation Neurologic Status

When the ascending aorta and aortic arch are involved,nursing interventions should include:

assessment of level of conciosness, pupil size andresponse to light, facial symmetry, tongue deviation,speech, ability to move upper extrimities, quality of handgrasps,

the carotid, radial, and temporal artery pulses should be

assessed

When the descending aorta is involved, nursing assessment

of:

the ability to move lower extrimities

pulses to be assessed may include the femoral, popliteal,

posterior tibial and dorsalis pedis



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Nursing Implementation- Peripheral Perfusion Status

When checking the pulses, the nurse should mark the locations lightlywith a felt-tip pen so that others can locate them easily

An ultrasonic Doppler is useful in assessment of peripheral pulses

It is also important to note the skin temperature and color,capillary refill time and sensation and movement of theextrimities



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Nursing Implementation- Peripheral Perfusion Status

A decreased or absent pulse in conjunction with a cool,

pale, mottled or painful extrimity may indicateembolization of aneurysmal thrombus or plaque or occlusion of the graft

Gaft occlusion is treated with reoperation if identified early

In rare instances, thrombolytic therapy may also be

considered

N i I l t ti R l P f i St t



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Nursing Implementation- Renal Perfusion Status

One of the causes of decreased renal perfusion is

embolization of a fragment of thrombus or plaque from theaorta that subsequently lodges in one or both of the renal

arteries

This can cause ischemia of one or both kidneys

Hypotension, dehydration, prolonged aortic clamping, or

blood loss can also lead to decreased renal perfusion

N i I l t ti R l P f i St t



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Nursing Implementation- Renal Perfusion Status

The patient return from surgery with an indwellingurinary catheter in place

An accurate record of fluid intake and urinary output should be kept until the patient resumes the preoperative diet

Daily weight also should be obtained

Central venous pressure reading and pulmonaryartery pressures also provide important informationregarding hydration status



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Diagnose

Risk for hemorrhage because of the risk of

bleeding at the graft

site, the client is at risk

for hemorrhage

Risk for deficientfluid volume

Outcome

The nurse will monitor for manifestations of

hemorrhage and notify

the physician if any

manifestations occur

Interventions Monitor the client for:



Interventions- Monitor the client for:

increase in pulse rate

decrease in blood

pressure

clammy skin

pallor

anxiety & restlessness

decreasing levels of conciousness

Cyanosis

thirst

oliguria

increase abdominal girth

increased chest tube

output greater than 100ml/hr/for 3 hours

back pain fromretroperitoneal bleeding



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Diagnose

Risk for impaired gasexchange

Impaired gas exchangerelated to ineffectivecough secondary to

pain from large incision

Outcome

The client will have

improved gas exchange as

evidenced by oxygensaturation or Pao2 greater

than 95%, increasing

effectiveness in coughing,and clearing of lung sounds

Intervention



Monitor settings on ventilator

to ensure the client isadequately oxygenated

Assess lung sounds every 1 to 2hours

Monitor oxygen saturationcontinously. Report anydesaturation

After extubation,

assist with coughing by usingincentives spirometry, provide splinting pillows before

coughing, encourage ambulation provide adequate analgesia

Spirometry

Di



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Diagnose

Risk for inadequate tissueperf usion

During the operation, aorta isclamped to stop bleeding whilethe graft is placed

During that time, peripheral

tissues are not perfused

The graft site can also becomeoccluded with thrombus

In addition the client often has preexisting arterial disease

Outcomes

The client will maintain adequatetissue perfusion as evidenced by:

pedal pulses

warm feet

capillary refill of less than 5

seconds, abscence of numbness or

tingling

ability to dorsiflex and

plantar flex both feet equally

Urin output adequate

lantar lexion lantar lexion lantar lexion lantar lexion xtension ofthe ankle

orsal lexion orsal lexion orsal lexion orsal lexionlexion of the



the ankleresulting in

the forefootmoving awayfrom the body

ex o of eankle resulting in

the top of the footmoving toward thebody

Intervention



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Risk for Inadequate Tissue Perfusion

Administer i.v. Fluid at

prescribed rates to ensureadequate hydration and renal perfusion

Maintain a warmenvironment to preventtemperature inducedvasoconstriction

Administer

anticoagulants and /or antiplatelet agents as

prescribed to preventthrombus formation

Monitor urinry outputdaily weights, BUN,and serum createnine to

detect signs of altered perfusion and renalfailure

A t P i



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Diagnosis:

Acute pain related to

surgical incision

Outcomes

The client will have increasedcomfort as evidenced by :

self-report of decreasing levelsof pain

use of decreasing amounts of opioid analgesics for paincontrol

ambulating or coughingwithout extreme pain

Acute Pain



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Intervention

Opioids are usually provided via a patient-controlled

analgesia system or through an epidural catheter

Asses the degree of pain often and record the baseline

level of pain and the degree to which pain is reduced bymedications or other intervention

When changing to an oral route for pain management, plan to pretreat the pain with oral medications 30minutes or more before discontinuing the infusion



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Diagnose:Risk for spinalcord ischemia

A rare but devastatingeffect of aortic abdominalaneurysm repair is spinalcord ischemia leading to

paralysis, with or without bowel and bladder involvement

It appears to be most

common in clients whohave suprarenal aorticreconstruction

Outcome

The nurse will monitor for manifestations of spinal corddamage and report any abnormaldata

Implementation

Monitor ability to move lower extrimities and sensation in bothlegs every 1-2 hours



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Anxiety

Explain all procedures and treatments, using simple and

understandable terms

Respond to all questions honestly, using a calm,

empathetic, but matter –of-fact manner

Honestly with the client and family promotes trust and

provides reassurance that the true nature of the situation is

not being ”hidden” from them Provide care in a calm, efficient manner

Nursing Implementation



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ambulatory and home care

The patient hould be instructed to gradually increase activities

Fatigue, poor appetite, and irregular bowel habits are to beexpected

Heavy lifting is avoided for at least 4 to 6 weeks followingsurgery

Observation of incisions for signs and symptoms of infectionis encouraged

Any reddness, swelling, increased pain, drainage fromincision or fever greater than 37.8 c should be reported to thehealth care provider




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The patient should be taught to observe for changes in color

or warmth of the extrimities

Patients may be taught to palpate peripheral pulses and to

assess changes in their quality

The patient who has received a synthetic graft should be

aware that prophylactic antibiotics may be required beforefuture invasive procedures, including any dental procedures




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Sexual ysfunction in male patients is not uncommon after aortic surgery

Sexual dysfunction may occur because the internalhypogastric artery is interrupted, leading to decreased arterial

blood flow to the penis

The periaortic sympathetic plexus may be disrupted by theurgical procedures

Preoperatively, baseline sexual function should be

documented and patient counselling is recommended

Postoperatively a referral to urologist may be considered if impotence is a problem




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Prescribed antihypertensive and anticoagulantmedicationsand their expected and unintended effects

The importance of adequate rest and nutrition for healing

Measures to prevent constipation and straining at stool

(such as increasing fluid and fiber in the diet)



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Self care

Driving may also be restricted because of postoperative weaknessand decreased response time

The client can resume sexual activities in about 4-6 weeks, whenhe or she is able to walk without shortness of breath (e.g., twoflights of stairs

The risk of impotance in male clients should be discussed beforedischarge

Causes vary from pre-existing aortoiliac disease or diabetes toside effects from aortic cross- clamping

Self Care



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The client should ambulate as tolerated, includingclimbing stairs and walking outdoors

If legs swelling develops, the leg should be wrappedin elastic bandages or support stockings should beused

Activities that involve lifting heavy objects are not

permitted for 6-12 weeks postoperatively



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Self care Most clients who require abdominal aortic aneurysm repair

have significant degree of arterial disease

Many of the postoperative instructions should address care of client with arterial disorders, which is discussed earlier

Review all medications to be used by the client to be certainthat he or she undertands their purpose, schedule, and sideeffect

Instruct the client about incision care and manifestation of infection

Home care when surgical repair is not



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immediately planned

Discuss the follwing topics when surgical repair is not

immediately planned and the aneurysm will be monitored

Measures to control hypertension, including lifestyle and

prescribed drugs

The benefits of smoking cessation

Manifestations of increasing aneurysm size or complications to

report to the physician

nursing aneurysm

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