Nursing Care Plan For Abdominal Aortic Aneurysm
Nursing Care Plan For Abdominal Aortic Aneurysm; An aortic aneurysm is an abnormal dilation of the arterial wall caused by localized weakness and stretching in the medial layer or wall of an artery. An aneurysm can be located anywhere along the abdominal aorta.
The goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture.
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Nursing Care
Assessment
- Prominent, pulsating mass in the abdomen, at or above the umbilicus
- Systolic bruit over the aorta
- Tenderness on deep palpation
- Abdominal or lower back pain Diagnostic
Evaluation
- Chest radiograph, angiogram, transesophageal echocardiography, and magnetic resonance imaging(MRI). because
- Duplex ultrasonography or computed tomography (CT) Primary Nursing Diagnosis Risk for fluid volume deficit related to hemorrhage. because
Other Diagnoses that may occur in Nursing Care Plans For Abdominal Aortic Aneurysm
Acute pain related to surgical tissue trauma, anxiety related to threat to health status, decreased cardiac output related to changes in intravascular volume, increased systemic vascular resistance, third-space fluid shift, deficient knowledge (preoperative and postoperative care) related to newly identified need for aortic surgery. Ineffective breathing pattern related to effects of general anesthesia, endotracheal intubation, and presence of an abdominal incision. Nursing care Plan For Abdominal Aortic Aneurysms because
Medical Management
Medical or surgical treatment depends on the type of an aneurysm. For a ruptured aneurysm, the prognosis is poor and surgery is performed immediately. When surgery can be delayed, medical measures can be taken. And thus they include strict control of blood pressure and reduction in pulsatile flow. Systolic pressure maintained at 100 to 120 mm Hg with antihypertensive drugs, such as nitroprusside. Pulsatile flow reduced by medications that reduce cardiac contractility, such as propranolol. because
Surgical Management Removal of an aneurysm and restoration of vascular continuity with a graft (resection and a bypass graft or endovascular grafting) is the goal of surgery. And the treatment of choice for abdominal aortic aneurysms larger than 5.5 cm (2 inches) in diameter or those that are enlarging. Nursing care Plan For Abdominal Aortic Aneurysm because
Nonsurgical Intervention
- Modify risk factors. because
- Instruct the client regarding the procedure for monitoring BP. because
- Explain the client on the importance of regular physician visits to follow the size of an aneurysm. because
- Instruct the client that if severe back or abdominal pain or fullness, soreness over the umbilicus, sudden development of discoloration in the extremities, or a persistent elevation of BP occurs to notify the physician immediately. because
- Explain the client with a thoracic aneurysm to report immediately the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness. Nursing care Plan For Abdominal Aortic Aneurysm because
Pharmacologic Highlights
- 1-10 mg IV of an opioid analgesic (morphine) to relieve surgical pain.
- 50–100 mcg IV of an opioid analgesic (Fentanyl) to relieve surgical pain.
- Antihypertensives and/or diuretics for rising BP may stress graft suture lines.
- 80-400 mg/day in divided doses of Beta blocker (propranolol) to use in people with small aneurysms without risk for rupture; decreases the rate of AAA expansion. Nursing care Plan For Abdominal Aortic Aneurysm because
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Nursing Intervention
- Monitor vital signs. because
- Assess risk factors for the arterial disease process.
- Obtain information regarding back or abdominal pain.
- Question the client regarding the sensation of palpation in the abdomen.
- Inspect the skin for the presence of vascular disease or breakdown.
- Check peripheral circulation, including pulses, temperature, and color.
- Observe for signs of rupture.
- Note any tenderness over the abdomen.
- Monitor for abdominal distention. because of Nursing Care Plan For Abdominal Aortic Aneurysm because
Documentation Guidelines
Location, intensity, and frequency of pain, and the factors that relieve pain. The appearance of the abdominal wound (color, temperature, intactness, drainage). Evidence of stability of vital signs, hydration status, bowel sounds, electrolytes. because
Presence of complications: Hypotension, hypertension, cardiac dysrhythmias, low urine output, thrombophlebitis, infection, graft occlusion, changes in consciousness, aneurysm rupture, excessive anxiety, poor wound healing. Nursing Care Plan For Abdominal Aortic Aneurysm because
Discharge and Home Healthcare Guidelines
Wound care
Explain the need to keep the surgical wound clean and dry. Teach the patient to observe the wound and report to the physician any increased swelling, redness, drainage, odor, or separation of the wound edges. Also, instruct the patient to notify the physician if a fever develops. Instruct the patient to lift nothing heavier than 5 pounds for about 6 to 12 weeks and to avoid driving until her or his physician permits. because
Braking while driving may increase intra-abdominal pressure and disrupt the suture line. Most surgeons temporarily discourage activities that require pulling, pushing, or stretching—activities such as vacuuming, changing sheets, playing tennis and golf, mowing grass, and chopping wood. 3. Smoking cessation. Encourage the patient to stop smoking and to attend smoking cessation classes. 4. Complications following surgery. Discuss with the patient the possibility of clot formation or graft blockage. because
Complications for patients not requiring surgery
Compliance with the regime of monitoring the size of an aneurysm by computed tomography over time is essential. The patient needs to understand the prescribed medication to control hypertension. Advise the patient to report abdominal fullness or back pain, which may indicate a pending rupture.
Nursing Care Plan For Abdominal Aortic Aneurysm because
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