4 Aortic Aneurysm Nursing Care Plan

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Aortic aneurysm (Abdominal Aneurysm; Dissecting Aneurysm; Thoracic Aneurysm;) is a localized, circumscribed, blood-filled abnormal dilation of an artery caused by disease or weakening of the vessel wall.

True aneurysms involve dilation of all layers of the vessel wall. The two types of true aneurysms are: (1) saccular, which is characterized by a bulbous out-pouching of one side of the artery resulting in localized stretching in localized stretching of the artery wall, and (2) fusiform, which is characterized by a uniformly shaped dilation of the entire circumference of the artery. True aneurysms are asymptomatic and are typically diagnosed by physical examination or a diagnostic ultrasound or computed tomography (CT) scan. The natural history of an aneurysm is enlargement; as a rule, the larger it is, the greater the chance of rupture. Aneurysms are most commonly seen in the abdominal aorta. Abdominal aortic aneurysm (AAAs) account for about 75% and thoracic aneurysms for about 25% of all cases. They occur more often in men than in women. Risk factors include smoking and familial history of aneurysms. When an aneurysm becomes large enough for risk for rupture, it can be repaired by open surgical repair or a less-invasive endograft-covered stent repair.

Dissecting aneurysms occur when the inner layer of the blood vessel wall tears and splits, creating a false channel and cavity of blood between the intimal and adventitial layers. They are typically classified according to the location. According to the Stanford classification, type A involves the ascending aorta and its transverse arch and type B involves the descending aorta. A dissecting AAA is the most catastrophe involving the aorta, and it has a high mortality rate if not detected early and treated with surgery. More than 90% of clients present with sudden onset of severe pain which is usually described, as sharp, tearing, or stabbing in nature. Symptoms depend on the size and location of the dissection or rupture. Risk factors for dissection include congenital, inflammatory, hypertension, pregnancy, trauma, and Marfan syndrome.

Nursing Care Plans

Nursing care plan for clients with an aortic aneurysm is to modify risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing the occurrence of a rupture.

Here are four (4) nursing care plans (NCP) for aortic aneurysm:

1. Anxiety

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Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to

• - Close monitoring by medical or nursing staff
• - Fear of death
• - Impending surgery
• - Multiple tests and procedures
• - Sudden onset of illness

Possibly evidenced by

• - Constant demands
• - Increased alertness
• - Increased questioning
• - Restlessness
• - Request to have family at bedside all the time
• - Tense, anxious appearance

Desired Outcomes

• - Client will verbalize strategies to reduce his anxiety level.
• - Client will demonstrate positive coping method.

Nursing Interventions	Rationale
Assess the client’s anxiety level (mild, severe). Note signs and symptoms, especially nonverbal communication.	Aortic dissection and/or rupture can result in an acute life-threatening situation that will produce high levels of anxiety in the client as well as in significant others.
Acknowledge awareness of the client’s anxiety.	Acknowledgement of the client’s feelings validates the feelings and communicates acceptance of those feelings.
Provide a quiet, private place for significant others to wait.	A quiet environment can reduce anxiety.
Reduce unnecessary external stimuli.	Anxiety may escalate with excessive conversation, noise, and equipment around the client.
Explain all procedures as appropriate, using simple, concrete words.	Information helps allay anxiety. Clients who are anxious may not be able to comprehend anything more than simple, clear, brief instructions.

2. Deficient Knowledge

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Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

• - New medical problem
• - Unfamiliarity with surgical procedure and hospital care

Possibly evidenced by

• - Expressed need for information
• - Multiple questions

Desired Outcomes

• - Client or significant others verbalize understanding of disease process, treatment options, and goals of therapy.

Nursing Interventions	Rationale
Assess the client’s knowledge of the disease and treatment options.	This information provides an important starting point in education.
Instruct medically treated clients about the following: - Goals of therapy (avoidance of excess BP and strain on the disease arterial wall) - Importance of follow-up computed tomography scanning - Signs and symptoms to report - Side effects of the drug - Use of antihypertensive medications as prescribed; importance of compliance	Clients treated medically need to maintain goal BP levels and comply with scheduled CT scans to monitor the size of the aneurysm. Knowledge of early warning signs facilitates rapid treatment. These may include pain in the chest, back, groin, abdomen; decreased urine output; cool, pale extremities.
Instruct surgical clients about the following: - Activity restrictions - Avoidance activities that are isometric or abruptly can raise BP (e.g., lifting and carrying of heavy objects, straining for bowel movements) - Signs and symptoms to report - Wound care	Discharge instructions guide clients regarding self-care measures; Heavy lifting of more than 5 to 10 pounds is restricted for 4 to 6 weeks after surgical repair of an aortic aneurysm. These restrictions reduce strain on suture lines until they are completely healed; Clients need to be aware of the warning signs that warrant medical attention.
Instruct endograft clients about the need for follow-up CT scans at 1 and 6 months and yearly for the rest of their lives.	The endograft may incur a leak; ongoing evaluation is needed so appropriate treatment can be initiated.

3. Risk for Decreased Cardiac Output

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Risk for Decreased Cardiac Output: At risk for inadequate blood pumped by the heart to meet metabolic demands of the body.

May be related to

• - Progressive dissection
• - Rupture of the aorta
• - Side effects of medications

Possibly evidenced by

• [not applicable]

Desired Outcomes

• - Client will maintain adequate cardiac output, as evidenced by HR of 60 to 100 beats per minute, normotensive BP, palpable pulse, clear lung sounds, urine output more than 30 ml/hr, and normal level of consciousness.

Nursing Interventions	Rationale
Asess for signs of myocardial ischemia: chest pain, tachycardia, or ST-segment and T-wave changes on electrocardiogram (ECG).	ECG changes help guide the timing of interventions.
Assess the client’s hemodynamic status. Monitor for signs of decreasing cardiac output, such as tachycardia, decreased urine output, and restlessness.	A dissecting abdominal aortic aneurysm (AAA) is the most common catastrophe involving the aorta, and it has a high mortality rate if not detected early and treated with surgery. Clients with decreasing or rupturing aneurysm are hemodynamically compromised. Early evaluation of warning signs facilitates prompt intervention.
If decreased cardiac output is related to further dissection (severe aortic insufficiency) or ruptured aorta, anticipate emergency angiography and surgery	Rapid, efficient intervention is critical to preserve circulation and life
- Administer medications, intravenous fluids, and blood as ordered.	These maintain adequate cardiac output before surgical intervention.
- Stay with the client.	The presence of a competent, calm staff may provide emotional support and reduce fear.
- Send a blood specimen for type and crossmatch and other routine preoperative blood work.	Blood replacement therapy may be required to maintain effective blood volume.
- Prepare the client for surgical repair.	Information helps to allay anxiety. Clients who are anxious may not be able to comprehend anything more than simple, brief instructions and explanations.
If decreased cardiac output is drug induced, anticipate the following:
- For beta-blocker: May stop the drug or reduce the dose.	Beta-blockers have a negative inotropic effect, which can potentiate heart failure. The presence of crackles and S3 indicates heart failure.
- For vasodilators: Stop the drug and administer isotonic solution (0.9% normal saline solution) or plasma expanders.	Fluids are usually required to maintained increased intravascular volume.

4. Risk for Ineffective Tissue Perfusion

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Risk for Ineffective Tissue Perfusion: At risk for decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level.

May be related to

• - Conditions that increase stress on the arterial wall, leading to risk for dissection
  • - Coarctation of the aorta
  • - Hypertension
  • - Pregnancy with hypervolemia
• - Defect in the vessel wall, leading to risk for dissection
• - Iatrogenic causes
• - Trauma

Possibly evidenced by

• [not applicable]

Desired Outcomes

• - Client will maintain adequate tissue perfusion as evidenced by strong palpable pulses; warm, dry extremities; BP within norma range for the client; urinary output greater than or equal to 30 ml/hr; alert, normal level of consciousness; normal bowel sounds; absence of abdominal or chest pain.
• - Client will have a reduce risk for complications from progressive dissection or rupture s a result of early detection of symptoms and appropriate intervention.

Nursing Interventions	Rationale
Assess and monitor the location and characteristic of pain. - Thoracic: pain in the neck, low back, shoulders, or abdomen. - Abdominal: pain in the abdomen or back, flank, or groin caused by the pressure on adjacent structures.	A description of pain can help differentiate the location and determine treatment. More than 90% of clients with abdominal aortic aneurysms have a sudden onset of severe pain described as sharp, tearing, or stabbing in nature.
Obtain a thorough history regarding risk factors for dissection or rupture.	Most clients are asymptomatic unless their aneurysm is dissecting or ruptures. History aids in ruling out a cerebrovascular, cardiac, renal, vascular, and occlusive disease. Poorly controlled hypertension increase stress on the aortic wall and its risk for dissection or rupture.
Monitor for signs and symptoms indicating progressive dissection.	A high index suspicion can determine the treatment to reduce mortality. Clinical signs and symptoms indicate the site and progression of dissection. Acute aortic dissection usually occurs along the thoracic aorta. Pain is severe and may mimic the pain associated with myocardial infarction. Pain may be located both above and below the diaphragm if the dissection is extensive. Changes in the level of consciousness and diminished carotid pulses are associated with dissection of the aortic arch. Dissection of the abdominal aorta can cause decreased urine output, diminished motor and sensory function in the lower extremities, abdominal pain, and bloody diarrhea.
For abdominal aneurysms:
Assess the lower extremities for signs of peripheral ischemia and insufficiency (such as paralysis, pain, paresthesia, pallor, pulselessness, and poikilothermia [decreased temperature, coolness]).	Dissection can cause reduced sensory and motor function in the lower extremities.
Monitor for abdominal distention, diarrhea, or severe abdominal pain and/or fever.	These signs rule out embolization or decreased perfusion to the mesenteric artery and rupture into the abdominal cavity.
Gently palpate the abdomen for a midline mass or pulsation.	An enlarging abdominal aortic aneurysm may present as a midline pulsatile abdominal mass. The pulsations may equal the apical heart rate. The technique for pulsation should be as gentle as possible to avoid trauma to the aneurysm.
Monitor urine output.	Decrease urine output may result from the compression of the renal arteries from the infrarenal abdominal aneurysm, cross-clamping of the aorta during surgery or embolization. Urine output may not be affected if the aneurysm is above the renal artery. However, most aneurysms are located below the renal artery.
For thoracic aneurysms:
Assess the quality of peripheral pulses.	Peripheral pulses assure distal perfusion. A suggested grading system is as follows: - 0 = absent - 1+ = present - 2+ = strong
Assess for respiratory compromise.	Respiratory compromise is a result of compression of the trachea or bronchus.
Assess for hemoptysis.	Hemoptysis results from compression of the trachea or lung.
Assess for dysphagia.	Dysphagia may be caused by esophageal compression.
Monitor BP for hypertension.	Hypertension is a risk factor for rupture. Differential arm BP may be present as a result of compression of the subclavian artery.
Assess for upper-extremity and head swelling with cyanosis.	These signs can be caused by the obstruction of the superior vena cava.
Anticipate further diagnostic studies: - Chest x-ray study and abdominal or lateral x-ray study of abdominal spine - Ultrasonography - Aortography - Computed tomography (CT) angiography scan - Magnetic resonance imaging (MRI) scan	Tests are required to confirm the diagnosis and delineate anatomy (location, shape, and size of aneurysms).
Provide nonpharmacological measures to alleviate pain: - Relaxation techniques - Physical comfort (such as cold towel application, hand-holding) - Position of comfort (e.g, place clients exhibiting back pain in a side-lying position)	These measures may be tried initially, but depending on the status of the aneurysm, they may not be effective.
Administer antihypertensive medications as indicated: angiotensin-converting enzyme (ACE) inhibitor, beta-blocker.	Bp control is imperative for maintaining tissue perfusion. The goal is to maintain systolic BP less than 120 mm Hg. These medications reduce the stress applied to the arterial walls and may reduce the risk for dissection in hypertensive clients.
Administer pain medication as indicated.	Persistent acute pain suggests ongoing dissection or rupture. Surgical intervention may be required to relieve pain.
For type A dissections (involving ascending aorta or transverse arch), prepare the client for surgical intervention.	The surgical procedure involves replacement of the ascending aorta to prevent aortic rupture or retrograde progression of the dissection.
For type B dissection (involving descending thoracic aorta), anticipate chronic medical treatment, which consists of the following long-term measures: - Reduce factors that will increase BP and HR. - Pace activities (eating, personal hygiene, visitors) appropriately. - Provide a quiet environment as much as possible. - Administer sedatives as indicated.	The major treatment approach for type B involves a pharmacological regimen to control BP. It may require surgical treatment if hypertension is uncontrollable, persistent pain occurs, compromise to major organ occurs, or the aorta ruptures.

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References and Sources : nurseslabs.com