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Aortic aneurysm. Dr. Aidah Abu Elsoud Alkaissi An-Najah National University Nursing College. Thorasic Aorta Aneurysm. May be a symptomatic Back, neck or substernal pain Dyspnea, stridor or brassy cough if pressing on trachea

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aortic aneurysm

Aortic aneurysm

Dr. Aidah Abu Elsoud Alkaissi

An-Najah National University

Nursing College

thorasic aorta aneurysm
Thorasic Aorta Aneurysm
  • May be a symptomatic
  • Back, neck or substernal pain
  • Dyspnea, stridor or brassy cough if pressing on trachea
  • Hoarseness and dysphagia if pressing on esophagus or laryngeal nerve
  • Edema of the face and neck
  • Distended neck vein
  • Complications: rupture and hemorrhage
abdominal aorta aneurysm
Abdominal Aorta Aneurysm
  • Client´s awareness of a pulsating mass in the abdomen, with or withourt pain, followed by abdominal pain and back pain
  • Flang pain or groin pain may be experienced because of increasing pressure on other structures sometimes mottling (the act of coloring with areas of different shades) of the extrimities or distal emboli in the feet alert the clinician to a source in the abdomen
abdominal aorta aneurysm7
Abdominal Aorta Aneurysm
  • Pulsating abdominal mass
  • 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 hemorrge
medication
Medication
  • Thorasic aorta aneurysms are treated with long-term beta blocker therapy and additional antihypertensive drugs as needed to control heart rate and blood pressure
  • Clients with aortic disection are intially treated with intravenous beta blocker such as propranolol (Inderal) , metoprolol (Lopressor), labetalol (Normodyne) , or esmolol (Brevibloc) to reduce the heart rate to about 60BPM.
  • Sodium nitroprusside (Nipride) infusion is started concurrently to reduce the systolic pressure to 120 mmHg or less
medication9
Medication
  • Calcium channel blockers also may be used
  • Direct vasodilator such as diazoxide (Hyperstat) and hydralazine (Apresoline) are avoided as they may actually worsen the dissection
  • Constant monitoring of vital signs, hemodynamic pressures (via Swan-Ganz catheter and urin outpt are vital to ensure adequate perfusion of vital organs
  • Following surgical correction of an aneurym, anticoagulant tharapy may be intiated
  • Heparin therapy is used initially, with conversion to oral anticoagulation prior to discharge
  • Many clients are manifested indefinitely on anticoagulation therapy, others may use lifelong, low- dose-aspirin therapy to reduce the risk of clot formation
abdominal aortic aneurysm repair
Abdominal Aortic Aneurysm Repair
  • (Abdominal Aneurysm - Open Repair, AAA Repair, Triple A Repair, Abdominal Aneurysmectomy, Endovascular Aneurysm Repair, EVAR)
procedure overview what is an abdominal aortic aneurysm repair
Procedure OverviewWhat is an abdominal aortic aneurysm repair?
  • Abdominal aortic aneurysm (AAA) repair is a procedure used to treat an aneurysm (abnormal enlargement) of the abdominal aorta.
  • Repair of an abdominal aortic aneurysm may be performed surgically through an open incision or in a minimally-invasive procedure called endovascular aneurysm repair (EVAR).
procedure overview what is an abdominal aortic aneurysm repair12
Procedure OverviewWhat is an abdominal aortic aneurysm repair?
  • Aggressive control of the blood pressure and prolonged bed restis the usual initial treatment for patients with uncomplicateddissection sparing the ascending aorta (Stanford type B)
  • asemergency surgery to the descending thoracic aorta carries asubstantial mortality when compared with medical treatment.
  • Surgery should be reconsidered if there is evidence of aorticrupture, proximal extension of the dissection, or ischaemiccomplications.
slide13
The optimal management of patients with suspected dissectionrequires close liaison between district hospitals and cardiacsurgical centres and use of local guidelines for investigationthat reflects the available skill.
  • Patients with a low clinicallikelihood of dissection who are in a stable cardiovascularstate should undergo prompt local investigation with a nominatednon-invasive technique.
  • Unstable patients with a high likelihoodof dissection should receive medical treatment and be transferredimmediately to the surgical centre for both diagnostic imagingand management.
slide14
If skill in transthoracic or transoesophagealechocardiography is available locally these procedures can beperformed while transport is awaited, but doing so should notdelay transfer.
  • A videotaped record of the study should accompanythe patient to the surgical centre, where repeat transoesophagealechocardiography can be performed in the anaesthetic room ifnecessary.
  • This approach minimises delay, an essential stepin lowering the mortality of acute dissection.
what is an abdominal aortic aneurysm
What is an abdominal aortic aneurysm?
  • An abdominal aortic aneurysm, also called AAA or triple A, is a bulging, weakened area in the wall of the aorta (the largest artery in the body) resulting in an abnormal widening or ballooning greater than 50 percent of the normal diameter (width).
slide16
The most common location of arterial aneurysm formation is the abdominal aorta, specifically, the segment of the abdominal aorta below the kidneys.
  • An abdominal aneurysm located below the kidneys is called an infrarenal aneurysm. An aneurysm can be characterized by its location, shape, and cause.
  • The shape of an aneurysm is described as being fusiform or saccular, which helps to identify a true aneurysm.
  • The more common fusiform-shaped aneurysm bulges or balloons out on all sides of the aorta. A saccular-shaped aneurysm bulges or balloons out only on one side.
slide17
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.
  • Sometimes, a tear can occur on the inside layer of the vessel resulting in blood filling in between the layers of the blood vessel wall, creating a pseudoaneurysm
slide18
The aorta is under constant pressure as blood is ejected from the heart. With each heart beat, the walls of the aorta distend (expand) and then recoil (spring back), exerting continual pressure or stress on the already weakened aneurysm wall.
  • Therefore, there is a potential for rupture (bursting) or dissection (separation of the layers of the aortic wall) of the aorta, which may cause life-threatening hemorrhage (uncontrolled bleeding) and, potentially, death.
slide19

The larger the aneurysm becomes, the greater the risk of rupture.

  • Because an aneurysm may continue to increase in size, along with progressive weakening of the artery wall, surgical intervention may be needed.
  • Preventing rupture of an aneurysm is one of the goals of therapy
slide20
Types of abdominal aneurysm repair:
  • There are two approaches to abdominal aortic aneurysm repair.
  • The standard surgical procedure for AAA repair is called the open repair.
  • A newer procedure is the endovascular aneurysm repair (EVAR).
slide21
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.
  • Once the abdomen is opened, the aneurysm will be repaired by the use of a long cylinder-like tube called a graft.
slide22
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
slide23
Grafts are made of various materials, such as Dacron (textile polyester synthetic graft) or polytetrafluoroethylene (PTFE, a non-textile synthetic graft).
  • 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.
complications
Complications
  • Caused by underlying coronary artery disease and chronic obstructive pulmonary duisease
  • These conditions decreased metabolism of anesthetic, increase the risk of postoperative atelectasis and decrease the client´s tolerance of hemodynamic changes from blood loss and fluid shifts
complications27
Complications
  • To reduce the risk of acute myocardial infarction, one of the most serious complications, clients may undergo coronary artery bypass before aneurysm repair
  • Prerenal failure can develop for several reasons
  • The kidney can sustain ischemia from decreased aortic blood flow, decreased cardiac output, emboli, inadequate hydration or the need for clamps on the aorta above the renal arteries during surgery
complications28
Complications
  • Emboli can also develop and lodge in the arteries of the lower extrimities or mesentery
  • Clinical manifestations include those of acute occlusion in the leg
  • Bowel necrosis is exhibited as fever, leukocytosis, ileus, diarrhea and abdominal pain
  • The spinal cord can also cbecome ischemic, resulting in paraplegia, rectal and urinary incontinence or loss of pain and temperature sensation
  • Spinal cord ischemia tends to occur more commonly when an abdominal aortic aneurysm has ruptured
complications29
Complications
  • Changes in sexual function may also develop following repair of an abdominal aortic aneurysm
  • Retrograde ejaculation occurs in about two third of male clients and loss of potency occurs in one third of males who have undergo repair of abdominal aortic aneurysm
slide30
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).
slide31

The physician will make a small incision in each groin to visualize the femoral arteries in each leg.

  • 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.
slide32
A stent-graft is a long cylinder-like tube made of a thin metal framework (stent), while the graft portion is made of various materials such as Dacron or polytetrafluoroethylene (PTFE) and may cover the 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 stent-graft.
slide33
Reasons for the Procedure
  • Reasons an abdominal aortic aneurysm repair may be performed include, but are not limited to, the following:
  • to prevent the risk of rupture
  • to relieve symptoms
  • to restore a good blood flow
  • size of aneurysm greater than 5 centimeters in diameter (about two inches)
  • growth rate of aneurysm of more than 0.5 centimeter (about 0.2 inch) over one year
  • when risk of rupture outweighs the risk of surgery
  • emergency life-threatening hemorrhage (uncontrolled bleeding) .
slide34
Risks of the Procedure
  • As with any surgical procedure, complications can occur. Some possible complications may include, but are not limited to, the following:
  • open repair:
  • myocardial infarction (heart attack)
  • irregular heart rhythms (arrhythmias)
  • bleeding during or after surgery
  • injury to the bowel (intestines)
  • limb ischemia (loss of blood flow to legs/ feet)
  • embolus (clot) to other parts of the body
  • infection of the graft
  • lung problems
  • kidney damage
  • spinal cord injury
slide35
EVAR:
  • damage to surrounding blood vessels, organs, or other structures by instruments
  • kidney damage
  • limb ischemia (loss of blood flow to leg/feet) from clots
  • groin wound infection
  • groin hematoma (large blood-filled bruise)
  • bleeding
  • endoleak (continual leaking of blood out of the graft and into the aneurysm sac with potential rupture)
  • spinal cord injury
  • Patients who are allergic to or sensitive to medications, contrast dyes, iodine, shellfish, or latex should notify their physician.
nursing care of the client having surgery of aorta preoperative care
Nursing Care of the client having surgery of aortaPreoperative Care
  • Preoperative assessment must include detection of concurrent coronary artery disease and cerebrovascular disease
  • Assess all peripheral pulses for baseline comparison postoperativelyIf emergent surgery is required, time for preoperative care and teaching may be limited
  • Implement measures to reduce fear and anxiety:
  • Orient to the intensive care unit, if appropriate
  • Describe and explain the reason for all equipment and tubes, sucgh as cardiac monitors, ventilators, nasogastric tubes, urinary catheters, intravenous lines and fluids and intra-arterial lines
  • Explain what to expect following surgery (sights, sounds, frequency of taking vital signs, dressing, pain relief measures, communication strategies)
nursing care of the client having surgery of aorta preoperative care37
Nursing Care of the client having surgery of aortaPreoperative Care
  • Allow time for questions and expression of fears and concerns
  • These explanation provide a sense of control for the client and family
nursing assessment
Nursing Assessment
  • A thorough nursing history and physical asessment should be performed, because atherosclerosis is a systemic desease process
  • It is important for the nurse to watch for signs of cardiac, pulmonary, cerebral and lower extrimity vascular problems
  • The patient should be monitored for indications of rupture of the aneurysm such as diaphoresis, paleness, weakness, tachycardia, hypotension, abdominal, back, groin or periumbilcal pain, changes in sensorium or a pulsating abdominal mass
  • 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
planning
planning
  • The overall goals for a patient undergoing aortic surgery include
  • 1. Normal tissue perfucsion
  • 2. Intact motor and sensory function
  • No complications related to surgical repair such as thrombosis or infection
nursing implementation health promotion
Nursing ImplementationHealth Promotion
  • The nurse must be aware of cardiovascular disease risk factors and be alert for opportunities to teach health promotion measures to patients in the hospital and the community
  • Special attention should be given to the patient with a strong family history of aneurysm or any evidence of other cardiovascular disease
nursing implementation health promotion41
Nursing ImplementationHealth Promotion
  • The patient should be encouraged to reduce risk factors known to be associated with atherosclerosis
  • These should include controlling hypertension, smoking cessation, and following a diet low in fats and cholesterol
  • These measures are also done to ensure contiued graft patency following surgical repair
nursing implementation acute intervention
Nursing ImplementationAcute intervention
  • Preoperative teaching should include a brief explanation of the disease process, the planned surgical procedures, preoperative routines, what to expect immediately after surgery ” e.g., recovery room, tubes/drains” and usual postoperative timelines
  • Preoperative routine, bowel preparation (laxatives, enemas) and have a preoperative shower with an antimicrobial soap the day before surgery, receive nothing by mouth after midnight the day before surgery and often are given preoperative intravenous antibiotics immediately before surgery
  • A tour of the ICU before surgery may be of interest to the patient and family
nursing implementation acute intervention43
Nursing ImplementationAcute intervention
  • When the pat arrives in the ICU, an endotrachial tube, an arterial line, a central venous catheter, or pulmonary artery catheter, peripheral i.v line, an indwelling urinary catheter and a nasogastric tube will likely be in place with continous ECG and pulse oximetry monitoring
  • If the thorax is entered during surgery, chest tube will also be in place, pain medication may be administered via epidural catheter or patient controlled analgesia
  • Maintaining adequate respiratory function, fluid and electrolytes balance , pain control
nursing implementation acute intervention44
Nursing ImplementationAcute intervention
  • The nurse must monitor graft patency, and renal perfusion
  • The nurse can also assist in preventing arrhythmia, infections and neurologic complications
nursing implementation graft patency
Nursing Implementationgraft 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 indicatedis 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 patient´s state of hydration
nursing implementation graft patency46
Nursing Implementationgraft 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
nursing implementation cardiovascular status
Nursing ImplementationCardiovascular status
  • In individuals with preexisiting 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
slide48

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
nursing implementation infection
Nursing ImplementationInfection
  • The development of a prosthetic vascular graft infection is relatively rare but possibly life threatening complications
  • Nursing prevention to prevent infection should include ensuring that the patients receives a broad spectrum antibiotic as prescribed
  • Assess body temperature regularly and report any elevations
  • Laboratory data should be monitored for elevated WBC
  • The nurse should ensure adequate nutrition and observe the surgical incision for any evidence of delaying healing, signs of infection or prolonged drainage
nursing implementation infection50
Nursing ImplementationInfection
  • All i.v, arterial and central venous catheter insertion sites should be cared for carefully with the use of sterile technique because they are frequently a portal of antry for bacteria
  • Meticulous perinial care for the patient withan indwelling urinary catheter is essential to minimize the risk of urinary tract infection
  • Surgical inncisions should be kept clean and dry
nursing implementation gastrointestinal status
Nursing ImplementationGastrointestinal 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 retroperitoneal surgical approach can be used to decrease the risk of bowel complications
  • 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
nursing implementation gastrointestinal status52
Nursing ImplementationGastrointestinal status
  • Thre 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
nursing implementation gastrointestinal status53
Nursing ImplementationGastrointestinal status
  • While the patient is NPO, meticulous mouth care should be given every few hours
  • Ice chips or lozenges may be given to the patient to soothe an irritated throat
  • If the blood supply to the bowel is disrupted during surgery, temporary ischemia or infarction of intestinal tissue may result
  • This is evidenced by lack of bowel sounds, fever, abdominal distention, diarrhea, and bloody stools
  • When bowel infarction does occur as a result of mesenteric ischemia, reoperation is necesary as soon as possible to restore blood flow, with likely resection of the infarcted bowel
nursing implementation neurologic status
Nursing ImplementationNeurologic 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
  • When the descending aorta is involved, nursing assessment of the ability to move lower extrimities is also important
  • These assessment shoud be recorded indetail with a careful description of the patient´s response
nursing implementation peripheral perfusion status
Nursing Implementationperipheral perfusion status
  • Tha anatomic location of the aneurysm indicates the areas of major concern related to peripheral perfusion
  • All peripheral pulses should be checked regularly and recorded
  • This should be done every hour for several hours, depending on the nursing policy and rutinely thereafter ar frequent intervals
  • When the ascending aorta and aortic arch are involved, the carotid, radial, and temporal artery pulses should be assessed
  • After surgery involving the descending aorta, pulses to be assessed may include the femoral, popliteal, posterior tibial and dorsalis pedis
nursing implementation peripheral perfusion status56
Nursing Implementationperipheral 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 Doppleris 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
  • Pulses in lower extrimities may be absent for a short time following surgery
nursing implementation peripheral perfusion status57
Nursing Implementationperipheral perfusion status
  • This is usually due to vasospasm and hypothermia
  • 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
  • In some patients the pulses may have been absent preoperatively because of coexistent pripheral arterial occlusive disease
nursing implementation peripheral perfusion status58
Nursing Implementationperipheral perfusion status
  • Comparison with the preoperative status is essential to determine the etiology of decreased or absent pulse and the proper treatment
nursing implementation renal perfusion status
Nursing Implementationrenal 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, can also lead to decreased renal perfusion
nursing implementation renal perfusion status60
Nursing Implementationrenal perfusion status
  • The patient return from surgery with an indwelling urinary catheter in place
  • In imediate postoperative period, hourly urin out puts are recorded
  • An accurate record of fluid intake and urinary out put 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
nursing implementation renal perfusion status61
Nursing Implementationrenal perfusion status
  • Daily blood urea nitrogen and serum creatinine studies are performed to evaluate renal function
  • Irreversible renal failure may occur after aortic surgery, particularly in high risk individuals
nursing implementation ambulatory and home care
Nursing Implementationambulatory and home care
  • The patient should 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
nursing implementation ambulatory and home care63
Nursing Implementationambulatory 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
nursing implementation ambulatory and home care64
Nursing Implementationambulatory and home care
  • Sexual dysfunction 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 surgical 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
nursing care of the client having surgery of aorta postoperative care
Nursing Care of the client having surgery of aortaPostoperative 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
nursing care of the client having surgery of aorta postoperative care66
Nursing Care of the client having surgery of aortaPostoperative 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)
nursing care of the client having surgery of aorta postoperative care67
Nursing Care of the client having surgery of aortaPostoperative 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
nursing care of the client having surgery of aorta postoperative care68
Nursing Care of the client having surgery of aortaPostoperative 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
nursing care of the client having surgery of aorta postoperative care69
Nursing Care of the client having surgery of aortaPostoperative 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
nursing care of the client having surgery of aorta postoperative care70
Nursing Care of the client having surgery of aortaPostoperative care
  • Report manifestations of spinal cord ischemia: lower extremity weakness or paraplegia.
  • Impaired spinal cord perfusion may lead to ischemia and impaired function
nursing care assessment
Nursing CareAssessment
  • 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, hear failure, peripheral vascular disease
nursing care assessment72
Nursing CareAssessment
  • 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
slide73
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

interventions
Interventions
  • Monitor the client for increase in pulse rate, decrease in blood pressure, clammy skin, anxiety, restlessness, decreasing levels of conciousness, pallor, cyanosis, thirst, oliguria (urine output less than 0.5 ml/kg/hr), increase abdominal girth, increased chest tube output greater than 100 ml/hr/for 3 hours and back pain (from retroperitoneal bleeding)
  • Monitor central venous pressure, left arterial pressure, pulmonary artery pressure, and pulmonary capillary wedge pressure continously
  • Assess for changes indicating hypovolemia
  • Report any of these manifestations immediately
slide75
Diagnose

Risk for impaired gas exchange

The large abdominal incision impairs deep inspiration and usually reduced effective coughing

At risk for impaired gas exchange related to ineffective cough secondary to pain from large incision

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

intervention
Intervention
  • Monitor settings on ventilator to ensure the client is adequately oxygenated
  • Assess lung sounds every 1 to 2 hours
  • Report any adventitious (belonging to a structure that develops in an unusual place) sounds
  • Monitor oxygen saturation continously
  • Report any desaturation
  • After extubation, assist with coughing by using incentives spirometry, provide splinting pillows before coughing, encourage ambulation and provide adequate analgesia
diagnosis ineffective tissue perfusion peripheral and or renal
DiagnosisIneffective tissue perfusion (peripheral and / or renal )
  • Related to graft thrombosis, embolism, prolonged aortic cross-clamping, hypotension sand blood loss as manifested by absent or diminished peripheral pulses, altered skin color, decreased urine output, altered ability to move extrimities
ineffective tissue perfusion peripheral and or renal
Diagnose

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

Ineffective tissue perfusion related to temporary decrease in blood supply

Outcomes

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 and ability to dorsiflex and plantar flex both feet equally

Patent arterial graft with adeuate distal perfusion

Urin output adequate

Ineffective tissue perfusion (peripheral and / or renal )
intervention risk for ineffective tissue perfusion
Assess dorsalis pedis and posterior tibial pulses every hour for 24 hours

Report change in pulse quality or absent pulses (assess with Doppler if needed)

Assess dorsiflexion and planter flexion and sensation (needles and pins sensation) every hour for 24 hr

Inspect lower extrimities for mottling, cyanosis, coolness, or numbness every 4 hours

Interventionrisk for ineffective tissue perfusion
intervantion
Asess for diminished or absent peripheral pulses in the extrimities, color or temperature changes in the extrimities, altered sensation and movement of the extrimities, increased pain level because theseare indicator for altered peripheral perfusion

Compare extrimities for warmth, capillary refill and color because differnces may indicate impaired blood flw

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

Intervantion
risk for 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

Risk for infection
intervention risk for infection
Monitor for signs of infetion such as elevared body temperature, elevated WBC count, heart rate and respiratory rate, decreased blood pressure, erythema and warmth along the incision line, persistent drainage from incisions as well as sites of invasive lines, separation of wound edges

Administer broad spectrum antibiotics as ordered to maintain adequate blood levels of the drug

Monitor WBC count because a rising count may be firsy si´gn of infection

Use septic technique in caring for incision and any indwelling i.v. Line, tubing, or catheter because these sites are potential portals of entry for infection

Ensure adequate nutrition, specifically a diet high in protein, vit c, vit A and zinc to promote healing

Intervention Risk for infection
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Diagnosis: Acute Pain

Abdominal aortic aneurysm repair necessitates a long incision

Acute pain related to surgical incision

Outcomes: 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, and 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
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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 ischemia of the bowel

If the client undergoes extensive aortic pricedures 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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Maintain accurate intake and outpit and analyze data hourly for 24 hr

Notify physician if urine output goes below 0.5 ml/kg/hr

Assess urine specific gravity and daily weight

Monitor blood urea nitrogen and creatinine levels

Assess bowel sounds every 4 hours

Keep the client NPO and provide oral care every 2-4 hr

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, coffee-ground appearance or is bright red)

Intervention
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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

The nurse will monitor for manifestations of spinal cord damage and report any abnormal data

implementation
implementation
  • Monitor ability to move lower extrimities (dorsiflexion and plantar flexion) and sensation in both legs every 1-2 hours
self care
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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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, should more than 15-20 lb, are not permitted for 6-12 weeks postoperatively
  • Activities that involve pushing, pulling, or straining may also be restricted
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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 importance in male clients should be discussed before discharge
  • Causes vary from pre-existing aortoiliac disease or diabetes to side effects from aortic cross- clamping
  • Referral may be appropriate if the client is amanable
nursing diagnosis and intervention
Nursing diagnosis and intervention
  • Nursing care for clients with an aneurysm of the aorta or its branches focuses on monitoring and maintaining tissue perfusion, relieving pain, and reducing anxiety
  • Nursing care usually is acute, precipitated by a complication or surgical repair of the aneurysm
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Risk for ineffective tissue perfusion

Client with aortic aneurysms are at risk for impaired tisue perfusion due to aneurysm rupture with resulting hemorrhage and lack of blood flow to tissues distal to the rupture

In addition, thrombi often form within the aneurysm and may become emboli, obstructing distal arterial blood flow

Practice alert

Immediately report manifestations of impending rupture, expansion, or dissection of the aneurysm: increased pain, discrepancy between upper and lowe extrimity blood pressure and peripheral pulses, increased mass size, change in LOC or motor or sensory function, laboratory results, rapid expansion may indicate increased risk for rupture, with resulting hemorrhage, shock and possible death

Elective or planned surgery may rapidly become emergemcy surgery to prevent complications

Nursing diagnosis and intervention
risk for ineffective tissue perfusion
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 defecation and instruct to avoid holding the breath while moving

Administer beta blockers and antihypertensive as prescibed

Activity, stress, and the valsalva maneuver increase blood pressure, increasing the risk of rupture

Elevating or crossing the legs restricts peripheral blood flow and increases pressure in the aorta or iliac arteries

Beta blockers and antihypertensives are argered to reduce pressure in the dilated vessel

Risk for ineffective tissue perfusion
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Contiously monitor cardiac rhythm

Report complaints of chest pain or changes in ECG tracing

Administer oxygen as indicated

Aortic dissection and repair place the client at significant risk for myocardial infarction (MI)

A major causes of potoperative mortality and morbidity

Rapid identification and treatment of this complication can reduce the risk of death or long-term adverse effects of MI

Risk for ineffective tissue perfusion
risk for injury
Potent antihypertensive drugs often are given intravenously to reduce the pressure on an expanding or dissecting aneurysm

Continous monitoring of infusions and hemodynamic parameters such a arterial presure, pulmonary pressures, and cardiac output is vital to ensure that adequate tissue perfusion is maintained during infusions of these potent drugs

Continously monitor arterial pressure and hemodynamic parameters as indicated

Promtly report results outside the specified parameters to the physician

Many of the drugs used are effective within minutes

Responses vary among individuals, particularly in the older adult, necessitating continous monitoring

Monitor urine output hourly. Report output less than 30 ml/hr. the kidneys are very sensitive to reduce perfusion pressure, inadequate renal blood flow can lead to acute renal failure

Risk for injury
anxiety
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
home care
Home Care
  • 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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Home Care
  • Following surgery, discuss the following topics in preparing the client and family for home care
  • Wound care and preventing infection;manifestations of impaired healing or infection to be reported
  • 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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The importance of avoiding prolonged sitting, lifting heavy objects, engaging in strenous exercise and having sexual intercourse until approved by the physician (usually 6-12 weeks)
  • Signs and symptoms of complications to report to the physician
  • Provide referrals to home health agency or community health service as necessary
practice alert
Report manifestation of arterial thrombosis or embolism: absent peripheral pulses, a pale or cyanotic, cool extrimity, severe, diffuse abdominal pain with guarding, or increased groin, lumbar, or lower extrimity pain

Sluggish blood flow within the aneurysm often causes thrombit to form

These thrombi can break loose, becoming emboli that can occlude peripheral arteries or arteries to the kidneys or mesentry

Arterial occlusion may necessitate emergency surgery to restore blood flow and prevent tissue infarct or gangrene

Immediately report changes in mental status or symptoms of peripheral neurologic impairment (weakness, parensthesias, paralysis)

The expanding aneurysm or dissection can affect carotid and cereberal blood flow or spinal cord perfuion, leading to neurologic symptoms

Immediate resoration of blood flow is vital to prevent permanent neurologic deficits

Practice Alert
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Use an infusion device for all drug infusions

These devices prevent accidental or inadvertent changes in the rate of the infusion and dose of the drug

Practice Alert
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