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Is a localized sac or dilation at a weak point of the aorta to a size greater than 1.5 times its normal diameter
The first classification is : Fusiform Aneurysm : dilation of the entire circumference of the artery Saccular Aneurysm : localized balloonshaped outpouching projects from one side of the artery
Occur most frequently in men between the ages 40 and 70 years About one third of patients with (TAA) die of rupture of the aneurysm
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Whos at risk?
In 20% of patients, familial clustering of aortic aneurysms suggests a hereditary tendency to develop aneurysms, aortic aneurysms also can be an individual aberration present at birth Pregnancy can hasten aneurysm development because of hormonal and hemodynamic changes
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rafts
Abdominal Aortic Aneurysm- Open Repair 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
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Open Repair
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
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The physician will make a small incision in each groin to visualize the femoral arteries in each leg
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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
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Nursing Care- Assessment 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, heart failure, peripheral vascular disease
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Nursing Care- Assessment 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
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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
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Nursing Care of the client having surgery of aorta Postoperative 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
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Nursing Care of the client having surgery of aorta Postoperative 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)
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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
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Report manifestations of spinal cord ischemia: lower extremity weakness or paraplegia Impaired spinal cord perfusion may lead to ischemia and impaired function
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Planning
The overall goals for a patient undergoing aortic surgery include: Normal tissue perfusion Intact motor and sensory function No complications related to surgical repair such as thrombosis or infection
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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
Nursing Implementation- Infection Nursing prevention to prevent infection should include ensuring that the patients receives a broad spectrum antibiotic as prescribed Monitor for signs of infetion The nurse should ensure adequate nutrition and observe the surgical incision for any evidence of delaying healing or prolonged drainage
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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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Intervention
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, coffeeground appearance or is bright red)
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Assess bowel sounds every 4 hours Keep the client NPO and provide oral care every 24 hr
It is also important to note the skin temperature and color, capillary refill time and sensation and movement of the extrimities
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Nursing Implementation- Peripheral Perfusion Status 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
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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, or blood loss can also lead to decreased renal perfusion
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The patient return from surgery with an indwelling urinary catheter in place An accurate record of fluid intake and urinary output 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
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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
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Diagnose Risk for impaired gas exchange Impaired gas exchange related to ineffective cough secondary to pain from large incision
Outcome 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
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Intervention
Monitor settings on ventilator to ensure the client is adequately oxygenated
Spirometry
Assess lung sounds every 1 to 2 hours Monitor oxygen saturation continously. Report any desaturation After extubation,
assist with coughing by using incentives spirometry, provide splinting pillows before coughing, encourage ambulation provide adequate analgesia
Diagnose
Outcomes
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
pedal pulses warm feet capillary refill of less than 5 seconds, abscence of numbness or tingling ability to dorsiflex and plantar flex both feet equally
Urin output adequate
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Acute Pain
Outcomes
self-report of decreasing levels of pain use of decreasing amounts of opioid analgesics for pain control 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 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 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
Outcome The nurse will monitor for manifestations of spinal cord damage and report any abnormal data Implementation Monitor ability to move lower extrimities and sensation in both legs every 1-2 hours
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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
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Nursing Implementation ambulatory 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
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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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Self care
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 impotance in male clients should be discussed before discharge Causes vary from pre-existing aortoiliac disease or diabetes to side effects from aortic cross- clamping
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Self Care 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 are not permitted for 6-12 weeks postoperatively
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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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