resource unit aaas

8/8/2019 Resource Unit Aaas

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RESOURCE UNIT

ABDOMINAL AORTIC ANEURYSM

Submitted by:

BSN 3-E, GROUP IV

Campos, Julie AnnMartinez, Ma. Carla

Matalaba, Anne KhriztineMonleon, Vanessa Mae

Monteron, Rodielyn MaeNajarro, Marie Kathleen

Natural, MeriamObani, Mie

Palmero, Johanna Marie

Palmitos, AngelicaPeaflor, Pinky

Sumalinog, Jo Anne

Tangkay, ChristineTorrevillas, Gail

Tuang, Jarric

Submitted to:

Ms. Cecilia C. Ramos, RNClinical Instructor


2/22

ABDOMINAL AORTIC ANEURSYM

General Objective: After 1 hour of lecture, the BSN IV students will be able to acquire positive attitude, basic knowledge and skills on the concept of abdominal aortic aneurysm.

SPECIFIC

OBJECTIVES

CONTENT TIME ALLOTMENT METHODOLOGY RESOURCES EVALUATION

Specifically, the BSN3E students will be

able to:1.Introduction:

Define-aneurysm- aortic aneurysm-abdominal

aneurysm

Overview

An aneurysm is an area of a localized widening

(dilation) of a blood vessel. (The word"aneurysm" is borrowed from the Greek"aneurysma" meaning "a widening").

An aortic aneurysm involves the aorta, one ofthe large arteries through which blood passesfrom the heart to the rest of the body. The aortabulges at the site of the aneurysm like a weakspot on an old worn tire.

Aortic aneurysms can develop anywhere alongthe length of the aorta. The majority, however,are located along the abdominal aorta. Most

(about 90%) of abdominal aneurysms arelocated below the level of the renal arteries, thevessels that leave the aorta to go to the kidneys.About two-thirds of abdominal aneurysms arenot limited to just the aorta but extend from theaorta into one or both of the iliac arteries.

Abdominal aortic aneurysm (also known asAAA, pronounced "triple-a") is a localizeddilatation (ballooning) of the abdominal aorta

exceeding the normal diameter by more than 50percent. Approximately 90 percent of abdominal

aortic aneurysms occur infrarenally (below thekidneys), but they can also occurpararenally(atthe level of the kidneys) orsuprarenally(abovethe kidneys). Such aneurysms can extend to

i. Prayer 2 min.

ii. Reading of Objectives 3 min.

iii. Lecture 1 hour

iv. Evaluation 15 min.

- lecture Human:

BSN 4E students

Internet:

www.medicinenet.comwww.webmd.comwww.intelihealth.comwww.bestpractice.bmj.com

Books:Textbook Medical

SurgicalNursing,10th

Ed.,Smeltzer andBare.

Medical SurgicalNursing ClinicalManagement forPositive Outcomes,8th Ed., Black and

Hawks.

After an hour of

lecture, the BSN 4Estudents were able toactively participate in

the question andanswer portion of thehealth teachingprogramme.
http://en.wikipedia.org/wiki/Dilatationhttp://en.wikipedia.org/wiki/Abdominal_aortahttp://en.wiktionary.org/wiki/infrarenalhttp://en.wiktionary.org/wiki/pararenalhttp://en.wiktionary.org/wiki/pararenalhttp://en.wiktionary.org/wiki/suprarenalhttp://en.wiktionary.org/wiki/suprarenalhttp://www.medicinenet.com/http://www.medicinenet.com/http://www.intelihealth.com/http://www.intelihealth.com/http://en.wikipedia.org/wiki/Abdominal_aortahttp://en.wiktionary.org/wiki/infrarenalhttp://en.wiktionary.org/wiki/pararenalhttp://en.wiktionary.org/wiki/suprarenalhttp://www.medicinenet.com/http://www.medicinenet.com/http://www.intelihealth.com/http://www.intelihealth.com/http://en.wikipedia.org/wiki/Dilatation


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include one or both of the iliac arteries in thepelvis.

Abdominal aortic aneurysms occur mostcommonly in individuals between 65 and 75years oldand are more common among men andsmokers. They tend to cause no symptoms,although occasionally they cause pain in theabdomen and back (due to pressure onsurrounding tissues) or in the legs (due todisturbed blood flow). The major complication

of abdominal aortic aneurysms is rupture, whichcan be life-threatening as large amounts of blood

spill into the abdominal cavity, and can lead todeath within minutes.
http://en.wikipedia.org/wiki/Iliac_arterieshttp://en.wikipedia.org/wiki/Iliac_arterieshttp://en.wikipedia.org/wiki/Elderlyhttp://en.wikipedia.org/wiki/Elderlyhttp://en.wikipedia.org/wiki/Elderlyhttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Bleedinghttp://en.wikipedia.org/wiki/Abdominal_cavityhttp://en.wikipedia.org/wiki/Abdominal_cavityhttp://en.wikipedia.org/wiki/Deathhttp://en.wikipedia.org/wiki/Iliac_arterieshttp://en.wikipedia.org/wiki/Elderlyhttp://en.wikipedia.org/wiki/Elderlyhttp://en.wikipedia.org/wiki/Painhttp://en.wikipedia.org/wiki/Bleedinghttp://en.wikipedia.org/wiki/Abdominal_cavityhttp://en.wikipedia.org/wiki/Death


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2. Enumerate the riskfactors of AAAs

The exact cause is unknown, but risk factors fordeveloping an aortic aneurysm include:

cigarette smoking not only increases therisk of developing an abdominal aorticaneurysm, the chance of aneurysmrupture (a life-threatening complication

of abdominal aneurysm) is also morecommon among active smokers.

High blood pressure

High cholesterol

Male gender

Emphysema

Genetic factors- There is a familialtendency to developing abdominal aorticaneurysms. Individuals with first-degreerelatives having abdominal aorticaneurysms have a higher risk ofdeveloping abdominal aortic aneurysmthan the general population. They alsotend to develop the aneurysms at

younger ages and have a highertendency to suffer aneurysm rupture

than individuals without family history.

Obesity

Age

3. Discuss the etiology. The primary event in the development of an

AAA involves proteolytic degradation of theextracellular matrix proteins elastin and

collagen. Various proteolytic enzymes,including matrix metalloproteinases, are criticalduring the degradation and remodeling of theaortic wall.4 Oxidative stress also plays animportant role, and there is an autoimmunecomponent to the development of AAA, with
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extensive lymphocytic and monocyticinfiltration with deposition of immunoglobulin

G in the aortic wall.4Cigarette smoking elicitsan increased inflammatory response within theaortic wall.5 An infectious etiologywith Chlamydia pneumoniae has been proposedbut not proven.4 Increased biomechanical wall

stress also contributes to the formation andrupture of aneurysms with increased walltension and disordered flow in the infrarenalaorta.4 Finally, 12 to 19 percent of first-degreerelatives, predominantly men, of a patient withan AAA will develop an aneurysm.6

4. Briefly discuss theanatomy andphysiology of theabdomen and itsarteries.

The abdomen (commonly called the belly) isthe body space between the thorax (chest) andpelvis. The diaphragm forms the upper surfaceof the abdomen. At the level of the pelvicbones, the abdomen ends and the pelvisbegins.The abdomen contains all the digestive

organs, including the stomach, small and largeintestines, pancreas, liver, and gallbladder.These organs are held together loosely byconnecting tissues (mesentery) that allowthem to expand and to slide against eachother. The abdomen also contains the kidneysand spleen.Many important blood vessels travel throughthe abdomen, including the aorta, inferior venacava, and dozens of their smaller branches. In

the front, the abdomen is protected by a thin,tough layer of tissue called fascia. In front of

the fascia are the abdominal muscles and skin.

In the rear of the abdomen are the backmuscles.
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The aorta is the largest artery in the body. It isconnected to the left ventricle of the heart andhas the job of carrying oxygenated blood fromthe heart to other parts of the body.The abdominalaorta is the last portion of theaorta and is located in the abdominal cavity. It

takes blood from the aorta, through the trunk,and to the abdominopelvic organs and legs. Theleft ventricle and thoracic aorta of the heart leadto the abdominal aorta which begins at

the diaphragm. This artery then crosses thediaphragm at the level of the T12 vertebrae.

From there it descends along the posterior wallof the abdomen in front of the vertebral column,following the natural curvature of the lumbarvertebrae and positioned slightly to the left ofthe midline of the body. It also lies parallel tothe inferior vena cava, which is located to itsright.

The abdominal aorta branches into three sets of

smaller arteries, becoming narrower as itdescends through the abdominal cavity. These

three sets are known as the visceral, parietal, andterminal arteries. These branches of theabdominal aorta and their associated vertebrallevels are defined as follows. From the vertebrallevel of T12, the abdominal aorta first branchesinto the inferior phrenic and celiac arteries(T12), superior mesenteric and middlesuprarenal arteries (L1), renal and gonadalarteries (L2), lumbar artery (L1-L4), inferiormesenteric artery (L3), and the median sacraland common iliac arteries (L4). At the L5 level,the artery then splits to form the two common
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iliac arteries that carry blood to the legs.

The most common ailment involving theabdominal aorta is an abdominalaortic aneurysm (AAA). An aneurysm is awidening (also known as dilation) of a blood

vessel due to a weakness in the vessel. At theweak portion, the aneurysm bulges and poses aserious risk of rupture. An AAA is morecommon in men, particularly those age 60 andolder. Approximately 5% of men over the age of60 suffer from abdominal aortic aneurysms. Riskfactors for the development of AAA includecigarette smoking, hypertension,highcholesterol (hypercholesterolemia),and diabetes mellitus. While there are severalpossible causes of an AAA, the most commoncause remains arteriosclerosis, or hardening ofthe arteries.

5 .Briefly explain thepathophysiology of theAAAs.

Histologically there is obliteration of collagenand elastin in the media and adventitia, smoothmuscle cell loss with resulting tapering of themedial wall, infiltration of lymphocytes andmacrophages, and neurovascularization.

Proteolytic degradation of aortic wall connectivetissue: matrix metalloproteinases (MMps) andother proteases are derived from macrophages

and aortic smooth muscle cells and secreted intothe extracellular matrix. Disproportionate

proteolytic enzyme activity in the aortic wallmay promoto deterioration of structural matrix proteins. Increased expression of collagenasesMMp-1 and MMP-13 and elastases MMp-2,
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distal emboli in the feet

Once the aneurysm bursts, symptoms include:

Severe back or abdominal pain that

begins suddenly

Paleness

Dry mouth/skin and excessive thirst

Nausea and vomiting

Signs of shock, such as shaking,dizziness, fainting, sweating, rapid

heartbeat and sudden weakness

7 .List the diagnosticprocedures to beperformed.

DIAGNOSTIC TOOLS:

Duplex Ultrasonographyhas about 98%accuracy in measuring the size of theaneurysm, and is safe and noninvasive. Butultrasound cannot accurately define theextent of the aneurysm and is inadequate forsurgical repair planning.

Computed Tomography (CT) scan of theabdomen, is highly accurate in determiningthe size and extent of the aneurysm, and itsrelation to the renal arteries. However,computerized tomography uses high dosesof radiation and for evaluation of blood

vessels, requires intravenous dye. Thiscarries some risk including allergic reaction

to the dye and irritation of the kidneys.

Arteriogram (real time x-rays) where dye is

directly injected into the aorta to assess itsanatomy, historically was the diagnostic test

of choice. Presently, it's indications may belimited to use when surgery or stenting is

considered


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MRI (magnetic resonance imaging) Inpatients with kidney diseases, the doctormay consider an MRA (magnetic resonanceangiography), which is a study of the aorta

and the other arteries using MRI scanning.

8. Discuss the medicalmanagement.

The treatment options for asymptomatic AAAareconservative management, surveillance witha view to eventual repair, and immediate repair.There are currently two modes of repairavailable for an AAA: open aneurysm repair(OR), and endovascular aneurysm repair(EVAR). An intervention is often recommendedif the aneurysm grows more than 1 cm per yearor it is bigger than 5.5 cm.Repair is alsoindicated for symptomatic aneurysms.

Conservative

Conservative management is indicated inpatients where repair carries a high risk ofmortality and in patients where repair is unlikelyto improve life expectancy. The mainstay of theconservative treatment is smoking cessation.

Surveillance is indicated in small asymptomaticaneurysms (less than 5.5 cm) where the risk ofrepair exceeds the risk of rupture. As an AAAgrows in diameter the risk of rupture increases.Surveillance until the aneurysm has reached adiameter of 5.5 cm has not been shown to have a

higher risk as compared to early intervention.
http://script/main/art.asp?articlekey=12199http://script/main/art.asp?articlekey=421http://en.wiktionary.org/wiki/conservative_treatmenthttp://en.wiktionary.org/wiki/conservative_treatmenthttp://en.wikipedia.org/wiki/EVARhttp://en.wikipedia.org/wiki/Tobacco_smokinghttp://script/main/art.asp?articlekey=12199http://script/main/art.asp?articlekey=421http://en.wiktionary.org/wiki/conservative_treatmenthttp://en.wikipedia.org/wiki/EVARhttp://en.wikipedia.org/wiki/Tobacco_smoking


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Medication

No medical therapy has been found to beeffective at decreasing the growth rate or rupturerate of asymptomatic AAAs.Blood pressure andlipids should however be treated like in any

atherosclerotic condition.Studies have suggestedpossible protective use effects of therapy withangiotensin converting enzyme inhibitors,beta-blockers, andstatins. Client should be monitoredfor blood pressure. Use opioids to reduce pain;tranquilizers may also be needed.

9. Discuss the surgicalmanagement.

Surgery for an abdominal aortic aneurysm isknown as AAA surgery or AAA repair. Thethreshold for repair varies slightly fromindividual to individual, depending on thebalance of risks and benefits when consideringrepair versus ongoing surveillance. The size ofan individual's native aorta may influence this,

along with the presence of comorbidities thatincrease operative risk or decrease lifeexpectancy.

Aneurysm repair

Aneurysm repair is recommended for allaneurysms greater than 6 cm wide. Electiverepair is also generally recommended foraneurysms between 4 and 6 cm in clients who

are good surgical risks. The more traditionalsurgical technique for aneurysm repair is done

through a midline incision that extends from thexyphoid process to the symphisis pubis. Theaneurysm is exposed, the aorta is clamped justabove and below the aneurysm to stop the flow
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of blood, the aneurysm is open, and a dacrongraft is placed within the aneurysm. Theaneurysm sac is then wrapped around the graftto protect it.

Endovascular repair

Endovascular repair is generally indicated inolder, high-risk patients or patients unfit foropen repair. Its is also a newer method for non

emergency treatment to repair abdominal aorticaneurysm.However, endovascular repair is

feasible for only a proportion of AAAs,depending on the morphology of the aneurysm.The main advantages over open repair are thatthere is less peri-operative mortality, less time inintensive care, less time in hospital overall andearlier return to normal activity. Two smallincisions are made in the groin, and a vascular

graft is guided into the aorta. At the tip of thecatheter are a deflated balloon and a tightlywrapped polyester cloth graft. When properlypositioned, the graft is secured in placed byinflating the balloon and opening the graft to thediameter needed to prevent blood flow into theaneurysm. The balloon is then deflated andremoved along with the catheter. At each end ofthe graft are hooks that help secure it to the innerwalls of the aorta. The graft allows blood flow tocontinue through the aorta to the arteries in thepelvis and legs, without filling the aneurysm.Disadvantages of endovascular repair include a

requirement for more frequent ongoing hospitalreviews, and a higher chance of further

procedures being required. According to the
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latest studies, the EVAR procedure does notoffer any benefit for overall survival or health-related quality of life compared to aneurysmsurgery, although aneurysm-related mortality islower.In patients unfit for aneurysm repair,EVAR plus conservative management was

associated with no benefit, more complications,subsequent procedures and higher costscompared to conservative management alone.

10. Enumerate possiblecomplications.

Abdominal aortic aneurysm repair is considereda major operation, and many specific postoperative complications can develop.Complications after abdominal aortic aneurysmrepair are generally caused by coronary arterydisease and chronic obstructive pulmonarydisease. These conditions decrease excretion ofanesthetic, increase the risk of postoperativeatelectasis, and decrease the client's tolerance of

hemodynamic changes from blood loss and fluid

shifts. To reduce the risk of acute myocardialinfarct ion, one of the most seriouscomplications, clients may undergo coronaryartery bypass before aneurysm repair.Prerenal failure can develop for several reasons.The kidney can sustain ischemia from decreaseaortic blood flow, decreased cardiac output,emboli, inadequate hydration, or the need forclamps on the aortic above the renal arteriesduring surgery.Emboli can also develop and lodge in thearteries of the lower extremities or mesentery.Clinical manifestations include those of acute

occlusion in the leg. Bowel necrosis is exhibitedas fever, leukocytosis, ileus, diarrhea, andabdominal pain.
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The spinal cord can also become ischemic,resulting in the paraplegia, rectal and urinary

incontinence, or loss of pain and temperaturesensation. Spinal cord ischemia tends to occurmore commonly when an abdominal aorticaneurysm has ruptured.Changes in sexual function may also develop

following repair of an abdominal aorticaneurysm. Retrograde ejaculation occurs inabout two thirds of male clients and loss ofpotency occurs in one third of males who haveundergone repair of abdominal aortic aneurysm.

11. Prognosis The outlook for an untreated abdominal aorticaneurysm depends on its size. An abdominal aortic aneurysm larger than 7centimeters in diameter has a 75% chance ofrupturing within 5 years. At 6 centimeters, the risk of rupture is 35%over 5 years. Between 5.0 and 5.9 centimeters, the rupture

risk is about 25% over 5 years. The risk of rupture is much lower foraneurysms smaller than 5 centimeters (2 inches).With successful surgical repair, the prognosis isgood and depends more on the severity ofatherosclerosis affecting other organs, especiallythe heart, brain and kidneys.

12. NursingManagement

Surgical repair of an aneurysm is usuallyperformed if the aneurysm is growing rapidlyand/or reaches a size of 5-6 cm or larger or if theclient experiences symptoms. The procedureoften involves the use of a synthetic graft, which

is inserted to replace or support the weakenedvessel.


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This care plan focuses on the adult clienthospitalized for surgical repair of an abdominal

aortic aneurysm. Much of the postoperativeinformation is applicable to clients receivingfollow-up care in an extended care facility orhome setting.

A. Preoperative :Abdominal aortic surgery is a majorsurgery; it last approximately 4 hours.During the hours under anesthesia, thepatient faces a great risk of pulmonaryand cardiac complications developing.Three operative assessment mustinclude:

1. Detection ofconcurrent coronaryartery disease andcerebrovascular

disease.2. Assessment of all

peripheral pulses forbaseline comparison,

post-operatively.3. Standard evaluation

for endovascularrepair due to potentialopen repair of theaneurysm.

B. Post-operative:Following surgery, clients usually return

to an intensive care unit. Acomprehensive postoperativeassessment of the client after open


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surgical repair for abdominal aorticaneurysm repair is essential. Potential

complications are many, because of theseriousness of the problem and thecomplexity of the repair. Even thoughextra corporeal perfusion(cardiopulmonary bypass) is not needed

for the surgery, arterial flow to tissuesdistal to the aneurysm is reduced duringthe time required to perform the surgerybecause the aorta is clamped.

1. Nursing diagnosis: Risk for

Hemorrhage

Assessment:Because of the risk of bleeding at thegraft site, the client is at risk forhemorrhage.

Outcome Criteria:The nurse will monitor for

manifestations of hemorrhage and notifythe physician if any manifestations

occur.

Intervention:

Assess for changes indicatinghypovolemia:

Increase pulse rate, decreased

BP

Clammy skin, pallor,cyanosis

Anxiety, restlessness,

decreasing levels ofconsciousness

Thirst, oliguria (urine output


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less than 0.five ml/kg/hr)

Increased abdominal girth,increased chest tube output>100 ml/hr for 3 hours.

Back pain (from retroperitonealbleeding)

Central venous pressure, left

atrial pressure, pulmonary arterypressure, and pulmonarycapillary wedge pressurecontinuously.

2. Risk for Impaired Gas Exchange:

The large abdominal incision impairsdeep inspiration and usually reducedeffective coughing

Outcomes:The client will have improved gasexchange as evidenced by oxygen

saturation >95%increasingeffectiveness in coughing and clearing

of lung sounds.

Interventions:Monitor settings on the ventilator toensure that the client is adequatelyoxygenated.

Assess lung sounds every 1 to 2hours, report any adventitiouslung sounds.

Monitor oxygen saturation

continuously, report anydesaturation.

After extubation, assist with


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coughing by using incentivespirometry, provide splinting

pillows before coughing,encouraging ambulation, andproviding adequate analgesia.

3. Risk for Ineffective tissue Perfusion:

During the operation, the aorta isclamped to stop bleeding while the graftplaced. During that time, distantperipheral tissues are not perfused. Thegraft site can also become occludedwith thrombus. In addition, the clientoften has free-existing arterial disease.

Outcomes:The client will maintain adequate tissueperfusion as evidenced by pedal pulses,warm feet, capillary refill of less than 5seconds, absence of numbness or

tingling, and availability to dorsiflex andplantiflex both feet equally.

Interventions:

Assess dorsalis pedis and posterior tibialpulses every hour for 24 hours. Reportchanges in pulse quality or absentpulses.

Assess dorsiflexion andplantiflexion and sensationevery hour for 24 hours.

Inspect lower extremeties formottling, cyanosis, coolness, ornumbness every 4 hours.


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4.Acute Pain

Abdominal aortic anuersym repairnecessitates a long incision.

Outcomes:The client will have increased comfort

as evidenced by self-report ofdecreasing levels of pain, use ofdecreasing amount of opioid analgesicsfor pain control, and ambulating orcoughing without extreme pain.

Interventions:Opioids are usually provided via apatient-controlled analgesia system orthrough an epidural catheter.

Assess the degree of pain oftenand record the baseline level of

pain and the degree to whichpain is reduced by medicationsor other interventions.

When changing to an oral routefor pain management, plan topretreat the pain with oralmedications 30 minutes or morebefore discontinuing theinfusion.

FIVE: Risk for Ischemia of the BowelIf the client undergoes extensive aortic

procedures that involve clamping themesenteric vessels, ischemic colitis candevelop. In addition, the inferior


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mesenteric artery can emobolize. Thelack of blood supply can lead to

ischemia and ileus.

Outcomes:The nurse will monitor the client for

abdominal distention, diarrhea, severe

abdominal pain, sudden elevations in whiteblood cell count and bowel sounds.

Interventions:

Assess bower sounds every 4 hours.

Keep the client nothing by

mouth( NPO ) and provide oral careevery 2 to 4 hours.

Provide routine nasogastric ( NG ) tubecare.

Assess nares for tissue impairment.

Perform guaiac tests of NG drainage

every hours or bleeding is suspected( i.e.,drainage has dark, coffee-groundappearance or is bright red).

6.Risk for Spinal Cord IschemiaA rare but devastation effect of aortic

abdominal aneurysm repair is spinal cordischemia leading to paralysis, with or withoutbowel and bladder involvement. It appears to bemost common in clients who have suprarenalaortic reconstruction.

Outcomes:

The nurse will monitor formanifestations of spinal cord damageand report any abnormal data.


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Interventions:

Monitor ability to move lowerextremities( dorsiflexion andplantar flextion) and sensationin both legs every 1 to 2 hours.

Report any changes from

basesline.


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Abdominal Aortic

Aneurysm

Proteolytic degradationof aortic cell wall

connective tissue

Inflammation and

immune responsesBiochemical wall stress

Disproportionateproteolytic enzyme

activity in the aortic wall

Release of cytokines thatactivate proteases

Decrease elastin-collagenratio

Obliteration of collagen

and elastin in tunicamedia and tunica

adventitia

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