Abdominal Aortic Aneurysm Nursing Care Plan & Management

Notes

Description
  • 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.
  • The 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.

Abdominal Aortic Aneurysm

Assessment
  1. Prominent, pulsating mass in abdomen, at or above the umbilicus
  2. Systolic bruit over the aorta
  3. Tenderness on deep palpation
  4. Abdominal or lower back pain
Diagnostic Evaluation
  1. Chest radiograph, angiogram, transesophageal echocardiography, and magnetic resonance imaging(MRI).
  2. Duplex ultrasonography or computed tomography (CT)
Primary Nursing Diagnosis
  • Risk for fluid volume deficit related to hemorrhage
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
    • presence of an abdominal incision
Medical Management

Medical or surgical treatment depends on the type of aneurysm. For a rupture aneurysm, prognosis is poor and surgery is performed immediately. When surgery can be delayed, medical measures 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 propanolol.
Surgical Management
  • Removal of the aneurysm and restoration of vascular continuity with a graft (resection and 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. Intensive monitoring in the critical care unit is required.
Nonsurgical Intervention
  1. Modify risk factors.
  2. Instruct the client regarding the procedure for monitoring BP.
  3. Instruct the client on the importance of regular physician visits to follow the size of the aneurysm.
  4. 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.
  5. Instruct the client with a thoracic aneurysm to report immediately the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness.
Pharmacologic Highlights
  1. 1-10 mg IV of opioid analgesic (morphine) to relieve surgical pain.
  2. 50–100 mcg IV of opioid analgesic (Fentanyl) to relieve surgical pain.
  3. Antihypertensives and/or diuretics for rising BP may stress graft suture lines.
  4. 80-400 mg/day in divide doses of Beta blocker (propanolol) to use in people with small aneurysms without risk for rupture; decreases rate of AAA expansion

Nursing Intervention
  1. Monitor vital signs.
  2. Assess risk factors for the arterial disease process.
  3. Obtain information regarding back or abdominal pain.
  4. Question the client regarding the sensation of palpation in the abdomen.
  5. Inspect the skin for the presence of vascular disease or breakdown.
  6. Check peripheral circulation, including pulses,temperature, and color.
  7. Observe for signs of rupture.
  8. Note any tenderness over the abdomen.
  9. Monitor for abdominal distention.
Documentation Guidelines
  • Location,intensity,and frequency of pain,and the factors that relieve pain
  • Appearance of abdominal wound (color,temperature,intactness,drainage)
  • Evidence of stability of vital signs,hydration status,bowel sounds,electrolytes
  • Presence of complications: Hypotension, hypertension, cardiac dysrhythmias, low urine out- put,thrombophlebitis,infection,graft occlusion,changes in consciousness,aneurysm rupture, excessive anxiety,poor wound healing
Discharge and Home Healthcare Guidelines
  1. 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.
  2. Activity restriction. 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. 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 surgey. Discuss with the patient the possibility of clot formation or graft blockage.
  5. Complicatios for patients not requiring surgery. Compliance with the regime of monitoring the size of the 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.

 

References:
ADAM for images
Saunders, Comprehensive Review for the NCLEX_RN Exam , 2005 ed
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing
Therapeutics Manual, 2007 3rd ed

Exam

Welcome to your MSN Exam for Abdominal Aortic Aneurysm! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 19 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Focus on the action that provides the most immediate information on the patient's hemodynamic status and overall condition.

1 / 19

1. After surgery, Ms. Thompson has her abdominal aortic aneurysm resected and replaced with a graft. When she arrives in the recovery room, she is still in shock. What should be the nurse’s priority action?

💡 Hint

Consider the combination of a palpable abdominal pulse, elevated blood pressure, and fatigue as key indicators.

2 / 19

2. A 55-year-old man enters the ER with complaints of back pain and feeling fatigued. Upon examination, his blood pressure is 190/100, pulse is 118, and both hematocrit and hemoglobin levels are low. The nurse palpates his abdomen, which is soft and non-tender, and auscultates an abdominal pulse. What is the most likely diagnosis?

💡 Hint

Focus on the symptom that typically involves a rhythmic expansion in the abdominal area.

3 / 19

3. Nurse Williams is assessing Mr. Barker, who presents with a palpable, pulsating mass in his abdomen. She is determining which condition this symptom most likely indicates. What should she consider as the primary possibility?

 

💡 Hint

Focus on the symptom pattern that indicates significant internal bleeding and systemic response.

4 / 19

4. Nurse Kim is providing emergency care for Mr. Johnson, a 70-year-old patient suspected of having a ruptured abdominal aneurysm. She carefully monitors his symptoms to confirm the diagnosis. Which group of symptoms should Nurse Kim be most concerned about?

💡 Hint

Consider the symptom directly related to the location and nature of the aneurysm in the abdomen.

5 / 19

5. Nurse Johnson is assessing Mr. Miller, who has been admitted with a suspected abdominal aortic aneurysm (AAA). She reviews his symptoms to confirm the diagnosis. What is a common complaint among clients with an abdominal aortic aneurysm?

💡 Hint

Think about the importance of respecting a patient’s cultural and spiritual needs in providing comprehensive care.

6 / 19

6. Mr. Lopez is in the ICU after a repair of an abdominal aortic aneurysm and is experiencing continued slow bleeding from the graft. Due to his unstable condition, visitor restrictions are in place, limiting visits to family members. Mr. Lopez insists on a visit from a medicine man whom his family regularly consults. How should the nurse interpret this request?

💡 Hint

Consider the type of sound produced by turbulent blood flow in a vessel with an aneurysm.

7 / 19

7. Nurse Parker is training a group of new nurses on the proper techniques for auscultating patients with suspected abdominal aortic aneurysms. She explains which specific sound they should listen for over the abdominal region. What sound should they expect to hear?

💡 Hint

Consider the primary vascular condition often linked with changes in arterial wall integrity.

8 / 19

8. Nurse Lee is conducting a community health seminar focusing on vascular health issues. She discusses the risk factors and causes of abdominal aortic aneurysms. Which cause does she identify as the most common for this condition?

💡 Hint

Reflect on which condition typically leads to an increase in venous pressure visible in the neck veins.

9 / 19

9. Nurse Patel is evaluating Mr. Thompson, an 80-year-old patient exhibiting signs of increased central venous pressure. She is assessing for physical signs that might indicate the underlying cause. Which disorder should Nurse Patel consider primarily if she observes prominent jugular vein distention?

💡 Hint

Focus on the most urgent and life-threatening complication associated with this condition.

10 / 19

10. Nurse Thompson is reviewing potential complications with the surgical team for a patient scheduled for abdominal aneurysm surgery. She emphasizes the primary concern they need to monitor for in the preoperative phase. Which complication warrants the greatest vigilance?

💡 Hint

Think about the symptoms directly related to the abdominal area and consider the severity and suddenness of the pain indicating a serious complication.

11 / 19

11. Nurse Anderson is closely monitoring Mr. Lee, a 67-year-old patient with a known abdominal aortic aneurysm. Given the risk associated with this condition, she is vigilant for any signs that could indicate rapid expansion and the possibility of an impending rupture. Which symptom should she be most alert to?

💡 Hint

Consider the primary symptom that directly relates to the anatomical location of the condition discussed.

12 / 19

12. Nurse Mitchell is evaluating Mr. Green, who is suspected of having an abdominal aortic aneurysm. She reviews the most common symptoms associated with this condition to better focus her assessment. Which symptom is most commonly reported by patients with this condition?

💡 Hint

Consider the complication that involves bleeding from the repair site, leading to an unusual hematoma location.

13 / 19

13. Nurse Adams is conducting a post-operative assessment on Mr. Davis, who recently underwent an abdominal aortic repair. She notices a hematoma in the perineal area and considers the possible complications. Which complication does this finding most likely indicate?

💡 Hint

Focus on the condition that significantly affects blood vessel integrity and pressure, contributing to the development of aneurysms.

14 / 19

14. Nurse James is presenting a lecture on the risk factors associated with abdominal aortic aneurysms. He highlights a condition that is linked to more than 50% of clients diagnosed with this type of aneurysm. Which condition should he emphasize?

💡 Hint

Focus on the layers involved in maintaining the structure and elasticity of blood vessels, which are often compromised in aneurysms.

15 / 19

15. Nurse Cooper is conducting an educational session on vascular health and the anatomy involved in aneurysms. She explains to the nursing students which layers of a blood vessel are most commonly affected in patients with an aneurysm. Which layers should she highlight?

💡 Hint

Consider the anatomical location of the aorta in relation to the umbilicus for palpation techniques.

16 / 19

16. During a clinical workshop on vascular assessments, Nurse Roberts demonstrates the correct procedure for assessing a patient for an abdominal aortic aneurysm. She explains the specific area of the abdomen that is most commonly palpated for this purpose. Which area should she focus on?

💡 Hint

Consider a non-invasive imaging test specifically designed to visualize the abdominal area and detect aneurysms.

17 / 19

17. Nurse Garcia is coordinating diagnostic procedures for a patient with suspected vascular issues. She consults with the medical team to determine the definitive test for diagnosing an abdominal aortic aneurysm. Which test should they primarily consider?

💡 Hint

Consider where along the aorta aneurysms are most frequently diagnosed relative to major arterial branches.

18 / 19

18. Nurse Carter is updating the medical team on a case involving a patient suspected of having an abdominal aortic aneurysm. She highlights the importance of focusing imaging studies on the most common location for this type of aneurysm. Where should the team primarily look?

💡 Hint

Consider the urgency and typical course of action required for a rapidly enlarging aneurysm.

19 / 19

19. Mr. Carter arrives at the emergency department with severe abdominal pain. Diagnostic tests reveal a rapidly enlarging abdominal aortic aneurysm. What action should the nurse anticipate?

Nursing Care Plan