#19771 - Abdominal Aortic Aneurysm Nursing Care Plan & Management - Abdominal Aortic Aneurysm Nursing Care Plan & Management

Abdominal Aortic Aneurysm Nursing Care Plan & Management

• NOTES

• EXAM

• NURSING CARE PLAN

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

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.

Abdominal Hysterectomy

Definition

• Surgical removal of the entire uterus through an abdominal incision.

• A hysterectomy is indicated for a variety of conditions, including endometriosis, adnexal disease, postmenopausal bleeding, dysfunctional uterine bleeding, and benign fibromas or malignant tumors.

• For women in their childbearing years, this surgery, as with a vaginal hysterectomy, can be a devastating blow psychologically, since they may feel they have lost their primary sexual characteristic and therefore can no longer function as women.

Positioning

• Supine, with arms extended on armboards.

Incision Sites

• Lower transverse (Pfannenstiel), vertical, midline, or paramedian.

Packs/ Drapes

• Laparatomy pack and/ or transverse Lap sheet.

• Four folded towels

Instrumentation

• Major Laparotomy tray or abdominal hysterectomy tray

• Self-retraining retractor

• Internal stapling instruments

Supplies/ Equipment

• Basin set

• Blades

• Needle counter

• Suction

• Foley catheter with drainage bag

• Solutions

• Suture

• Internal stapling

Procedure Overview

1. After incising the skin, the incision is deepened through the subcutaneous tissue with the deep knife or cautery pencil.

2. The fascia is nicked with the deep knife and incised using a curved Mayo dissecting scissors.

3. Grasping one edge of the fascial margin with two or more Kocher clamps, blunt dissection separates the fascia from the underlying muscle.

4. The muscle is divided manually. The peritoneum is then knicked with the deep knife, and the incision is lengthened with Metzenbaum scissors.

5. A self-retraining retractor is placed in the wound, with moist lap sponges to protect the wound edges; the surgeon will “pack the bowel” away from the uterus with additional moist warm Lap sponges, and the operating table is placed in slight Trendelenberg position.

6. The uterus is isolated by severing it from the uterine ligaments ans adnexa.

7. The round ligaments of the uterus are ligated, divided, sutured, and tagged with a hemostat.

8. To divide the ligaments, a curved Mayo scissors or scalpel is used. An internal stapling device can be used to free the uterus from the adnexa.

9. The surgeon mobilizes the uterus to the level of the bladder.

10. Using a Metzenbaum scissors and long tissue forceps, the surgeon separates the two structures by dissecting the peritoneal covering away from the bladder. This is called the bladder flap, and will be reattached (reperitonealized) later.

11. Once the bladder has been separated from the uterus, mobilization is continued.

12. At the level of the cervix, long Allis or Kocher clamps are placed around the edge of the cervix, and it is divided from the vagina using a long scissors or a long knife.

13. If the ovaries are to be preserved, the ovarian ligaments is ligated and divided adjacent to the uterus.

14. The uterosacral ligaments are ligated and divided, along with the cardinal ligaments.

15. To close the wound, the surgeon begins by suturing the vaginal vault using an absorbable suture.

16. The wound is irrigated with warm saline, and hemostasis is achieved.

17. To close the peritoneum, the surgeon grasps the edges with several Kelly hemostats and the peritoneum is closed with a running suture.

Perioperative Nursing Considerations

1. Foley catheterization is usually performed after the internal vaginal prep is completed but before the abdominal prep is begun.

2. A sterilization permit may be required in addition to the operative permit.

3. Instruments that have come in contact with the cervix and or vagina must be treated as contaminated and discarded into a basin that can be passed off the yield.

4. Once the abdomen is opened, 4 x 4 Raytec sponges should be replaced by Lap sponges.

5. If a free sponge has been placed in the vagina prior to closing, it is included in the sponge count and must be removed from the vagina before the count is correct and the patient leaves the room.

6. Internal staples are usually contraindicated in severe cases of pelvic inflammatory disease or endometriosis.

Abdominoplasty

Definition

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