An-Najah National University Faculty of Nursing Dr Aidah Abu Alsoud Alkaissi RN, BSc, MSc, PhD

Nursing Care Plan of Aortic Aneurysm

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

What are the causes of Aortic Aneurysm ?

Most aneurysms are arteriosclerotic in origin Syphilis

Trauma Hypertension Smoking

Infection Aortic dissection Inflammatory diseases

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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 balloonshaped outpouching projects from one side of the artery

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

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
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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
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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

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Clinical manifestations of (AAA)

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

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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 Rupture and hemorrage
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Whos 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

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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 genetic connective tissue disorder that affects the skeleton, eyes, and cardiovascular system) Mycotic aneurysms, develop from streptococcal, staphylococcal, or salmonella infections of the aorta

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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 Prevent straining during deafecation 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

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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

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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 the graft to protect it

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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

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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
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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

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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
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Risks of the Procedure- open repair

Lung problems Myocardial infarction Kidney damage Irregular heart rhythms Spinal cord injury Bleeding during or after surgery Injury to the bowel Limb ischemia Embolus to other parts of the body Infection of the graft Damage to surrounding blood vessels, organs, or other structures by instruments Groin wound infection Groin hematoma Endoleak Allergy

Nursing Care- Assessment 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, heart failure, peripheral vascular disease

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Nursing Care- Assessment 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

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Nursing Care- 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
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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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Nursing Care of the client having surgery of aorta Postoperative care Monitor for and report manifestations of graft leakage:
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 the extrimities 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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Nursing Care of the client having surgery of aorta 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 expanding hematoma or bowel ischemia Decreased renal perfusion causes the glomerular filtration rate and urine output to fall

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Nursing Care of the client having surgery of aorta Postoperative care

Maintain fluid replacement and blood or volume expanders as ordered Promptly report changes in vital signs, level of consciousness and urine outpit Hypovolemic shock may develop due to blood loss during surgery, 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 to vasospasm; however absent pules with pain, changes in sensation, and a pale, cool extrimity are indicative of arterial occlusion
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Nursing Care of the client having surgery of aorta Postoperative care

Report manifestations of bowel ischemia or gangrene: abdominal pain and distention, occult or fresh blood in stools, 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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Nursing Care of the client having surgery of aorta 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 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 patients state of hydration
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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

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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 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
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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

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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 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
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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
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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

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Intervention
Provide routine nasogastric tube care and assess nares for tissue impairment Perform guaiag test (Test 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)
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Assess bowel sounds every 4 hours Keep the client NPO and provide oral care every 24 hr

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
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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
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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 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

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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 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
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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
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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 deficient fluid volume

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

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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 100 ml/hr/for 3 hours back pain from retroperitoneal bleeding

Diagnose Risk for impaired gas exchange Impaired gas exchange related to ineffective cough secondary to pain from large incision

Outcome 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

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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 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:

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
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lantarlexion xtensionof theankle resulting in theforefoot movingaway fromthebody

orsallexion lexionofthe ankleresulting in thetop ofthefoot movingtoward 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
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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
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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 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
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Diagnose: Risk for spinal cord ischemia 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

Outcome 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

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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

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Nursing Implementation ambulatory and home care

The patient hould be instructed to gradually increase activities Fatigue, poor appetite, and irregular bowel habits are to be expected Heavy lifting is avoided for at least 4 to 6 weeks following surgery Observation 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

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Nursing Implementation ambulatory and home care 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 before future invasive procedures, including any dental procedures
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Nursing Implementation ambulatory and home care

Sexual ysfunction 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 The periaortic sympathetic plexus may be disrupted by the urgical 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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Nursing Implementation ambulatory and home care

Prescribed antihypertensive and anticoagulant medicationsand 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 weakness and decreased response time The 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 impotance in male clients should be discussed before discharge Causes vary from pre-existing aortoiliac disease or diabetes to side effects from aortic cross- clamping
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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
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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 certain that he or she undertands their purpose, schedule, and side effect Instruct the client about incision care and manifestation of infection
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Home care when surgical repair is not 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
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