Transcript Nursing Care Plan of Aortic Aneurysm - An

An-Najah National University
Faculty of Nursing
Second year students
Nursing Care Plan of
Aortic Aneurysm
Prepared by: Abed Alaziz Al Masri
Obiedah Nasfat
Abed Elsalam Isa
1
2
What is Aortic Aneurysm ?

Is a localized sac or
dilation at a weak point
of the aorta to a size
greater than 1.5 times
its normal diameter
3
What are the causes of Aortic Aneurysm ?

Most aneurysms are
arteriosclerotic in origin
 Syphilis
 Infection
 Inflammatory diseases

Trauma
 Hypertension
 Smoking
 Aortic dissection
4
What are the classifications of aneurysms according to their
shape ?

The first classification is
:

Fusiform Aneurysm :
dilation of the entire
circumference of the
artery

Saccular Aneurysm :
localized balloon- shaped
outpouching projects
from one side of the
artery
5
The second classification is :

True Aneurysm : involve
the entire vessel wall

False Aneurysm : is formed
when blood leaks outside of
the artery but is contained
by the surrounding tissues

A pseudoaneurysm, or false
aneurysm, is an enlargement
of only the outer layer of the
blood vessel wall

A false aneurysm may be the
result of a prior surgery or
trauma
6
Thoracic Aortic Aneurysm (TAA)

Occur most frequently in
men between the ages 40
and 70 years

About one third of
patients with (TAA) die
of rupture of the
aneurysm
7
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
8
What are the diagnostic tests for (TAA) ?

Chest x-ray


Computed
tomography (CT)

Transesophagial
echocardiography
Abdominal Aortic Aneurysm (AAA)

Affects men four times
more often than women
and is most prevalent in
elderly patients

Most of these aneurysms
occur below renal arteries
(infrarenal aneurysm)

Untreated, the eventual
outcome may be rupture
and death
10
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 mottling
of the extrimities or distal emboli in the feet alert the
clinician to a source in the abdomen
11
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

Rupture and hemorrage
12
Who’s at risk?

In 20% of patients, familial clustering of aortic aneurysms
suggests a hereditary tendency to develop aneurysms, aortic
aneurysms also can be an individual aberration present at
birth

Pregnancy can hasten aneurysm development because of
hormonal and hemodynamic changes
13
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 genetic
connective tissue disorder
that affects the skeleton,
eyes, and cardiovascular
system)
 Mycotic aneurysms,
develop from streptococcal,
staphylococcal, or
salmonella infections of the
aorta
Indications for Surgical Repair of Aortic Aneurysms
 Thoracic
 Diameter 6 cm (5 cm in patients with Marfan
syndrome)
 Symptoms suggesting expansion or
compression of surrounding structures

Abdominal
 Diameter 5 cm or more
 Diameter 4 cm or less, need regular follow-up
 Diameter 4–5 cm, management is controversial
 Others
 Rapidly expanding aneurysms (growth rate > 0.5
cm over a 6-month period)
 Symptomatic aneurysm regardless of size
Implement Interventions to Reduce the Risk of
Aneurysm Rupture
 Maintain bed rest with
legs flat
 Maintain a calm
environment,
implementing measures
to reduce psychologic
stress
 Administer beta blockers
and antihypertensive as
prescibed
 Elevating or crossing the
legs restricts peripheral
blood flow and increases
pressure in the aorta or
iliac arteries
 Prevent straining during
deafecation
16
Abdominal Aortic Aneurysm- Open Repair

Open repair of an abdominal aortic aneurysm involves an
incision of the abdomen to directly visualize the aortic
aneurysm

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 the
navel or across the abdomen and down the center
17
Grafts
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 the
graft to protect it
19
Open Repair

The graft is sutured to the
aorta connecting one end
of the aorta at the site of
the aneurysm to the other
end of the aorta

Open repair remains the
standard procedure for an
abdominal aortic aneurysm
repair
20
Endovascular
Aneurysm 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, radiology
department, 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
21
Endovascular
Aneurysm Repair
(EVAR)

With the use of special endovascular instruments, along
with x-ray images for guidance, a stent-graft will be
inserted through the femoral artery and advanced up into
the aorta to the site of the aneurysm
22
Endovascular Aneurysm Repair (EVAR(

A stent-graft is a long cylinder-like tube made of a thin
metal framework (stent). The stent helps to hold the graft
in 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 a
spring-like fashion), attaching to the wall of the aorta to
support the wall of the aorta

The aneurysm will eventually shrink down onto the stentgraft
23
Risks of the Procedure- open repair




Lung problems

Kidney damage

Spinal cord injury

Damage to surrounding
blood vessels, organs, or
other structures by
instruments

Groin wound infection
Myocardial infarction
Irregular heart rhythms
Bleeding during or after
surgery

Injury to the bowel

Limb ischemia
Embolus to other parts of the  Groin hematoma
body
 Endoleak
 Infection of the graft
 Allergy

Nursing Assessment
 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 surgery
25
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
26
Nursing Implementation- Graft Patency

Maintain adequate blood pressure to promote graft patency.
Prolonged hypotention may result in graft thrombosis due
to decreased blood flow

Administration of of i.v. fluids and blood components as
indicated is essential to maintaining adequate blood flow to
the graft

Central venous pressure readings or pulmonary artery
pressures and urinary output should be monitored hourly in
the immediate postoperative period to help assess the
patient´s state of hydration
27
Nursing Implementation- Graft Patency

Severe hypertention may cause undue stress on the arterial
anastomosis 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
28
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 the
heart or increased oxygen demands on the heart. Cardiac
rhythmias 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 medications
as needed

Replacement of electrolytes as indicated, adequate pain
control and resumption of preoperative cardiac medications
29
Infection
Diagnosis
 Risk for infection related to presence of a prosthetic
vascular graft and invasive lines
Outcome

Normal body temperature

No signs of infection

Wound is well approximated
Nursing Implementation- Infection
 Nursing
prevention to prevent infection should
include ensuring that the patients receives a broad
spectrum antibiotic as prescribed
 Monitor
for signs of infetion
 The
nurse should ensure adequate nutrition and
observe the surgical incision for any evidence of
delaying healing or prolonged drainage
31
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
32
Nursing Implementation- Gastrointestinal Status

Paralytc ileus may develop as a result of anesthesia and the
manual 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 connected
to low, intermittent suction

This decompreses the stomach and duodenum, prevent
aspiration of stomch contents, and decrease pressure on
suture lines
33
Nursing Implementation- Gastrointestinal Status

The nasogastric tube should be irrigated with normal saline
solution 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 bowel
function and shoud be noted

Early ambulation will assist with the resumption of bowel
functioning

It is unusual for paralytic ileus to persist beyond the fourth
postoperative day
34
Diagnose: risk for ischemia
of the bowel

If the client undergoes extensive
aortic procedures that involve
clamping the mesenteric vessels,
ischemic colitis can develop

Inferior mesenteric artery can
embolize

The lack of blood supply can
lead to ischemia and ileus
Outcomes

The nurse will monitor the client
for abdominal distention,
diarrhea, severe abdominal pain,
sudden elevation in white blood
cell count and bowel sound
35
Intervention

Provide routine nasogastric
tube care and assess nares
for tissue impairment

Assess bowel sounds
every 4 hours

Keep the client NPO and
provide oral care every 2-  Perform guaiag test (Test
4 hr
for blood in stool) of NG
drainage every 4 hours or if
bleeding is suspected (i.e.,
drainage has dark, coffeeground appearance or is
bright red)
36
Nursing Implementation- Neurologic Status

When the ascending aorta and aortic arch are involved,
nursing interventions should include:
 assessment of level of conciosness, pupil size and
response to light, facial symmetry, tongue deviation,
speech, ability to move upper extrimities, quality of hand
grasps,
 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
37
Nursing Implementation- Peripheral Perfusion Status

When checking the pulses, the nurse should mark the locations lightly
with 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 the
extrimities
38
Nursing Implementation- Peripheral Perfusion Status

A decreased or absent pulse in conjunction with a cool,
pale, mottled or painful extrimity may indicate
embolization 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
39
Nursing Implementation- Renal Perfusion Status

One of the causes of decreased renal perfusion is
embolization of a fragment of thrombus or plaque from the
aorta 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
40
Nursing Implementation- Renal Perfusion Status
 The
patient return from surgery with an indwelling
urinary 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 pulmonary
artery pressures also provide important information
regarding hydration status
41
Diagnose
 Risk for hemorrhage
because of the risk of
bleeding at the graft
site, the client is at risk
for hemorrhage

Outcome
 The nurse will monitor
for manifestations of
hemorrhage and notify
the physician if any
manifestations occur
Risk for deficient fluid
volume
42
Interventions- Monitor the client for:
 increase in pulse rate
 Cyanosis
 decrease in blood
 thirst
pressure
 clammy skin
 pallor
 anxiety & restlessness
 oliguria
 increase abdominal girth
 increased chest tube
output greater than 100
ml/hr/for 3 hours
 decreasing levels of
conciousness
 back pain from
retroperitoneal bleeding
Diagnose
Outcome
Risk for impaired gas
exchange


Impaired gas exchange
related to ineffective
cough secondary to
pain from large incision
The client will have
improved gas exchange as
evidenced by oxygen
saturation or Pao2 greater
than 95%, increasing
effectiveness in coughing,
and clearing of lung sounds
44
Intervention

Monitor settings on ventilator
to ensure the client is
adequately oxygenated
Spirometry

Assess lung sounds every 1 to 2
hours

Monitor oxygen saturation
continously. Report any
desaturation

After extubation,
 assist with coughing by using
incentives spirometry,
 provide splinting pillows before
coughing,
 encourage ambulation
 provide adequate analgesia
Diagnose
Outcomes



Risk for inadequate tissue
perfusion

During the operation, aorta is
clamped to stop bleeding while
the graft is placed
 pedal pulses
 warm feet
 capillary refill of less than 5
During that time, peripheral
tissues are not perfused

The graft site can also become
occluded with thrombus

In addition the client often has
preexisting arterial disease
The client will maintain adequate
tissue perfusion as evidenced by:
seconds,
 abscence of numbness or
tingling
 ability to dorsiflex and
plantar flex both feet equally

Urin output adequate
46
Plantar Flexion
Extension of the ankle resulting in
the forefoot moving away from
the body.
Dorsal Flexion
Flexion of the ankle resulting in the top of
the foot moving toward the body
Intervention
Risk for Inadequate Tissue Perfusion

Administer i.v. Fluid at
prescribed rates to ensure
adequate hydration and renal
perfusion

Maintain a warm
environment to prevent
temperature induced
vasoconstriction

Administer
anticoagulants and /or
antiplatelet agents as
prescribed to prevent
thrombus formation

Monitor urinry output
daily weights, BUN,
and serum createnine to
detect signs of altered
perfusion and renal
failure
48
Acute Pain
Outcomes
Diagnosis:

Acute pain related to
surgical incision

The client will have increased
comfort as evidenced by :
 self-report of decreasing levels
of pain
 use of decreasing amounts of
opioid analgesics for pain
control
 ambulating or coughing
without extreme pain
49
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 by
medications or other intervention

When changing to an oral route for pain management,
plan to pretreat the pain with oral medications 30
minutes or more before discontinuing the infusion
50
Diagnose:
Risk for spinal
cord ischemia
Outcome



A rare but devastating
effect of aortic abdominal
aneurysm repair is spinal
cord ischemia leading to
paralysis, with or without
bowel and bladder
involvement
It appears to be most
common in clients who
have suprarenal aortic
reconstruction
The nurse will monitor for
manifestations of spinal cord
damage and report any abnormal
data
Implementation
 Monitor ability to move lower
extrimities and sensation in both
legs every 1-2 hours
51
Nursing Implementation- Ambulatory and
Home Care

Sexual dysfunction in male patients is not uncommon after
aortic surgery

Sexual dysfunction may occur because the internal
hypogastric artery is interrupted, leading to decreased
arterial blood flow to the penis

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
52
Self Care
 The
client should ambulate as tolerated, including
climbing stairs and walking outdoors
 If
legs swelling develops, the leg should be wrapped
in elastic bandages or support stockings should be
used
 Activities
that involve lifting heavy objects are not
permitted for 6-12 weeks postoperatively
53