Aortic aneurysm Dr. Aidah Abu Elsoud Alkaissi An-Najah National University Nursing College

Aortic aneurysm

Dr. Aidah Abu Elsoud AlkaissiAn-Najah National University

Nursing College

Thorasic Aorta AneurysmMay be a symptomaticBack, neck or substernal painDyspnea, stridor or brassy cough if pressing on tracheaHoarseness and dysphagia if pressing on esophagus or laryngeal nerveEdema of the face and neckDistended neck vein Complications: rupture and hemorrhage

Abdominal Aorta Aneurysm

Client´s awareness of a pulsating mass in the abdomen, with or withourt pain, followed by abdominal pain and back painFlang pain or groin pain may be experienced because of increasing pressure on other structures sometimes mottling (the act of coloring with areas of different shades) of the extrimities or distal emboli in the feet alert the clinician to a source in the abdomen

Abdominal Aorta Aneurysm

Pulsating abdominal massAortic calcification noted on x-rayMild to severe midabdominal or lumbar back painCool, cyanotic extrimities if iliac arteries are involvedClaudication (ischemic pain with exercise, relieved by rest)Complication: peripheral emboli to lower extrimitiesRupture and hemorrge

MedicationThorasic aorta aneurysms are treated with long-term beta blocker therapy and additional antihypertensive drugs as needed to control heart rate and blood pressureClients with aortic disection are intially treated with intravenous beta blocker such as propranolol (Inderal) , metoprolol (Lopressor), labetalol (Normodyne) , or esmolol (Brevibloc) to reduce the heart rate to about 60BPM.Sodium nitroprusside (Nipride) infusion is started concurrently to reduce the systolic pressure to 120 mmHg or less

MedicationCalcium channel blockers also may be usedDirect vasodilator such as diazoxide (Hyperstat) and hydralazine (Apresoline) are avoided as they may actually worsen the dissectionConstant monitoring of vital signs, hemodynamic pressures (via Swan-Ganz catheter and urin outpt are vital to ensure adequate perfusion of vital organsFollowing surgical correction of an aneurym, anticoagulant tharapy may be intiatedHeparin therapy is used initially, with conversion to oral anticoagulation prior to dischargeMany clients are manifested indefinitely on anticoagulation therapy, others may use lifelong, low- dose-aspirin therapy to reduce the risk of clot formation

Abdominal Aortic Aneurysm Repair

(Abdominal Aneurysm - Open Repair, AAA Repair, Triple A Repair, Abdominal Aneurysmectomy, Endovascular Aneurysm Repair, EVAR)

Procedure OverviewWhat is an abdominal aortic aneurysm repair?

Abdominal aortic aneurysm (AAA) repair is a procedure used to treat an aneurysm (abnormal enlargement) of the abdominal aorta. Repair of an abdominal aortic aneurysm may be performed surgically through an open incision or in a minimally-invasive procedure called endovascular aneurysm repair (EVAR).

Procedure OverviewWhat is an abdominal aortic

aneurysm repair?

Aggressive control of the blood pressure and prolonged bed rest is the usual initial treatment for patients with uncomplicated

dissection sparing the ascending aorta (Stanford type B) as emergency surgery to the descending thoracic aorta carries a substantial mortality when compared with medical treatment.

Surgery should be reconsidered if there is evidence of aortic rupture, proximal extension of the dissection, or ischaemic complications.

The optimal management of patients with suspected dissection requires close liaison between district hospitals and cardiac surgical centres and use of local guidelines for investigation that reflects the available skill.

Patients with a low clinical likelihood of dissection who are in a stable cardiovascular state should undergo prompt local investigation with a nominated non-invasive technique.

Unstable patients with a high likelihood of dissection should receive medical treatment and be transferred immediately to the surgical centre for both diagnostic imaging and management.

If skill in transthoracic or transoesophageal echocardiography is available locally these procedures can be performed while transport is awaited, but doing so should not delay transfer. A videotaped record of the study should accompany the patient to the surgical centre, where repeat transoesophageal echocardiography can be performed in the anaesthetic room if necessary. This approach minimises delay, an essential step in lowering the mortality of acute dissection.

What is an abdominal aortic aneurysm?

An abdominal aortic aneurysm, also called AAA or triple A, is a bulging, weakened area in the wall of the aorta (the largest artery in the body) resulting in an abnormal widening or ballooning greater than 50 percent of the normal diameter (width).

The most common location of arterial aneurysm formation is the abdominal aorta, specifically, the segment of the abdominal aorta below the kidneys.

An abdominal aneurysm located below the kidneys is called an infrarenal aneurysm. An aneurysm can be characterized by its location, shape, and cause.

The shape of an aneurysm is described as being fusiform or saccular, which helps to identify a true aneurysm. The more common fusiform-shaped aneurysm bulges or balloons out on all sides of the aorta. A saccular-shaped aneurysm bulges or balloons out only on one side.

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.

Sometimes, a tear can occur on the inside layer of the vessel resulting in blood filling in between the layers of the blood vessel wall, creating a pseudoaneurysm

The aorta is under constant pressure as blood is ejected from the heart. With each heart beat, the walls of the aorta distend (expand) and then recoil (spring back), exerting continual pressure or stress on the already weakened aneurysm wall.

Therefore, there is a potential for rupture (bursting) or dissection (separation of the layers of the aortic wall) of the aorta, which may cause life-threatening hemorrhage (uncontrolled bleeding) and, potentially, death.

The larger the aneurysm becomes, the greater the risk of rupture. Because an aneurysm may continue to increase in size, along with progressive weakening of the artery wall, surgical intervention may be needed. Preventing rupture of an aneurysm is one of the goals of therapy

Types of abdominal aneurysm repair:

There are two approaches to abdominal aortic aneurysm repair. The standard surgical procedure for AAA repair is called the open repair. A newer procedure is the endovascular aneurysm repair (EVAR).

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. Once the abdomen is opened, the aneurysm will be repaired by the use of a long cylinder-like tube called a graft.

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 anuerysmThe aneurysm sac is then wrapped around the graft to protect it

Grafts are made of various materials, such as Dacron (textile polyester synthetic graft) or polytetrafluoroethylene (PTFE, a non-textile synthetic graft). 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.

ComplicationsCaused by underlying coronary artery disease and chronic obstructive pulmonary duiseaseThese conditions decreased metabolism of anesthetic, increase the risk of postoperative atelectasis and decrease the client´s tolerance of hemodynamic changes from blood loss and fluid shifts

ComplicationsTo reduce the risk of acute myocardial infarction, one of the most serious complications, clients may undergo coronary artery bypass before aneurysm repairPrerenal failure can develop for several reasonsThe kidney can sustain ischemia from decreased aortic blood flow, decreased cardiac output, emboli, inadequate hydration or the need for clamps on the aorta above the renal arteries during surgery

ComplicationsEmboli can also develop and lodge in the arteries of the lower extrimities or mesenteryClinical manifestations include those of acute occlusion in the legBowel necrosis is exhibited as fever, leukocytosis, ileus, diarrhea and abdominal painThe spinal cord can also cbecome ischemic, resulting in paraplegia, rectal and urinary incontinence or loss of pain and temperature sensationSpinal cord ischemia tends to occur more commonly when an abdominal aortic aneurysm has ruptured

ComplicationsChanges in sexual function may also develop following repair of an abdominal aortic aneurysmRetrograde ejaculation occurs in about two third of male clients and loss of potency occurs in one third of males who have undergo repair of abdominal aortic aneurysm

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. 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.

A stent-graft is a long cylinder-like tube made of a thin metal framework (stent), while the graft portion is made of various materials such as Dacron or polytetrafluoroethylene (PTFE) and may cover the 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 stent-graft.

Reasons for the ProcedureReasons an abdominal aortic aneurysm repair may be performed include, but are not limited to, the following:to prevent the risk of rupture to relieve symptoms to restore a good blood flow size of aneurysm greater than 5 centimeters in diameter (about two inches) growth rate of aneurysm of more than 0.5 centimeter (about 0.2 inch) over one year when risk of rupture outweighs the risk of surgery emergency life-threatening hemorrhage (uncontrolled bleeding) .

Risks of the ProcedureAs with any surgical procedure, complications can occur. Some possible complications may include, but are not limited to, the following:open repair: myocardial infarction (heart attack) irregular heart rhythms (arrhythmias) bleeding during or after surgery injury to the bowel (intestines) limb ischemia (loss of blood flow to legs/ feet) embolus (clot) to other parts of the body infection of the graft lung problems kidney damage spinal cord injury

EVAR: damage to surrounding blood vessels, organs, or other structures by instruments kidney damage limb ischemia (loss of blood flow to leg/feet) from clots groin wound infection groin hematoma (large blood-filled bruise) bleeding endoleak (continual leaking of blood out of the graft and into the aneurysm sac with potential rupture) spinal cord injury Patients who are allergic to or sensitive to medications, contrast dyes, iodine, shellfish, or latex should notify their physician.

Nursing Care of the client having surgery of aorta

Preoperative CarePreoperative assessment must include detection of concurrent coronary artery disease and cerebrovascular diseaseAssess all peripheral pulses for baseline comparison postoperativelyIf emergent surgery is required, time for preoperative care and teaching may be limitedImplement measures to reduce fear and anxiety:Orient to the intensive care unit, if appropriateDescribe and explain the reason for all equipment and tubes, sucgh as cardiac monitors, ventilators, nasogastric tubes, urinary catheters, intravenous lines and fluids and intra-arterial linesExplain what to expect following surgery (sights, sounds, frequency of taking vital signs, dressing, pain relief measures, communication strategies)


Preoperative Care

Allow time for questions and expression of fears and concernsThese explanation provide a sense of control for the client and family

Nursing AssessmentA thorough nursing history and physical asessment should be performed, because atherosclerosis is a systemic desease processIt is important for the nurse to watch for signs of cardiac, pulmonary, cerebral and lower extrimity vascular problemsThe patient should be monitored for indications of rupture of the aneurysm such as diaphoresis, paleness, weakness, tachycardia, hypotension, abdominal, back, groin or periumbilcal pain, changes in sensorium or a pulsating abdominal massAttention to the character and quality of the peripheral pulses and the neurologic statusPedal pulse sites (dorsalis pedis and posterial tibial) and skin lesions on the lower extrimities should be marked and documented before surgery

planningThe overall goals for a patient undergoing aortic surgery include1. Normal tissue perfucsion2. Intact motor and sensory functionNo complications related to surgical repair such as thrombosis or infection

Nursing ImplementationHealth Promotion

The nurse must be aware of cardiovascular disease risk factors and be alert for opportunities to teach health promotion measures to patients in the hospital and the communitySpecial attention should be given to the patient with a strong family history of aneurysm or any evidence of other cardiovascular disease

Nursing ImplementationHealth Promotion

The patient should be encouraged to reduce risk factors known to be associated with atherosclerosisThese should include controlling hypertension, smoking cessation, and following a diet low in fats and cholesterolThese measures are also done to ensure contiued graft patency following surgical repair

Nursing ImplementationAcute intervention

Preoperative teaching should include a brief explanation of the disease process, the planned surgical procedures, preoperative routines, what to expect immediately after surgery ” e.g., recovery room, tubes/drains” and usual postoperative timelinesPreoperative routine, bowel preparation (laxatives, enemas) and have a preoperative shower with an antimicrobial soap the day before surgery, receive nothing by mouth after midnight the day before surgery and often are given preoperative intravenous antibiotics immediately before surgeryA tour of the ICU before surgery may be of interest to the patient and family


When the pat arrives in the ICU, an endotrachial tube, an arterial line, a central venous catheter, or pulmonary artery catheter, peripheral i.v line, an indwelling urinary catheter and a nasogastric tube will likely be in place with continous ECG and pulse oximetry monitoringIf the thorax is entered during surgery, chest tube will also be in place, pain medication may be administered via epidural catheter or patient controlled analgesiaMaintaining adequate respiratory function, fluid and electrolytes balance , pain control


The nurse must monitor graft patency, and renal perfusion

The nurse can also assist in preventing arrhythmia, infections and neurologic complications

Nursing Implementationgraft patency

Maintain adequate blood pressure to promote graft patency. Prolonged hypotention may result in graft thrombosis due to decreased blood flowAdministration of of i.v. Fluids and blood components as indicatedis 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

Nursing Implementationgraft patency

Severe hypertention may cause undue stress on the arterial anastomosisResulting in leakage blood or rupture at the suture linesDrug therapy with duiretics or i.v antihypertensive agents may be indicated if severe hypertension persists

Nursing ImplementationCardiovascular status

In individuals with preexisiting 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 neededReplacement of electrolytes as indicated, adequate pain control and resumption of preoperative cardiac medications

Nursing ImplementationInfection

The development of a prosthetic vascular graft infection is relatively rare but possibly life threatening complicationsNursing prevention to prevent infection should include ensuring that the patients receives a broad spectrum antibiotic as prescribedAssess body temperature regularly and report any elevationsLaboratory data should be monitored for elevated WBCThe nurse should ensure adequate nutrition and observe the surgical incision for any evidence of delaying healing, signs of infection or prolonged drainage

Nursing ImplementationInfection

All i.v, arterial and central venous catheter insertion sites should be cared for carefully with the use of sterile technique because they are frequently a portal of antry for bacteriaMeticulous perinial care for the patient withan indwelling urinary catheter is essential to minimize the risk of urinary tract infectionSurgical inncisions should be kept clean and dry

Nursing ImplementationGastrointestinal status

Paralytc ileus may develop as a result of anesthesia and the manual manipulation and displacement of the bowel for long periods during surgeryThe intestine may become swollen and bruised and pristalsis ceases for variable intervalsA retroperitoneal surgical approach can be used to decrease the risk of bowel complicationsA nasogastric tube is inserted during surgery and connected to low, intermittent suctionThis decompreses the stomach and duodenum, prevent aspiration of stomch contents, and decrease pressure on suture lines


Thre nasogastric tube should be irrigated with normal saline solution as needed and the amount and character of the drainage should be recordedThe nurse should auscultate for the return of bowel soundsThe passing of the flatus is a key sign of returning bowel function and shoud be notedEarly ambulation will assist with the resumption of bowel functioningIt is unusual for paralytic ileus to persist beyond the fourth postoperative day


While the patient is NPO, meticulous mouth care should be given every few hoursIce chips or lozenges may be given to the patient to soothe an irritated throatIf the blood supply to the bowel is disrupted during surgery, temporary ischemia or infarction of intestinal tissue may resultThis is evidenced by lack of bowel sounds, fever, abdominal distention, diarrhea, and bloody stoolsWhen bowel infarction does occur as a result of mesenteric ischemia, reoperation is necesary as soon as possible to restore blood flow, with likely resection of the infarcted bowel

Nursing ImplementationNeurologic 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 graspsWhen the descending aorta is involved, nursing assessment of the ability to move lower extrimities is also importantThese assessment shoud be recorded indetail with a careful description of the patient´s response

Nursing Implementationperipheral perfusion status

Tha anatomic location of the aneurysm indicates the areas of major concern related to peripheral perfusionAll peripheral pulses should be checked regularly and recordedThis should be done every hour for several hours, depending on the nursing policy and rutinely thereafter ar frequent intervalsWhen the ascending aorta and aortic arch are involved, the carotid, radial, and temporal artery pulses should be assessedAfter surgery involving the descending aorta, pulses to be assessed may include the femoral, popliteal, posterior tibial and dorsalis pedis


When checking the pulses, the nurse should mark the locations lightly with a felt-tip pen so that others can locate them easilyAn ultrasonic Doppleris useful in assessment of peripheral pulsesIt is also important to note the skin temperature and color, capillary refill time and sensation and movement of the extrimitiesPulses in lower extrimities may be absent for a short time following surgery


This is usually due to vasospasm and hypothermiaA 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 graftGaft occlusion is treated with reoperation if identified earlyIn rare instances, thrombolytic therapy may also be consideredIn some patients the pulses may have been absent preoperatively because of coexistent pripheral arterial occlusive disease


Comparison with the preoperative status is essential to determine the etiology of decreased or absent pulse and the proper treatment

Nursing Implementationrenal 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 arteriesThis can cause ischemia of one or both kidneysHypotension, dehydration, prolonged aortic clamping, can also lead to decreased renal perfusion


The patient return from surgery with an indwelling urinary catheter in placeIn imediate postoperative period, hourly urin out puts are recordedAn accurate record of fluid intake and urinary out put should be kept until the patient resumes the preoperative dietDaily weight also should be obtainedCentral venous pressure reading and pulmonary artery pressures also provide important information regarding hydration status


Daily blood urea nitrogen and serum creatinine studies are performed to evaluate renal function

Irreversible renal failure may occur after aortic surgery, particularly in high risk individuals

Nursing Implementationambulatory and home care

The patient should be instructed to gradually increase activitiesFatigue, poor appetite, and irregular bowel habits are to be expected Heavy lifting is avoided for at least 4 to 6 weeks following surgeryObservation of incisions for signs and symptoms of infection is encouraged Any reddness, swelling, increased pain, drainage from incision or fever greater than 37.8 c should be reported to the health care provider


The patient should be taught to observe for changes in color or warmth of the extrimitiesPatients may be taught to palpate peripheral pulses and to assess changes in their qualityThe patient who has received a synthetic graft should be aware that prophylactic antibiotics may be required before future invasive procedures, including any dental procedures


Sexual dysfunction in male patients is not uncommon after aortic surgerySexual dysfunction may occur because the internal hypogastric artery is interrupted, leading to decreased arterial blood flow to the penisThe periaortic sympathetic plexus may be disrupted by the surgical proceduresPreoperatively, baseline sexual function should be documented and patient counselling is recommendedPostoperatively a referral to urologist may be considered if impotence is a problem


Postoperative care

Assess the surgical sites for swelling and pain (hematoma) and bleedingMonitor peripheral perfusion closely, ambulation is allowed the day after surgeryClients may ask if they can feel the hooks in the aortaThey should be told that they will not be able to feel the hooks because the aorta can not sense the hooksBefore dismissal, the location of the graft may be confirmed with CT scan, ultrasound, or x ray study


Postoperative careMonitor for and report manifestations of graft leakage:

Ecchymoses of the scrotum, perinium, or penis; a new expanding hematomaIncreased abdominal girthWeak or absent peripheral pulses, tachycardia, hypotensionDecreased motor function or sensation in the extrimitiesFall in Hb and HTIncreasing abdominal, pelvic, back or groin painDecreasing urinary out put (less than 30 ml/ hr)


Postoperative care

Decreasing CVP , pulmonary artery pressure, or pulmonary artery wedge pressureThese manifestation may signal graft leakage and possible hemorrhage

Pain may be due to pressure from an expanding hematoma or bowel ischemiaDecreased renal perfusion causes the glomerular filtration rate and urine output to fall


Postoperative careMaintain fluid replacement and blood or volume expanders as orderedPromptly report changes in vital signs, level of consciousness and urine outpitHypovolemic shock may develop due to blood loss during surgery, third spacing, inadequate fluid replacement and/or hemorrhage if graft separation or leakage occursReport manifestations of lower extrimity embolism: pain and numbness in lower extrimities, decreasing pulses, and pale, cool, or cyanotic skinPulses may be absent for 4-12 hr postoperatively due to vasospasm; however absent pules with pain, changes in sensation, and a pale, cool extrimity are indicative of arterial occlusion


Postoperative careReport manifestations of bowel ischemia or gangrene: abdominal pain and distention, occult or fresh blood in stools, and diarrheaBowel ischemia may result from an embolism or ocur as a complication of surgeryReport manifestations of impaired renal function: urine output less than 30 ml per hour, fixed specific gravity, increasing BUN and serum creatinine levelsHypovolemia or clamping of the aorta during surgery may impair renal perfusion, leading to acute renal failure


Postoperative care

Report manifestations of spinal cord ischemia: lower extremity weakness or paraplegia. Impaired spinal cord perfusion may lead to ischemia and impaired function

Nursing CareAssessment

Focused assessment for the client with a suspected aortic aneurysm includes:Health history: complaints of chest, back, cough, difficult or painful swallowing, hoarseness, history of hypertension, coronary heart diseas, hear failure, peripheral vascular disease

Nursing CareAssessment

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

DiagnoseRisk for hemorrhage because of the risk of bleeding at the graft site, the client is at risk for hemorrhageRisk for deficient fluid volume

OutcomeThe nurse will monitor for manifestations of hemorrhage and notify the physician if any manifestations occur

InterventionsMonitor the client for increase in pulse rate, decrease in blood pressure, clammy skin, anxiety, restlessness, decreasing levels of conciousness, pallor, cyanosis, thirst, oliguria (urine output less than 0.5 ml/kg/hr), increase abdominal girth, increased chest tube output greater than 100 ml/hr/for 3 hours and back pain (from retroperitoneal bleeding)Monitor central venous pressure, left arterial pressure, pulmonary artery pressure, and pulmonary capillary wedge pressure continouslyAssess for changes indicating hypovolemiaReport any of these manifestations immediately

DiagnoseRisk for impaired gas exchangeThe large abdominal incision impairs deep inspiration and usually reduced effective coughingAt risk for 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

InterventionMonitor settings on ventilator to ensure the client is adequately oxygenatedAssess lung sounds every 1 to 2 hoursReport any adventitious (belonging to a structure that develops in an unusual place) soundsMonitor oxygen saturation continouslyReport any desaturationAfter extubation, assist with coughing by using incentives spirometry, provide splinting pillows before coughing, encourage ambulation and provide adequate analgesia

DiagnosisIneffective tissue perfusion

(peripheral and / or renal )Related to graft thrombosis, embolism, prolonged aortic cross-clamping, hypotension sand blood loss as manifested by absent or diminished peripheral pulses, altered skin color, decreased urine output, altered ability to move extrimities

Ineffective tissue perfusion (peripheral and

/ or renal )DiagnoseRisk for inadequate tissue perfusionDuring the operation, aorta is clamped to stop bleeding while the graft is placedDuring that time, peripheral tissues are not perfusedThe graft site can also become occluded with thrombusIn addition the client often has preexisting arterial diseaseIneffective tissue perfusion related to temporary decrease in blood supply

OutcomesThe client will maintain adequate tissue perfusion as evidenced by pedal pulses, warm feet, capillary refill of less than 5 seconds, abscence of numbness or tingling and ability to dorsiflex and plantar flex both feet equallyPatent arterial graft with adeuate distal perfusionUrin output adequate

Interventionrisk for ineffective tissue perfusion

Assess dorsalis pedis and posterior tibial pulses every hour for 24 hoursReport change in pulse quality or absent pulses (assess with Doppler if needed)

Assess dorsiflexion and planter flexion and sensation (needles and pins sensation) every hour for 24 hrInspect lower extrimities for mottling, cyanosis, coolness, or numbness every 4 hours

IntervantionAsess for diminished or absent peripheral pulses in the extrimities, color or temperature changes in the extrimities, altered sensation and movement of the extrimities, increased pain level because theseare indicator for altered peripheral perfusionCompare extrimities for warmth, capillary refill and color because differnces may indicate impaired blood flw

Administer i.v. Fluid at prescribed rates to ensure adequate hydration and renal perfusionMaintain a warm environment to prevent temperature induced vasoconstrictionAdminister anticoagulants and or antiplatelet agents as prescribed to prevent thrombus formationMonitor urinry output daily weights, BUN, and serum createnine to detect signs of altered perfusion and renal failure

Risk for infectionDiagnosisRisk for infection related to presence of a prosthetic vascular graft and invasive lines

OutcomeNormal body temperatureNo signs of infection Wound is well approximated

Intervention Risk for infection

Monitor for signs of infetion such as elevared body temperature, elevated WBC count, heart rate and respiratory rate, decreased blood pressure, erythema and warmth along the incision line, persistent drainage from incisions as well as sites of invasive lines, separation of wound edges

Administer broad spectrum antibiotics as ordered to maintain adequate blood levels of the drugMonitor WBC count because a rising count may be firsy si´gn of infectionUse septic technique in caring for incision and any indwelling i.v. Line, tubing, or catheter because these sites are potential portals of entry for infectionEnsure adequate nutrition, specifically a diet high in protein, vit c, vit A and zinc to promote healing

Diagnosis: Acute PainAbdominal aortic aneurysm repair necessitates a long incisionAcute pain related to surgical incision

Outcomes: 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, and ambulating or coughing without extreme pain

InterventionOpioids are usually provided via a patient-controlled analgesia system or through an epidural catheterAsses 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

Diagnose: risk for ischemia of the bowelIf the client undergoes extensive aortic pricedures that involve clamping the mesenteric vessels, ischemic colitis can developInferior mesenteric artery can embolizeThe 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

InterventionMaintain accurate intake and outpit and analyze data hourly for 24 hrNotify physician if urine output goes below 0.5 ml/kg/hrAssess urine specific gravity and daily weightMonitor blood urea nitrogen and creatinine levelsAssess bowel sounds every 4 hours

Keep the client NPO and provide oral care every 2-4 hrProvide routine nasogastric tube care and assess nares for tissue impairmentPerform guaiag test (Test for blood in stool) of NG drainage every 4 hours or if bleeding is suspected (i.e., drainage has dark, coffee-ground appearance or is bright red)

Diagnose: risk for spinal cord ischemiaA 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

implementationMonitor ability to move lower extrimities (dorsiflexion and plantar flexion) and sensation in both legs every 1-2 hours

Self careMost clients who require abdominal aortic aneurysm repair have significant degree of arterial diseaseMany of the postoperative instructions should address care of client with arterial disorders, which is discussed earlierReview all medications to be used by the client to be certain that he or she undertands their purpose, schedule, and side effectInstruct the client about incision care and manifestation of infection

The client should ambulate as tolerated, including climbing stairs and walking outdoorsIf legs swelling develops, the leg should be wrapped in elastic bandages or support stockings should be usedActivities that involve lifting heavy objects, should more than 15-20 lb, are not permitted for 6-12 weeks postoperativelyActivities that involve pushing, pulling, or straining may also be restricted

Driving may also be restricted because of postoperative weakness and decreased response timeThe client can resume sexual activities in about 4-6 weeks, when he or she is able to walk without shortness of breath (e.g., two flights of stairs.The risk of importance in male clients should be discussed before dischargeCauses vary from pre-existing aortoiliac disease or diabetes to side effects from aortic cross- clampingReferral may be appropriate if the client is amanable

Nursing diagnosis and intervention

Nursing care for clients with an aneurysm of the aorta or its branches focuses on monitoring and maintaining tissue perfusion, relieving pain, and reducing anxietyNursing care usually is acute, precipitated by a complication or surgical repair of the aneurysm

Nursing diagnosis and intervention

Risk for ineffective tissue perfusionClient with aortic aneurysms are at risk for impaired tisue perfusion due to aneurysm rupture with resulting hemorrhage and lack of blood flow to tissues distal to the ruptureIn addition, thrombi often form within the aneurysm and may become emboli, obstructing distal arterial blood flow

Practice alertImmediately report manifestations of impending rupture, expansion, or dissection of the aneurysm: increased pain, discrepancy between upper and lowe extrimity blood pressure and peripheral pulses, increased mass size, change in LOC or motor or sensory function, laboratory results, rapid expansion may indicate increased risk for rupture, with resulting hemorrhage, shock and possible deathElective or planned surgery may rapidly become emergemcy surgery to prevent complications

Risk for ineffective tissue perfusion

Implement interventions to reduce the risk of aneurysm rupture:Maintain bed rest with legs flatMaintain a calm environment, implementing measures to reduce psychologic stressPrevent straining during defecation and instruct to avoid holding the breath while movingAdminister beta blockers and antihypertensive as prescibed

Activity, stress, and the valsalva maneuver increase blood pressure, increasing the risk of ruptureElevating or crossing the legs restricts peripheral blood flow and increases pressure in the aorta or iliac arteriesBeta blockers and antihypertensives are argered to reduce pressure in the dilated vessel

Risk for ineffective tissue perfusion

Contiously monitor cardiac rhythmReport complaints of chest pain or changes in ECG tracingAdminister oxygen as indicatedAortic dissection and repair place the client at significant risk for myocardial infarction (MI)

A major causes of potoperative mortality and morbidityRapid identification and treatment of this complication can reduce the risk of death or long-term adverse effects of MI

Risk for injuryPotent antihypertensive drugs often are given intravenously to reduce the pressure on an expanding or dissecting aneurysmContinous monitoring of infusions and hemodynamic parameters such a arterial presure, pulmonary pressures, and cardiac output is vital to ensure that adequate tissue perfusion is maintained during infusions of these potent drugs

Continously monitor arterial pressure and hemodynamic parameters as indicatedPromtly report results outside the specified parameters to the physicianMany of the drugs used are effective within minutesResponses vary among individuals, particularly in the older adult, necessitating continous monitoringMonitor urine output hourly. Report output less than 30 ml/hr. the kidneys are very sensitive to reduce perfusion pressure, inadequate renal blood flow can lead to acute renal failure

AnxietyExplain all procedures and treatments, using simple and understandable termsRespond to all questions honestly, using a calm, empathetic, but matter –of-fact mannerHonestly with the client and family promotes trust and provides reassurance that the true nature of the situation is not being ”hidden” from themProvide care in a calm, efficient manner

Home CareDiscuss the follwing topics when surgical repair is not immediately planned and the aneurysm will be monitoredMeasures to control hypertension, including lifestyle and prescribed drugsThe benefits of smoking cessationManifestations of increasing aneurysm size or complications to report to the physician

Home CareFollowing surgery, discuss the following topics in preparing the client and family for home careWound care and preventing infection;manifestations of impaired healing or infection to be reportedPrescribed antihypertensive and anticoagulant medicationsand their expected and unintended effectsThe importance of adequate rest and nutrition for healingMeasures to prevent constipation and straining at stool (such as increasing fluid and fiber in the diet)

The importance of avoiding prolonged sitting, lifting heavy objects, engaging in strenous exercise and having sexual intercourse until approved by the physician (usually 6-12 weeks)Signs and symptoms of complications to report to the physicianProvide referrals to home health agency or community health service as necessary

Practice AlertReport manifestation of arterial thrombosis or embolism: absent peripheral pulses, a pale or cyanotic, cool extrimity, severe, diffuse abdominal pain with guarding, or increased groin, lumbar, or lower extrimity painSluggish blood flow within the aneurysm often causes thrombit to formThese thrombi can break loose, becoming emboli that can occlude peripheral arteries or arteries to the kidneys or mesentryArterial occlusion may necessitate emergency surgery to restore blood flow and prevent tissue infarct or gangrene

Immediately report changes in mental status or symptoms of peripheral neurologic impairment (weakness, parensthesias, paralysis)The expanding aneurysm or dissection can affect carotid and cereberal blood flow or spinal cord perfuion, leading to neurologic symptomsImmediate resoration of blood flow is vital to prevent permanent neurologic deficits

Practice AlertUse an infusion device for all drug infusionsThese devices prevent accidental or inadvertent changes in the rate of the infusion and dose of the drug

Documents

Aortic aneurysm Dr. Aidah Abu Elsoud Alkaissi An-Najah National University Nursing College