Which of the following is most important to monitor in the client after surgery for abdominal aortic aneurysm?

Abdominal aortic aneurysm (AAA) occurs when atherosclerosis or plaque buildup causes the walls of the abdominal aorta to become weak and bulge outward like a balloon. An AAA develops slowly over time and has few noticeable symptoms. The larger an aneurysm grows, the more likely it will burst or rupture, causing intense abdominal or back pain, dizziness, nausea or shortness of breath.

Your doctor can confirm the presence of an AAA with an abdominal ultrasound, abdominal and pelvic CT or angiography. Treatment depends on the aneurysm's location and size as well as your age, kidney function and other conditions. Aneurysms smaller than five centimeters in diameter are typically monitored with ultrasound or CT scans every six to 12 months. Larger aneurysms or those that are quickly growing or leaking may require open or endovascular surgery.

The aorta, the largest artery in the body, is a blood vessel that carries oxygenated blood away from the heart. It originates just after the aortic valve connected to the left side of the heart and extends through the entire chest and abdomen. The portion of the aorta that lies deep inside the abdomen, right in front of the spine, is called the abdominal aorta.

Over time, artery walls may become weak and widen. An analogy would be what can happen to an aging garden hose. The pressure of blood pumping through the aorta may then cause this weak area to bulge outward, like a balloon (called an aneurysm). An abdominal aortic aneurysm (AAA, or "triple A") occurs when this type of vessel weakening happens in the portion of the aorta that runs through the abdomen.

The majority of AAAs are the result of atherosclerosis, a chronic degenerative disease of the artery wall, in which fat, cholesterol, and other substances build up in the walls of arteries and form soft or hard deposits called plaques.

Abdominal aortic aneurysms typically develop slowly over a period of many years and hardly ever cause any noticeable symptoms. Occasionally, especially in thin patients, a pulsating sensation in the abdomen may be felt. The larger an aneurysm grows, the greater the chance it will burst, or rupture.

If an aneurysm expands rapidly, tears, or leaks, the following symptoms may develop suddenly:

intense and persistent abdominal or back pain that may radiate to the buttocks and legs
sweating and clamminess
dizziness
nausea and vomiting
rapid heart rate
shortness of breath
low blood pressure.

Major risk factors for an AAA include family history, smoking and longstanding high blood pressure. According to the Centers for Disease Control and Prevention (CDC), men who have a history of smoking should receive a one-time screening for triple A between the ages of 65 and 75. Men with a family history of AAA should be screened at age 60.

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Many abdominal aortic aneurysms are incidentally found on ultrasound examinations, x-rays or CT scans. The patient is often being examined for an unrelated reason. In other patients who experience symptoms and seek medical attention, a physician may be able to feel a pulsating aorta or hear abnormal sounds in the abdomen with the stethoscope.

To confirm the presence of an abdominal aortic aneurysm, a physician may order imaging tests including:

Abdominal Ultrasound (US): Ultrasound is a highly accurate way to measure the size of an aneurysm. A physician may also use a special technique called Doppler ultrasound to examine blood flow through the aorta. Occasionally the aorta may not be completely seen due to overlying bowel which blocks the view of ultrasound or in very large patients.
Abdominal and pelvic computed tomography (CT): This exam is highly accurate in determining the size and extent of an aneurysm. See the Safety page for more information about CT.
Angiography: This exam, which uses x-rays, CT or MRI and a contrast material to produce pictures of major blood vessels throughout the body, is used to help identify abnormalities such as abdominal aortic aneurysms.

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Treatment depends on a variety of factors, including size and location of the aneurysm within the abdominal aorta and the patient's age, kidney function and other conditions.

Patients with aneurysms that are smaller than five centimeters in diameter are typically monitored with ultrasound or CT scans every six to 12 months and may be advised to:

quit smoking
control high blood pressure
lower cholesterol.

Surgical treatment may be recommended for patients who have aneurysms that are:

larger than 5 centimeters (two inches) in diameter
quickly growing
leaking.

There are two treatment options:

Traditional (open) surgical repair: In this type of surgery, an incision is made in the abdomen and the damaged part of the aorta is removed and replaced with a synthetic tube called a stent graft, which is sewn into place.
Endovascular surgery: In this procedure, which is less invasive than an open repair, the stent graft is attached to the end of a thin plastic tube called a catheter, inserted through an artery in the leg and maneuvered up into the abdomen, where it is positioned inside the aneurysm and fastened in place with small hooks.

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Which test, procedure or treatment is best for me?

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This page was reviewed on April, 16, 2022

Medical & Surgical Nursing (Notes)

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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.

Assessment

Prominent, pulsating mass in 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).
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

Modify risk factors.
Instruct the client regarding the procedure for monitoring BP.
Instruct the client on the importance of regular physician visits to follow the size of the aneurysm.
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.
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

1-10 mg IV of opioid analgesic (morphine) to relieve surgical pain.
50–100 mcg IV of opioid analgesic (Fentanyl) to relieve surgical pain.
Antihypertensives and/or diuretics for rising BP may stress graft suture lines.
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

Monitor vital signs.
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.

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

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.
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.
Smoking cessation. Encourage the patient to stop smoking and to attend smoking cessation classes.
Complications following surgey. Discuss with the patient the possibility of clot formation or graft blockage.
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

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