Nursing Care Plan for Aortic Aneurysm
When the aorta is under extreme high pressure from hypertension, the wall of the vessel can weaken, causing a dilation or outpouching of the vessel that is extremely weak, causes turbulent flow, and is at high-risk for rupture.
Aortic aneurysms are classified by location: Thoracic and Abdominal. There are four types of aneurysms that can be seen on diagnostic imaging:
- Fusiform: dilation that involves the entire circumference
- Saccular: localized outpouching
- Dissecting: pressure tears lining of vessel away from outer layer, blood gets trapped between the layers – often decreases distal blood flow
- False: clot forms outside the vessel wall
Most commonly caused by chronic hypertension. Can also be caused by any other weakening of the vessel walls, such as in connective tissue disorders, Marfan Syndrome, or Elers-Danlos Syndrome.
We want to manage the patient’s blood pressure to prevent worsening or rupture of the aneurysm. The larger the aneurysm, the more likely it is to rupture. Therefore, preventing complications is the top priority.
Aortic Aneurysm Nursing Care Plan
- Chest pain
- Burning / tearing
- Radiates to back, shoulder, abdomen, flank, or groin
- s/s Low CO
- Shortness of breath
- Abdominal Assessment
- Visible and palpable pulsatile mass
- Systolic bruit
- s/s ↓ CO
- ↓ BP
- ↑ HR
- ↓ pulses
- Slow cap refill
- Skin – cool, pale, diaphoretic
- ↓ LOC
- ↓ UOP
- Hematoma on flank
Nursing Interventions and Rationales
- Full Pain Assessment (PQRST or OLDCARTS)
Need to determine how quickly the pain came on – sudden onset may indicate rupture. Need to determine if the pain radiates – aneurysms tend to radiate to the back and abdomen. Severe pain may indicate worsening aneurysm or even rupture.
- Full Abdominal Assessment
AAA’s can be seen and felt pulsating in the abdomen and a bruit can be heard. A detailed abdominal assessment can help to identify a AAA.
- Inspection – visible pulsation
- Auscultation – systolic bruit
- Palpation – pulsation and tenderness
- Assess VS and hemodynamics
Since cardiac output can be compromised, it’s important to monitor hemodynamics and vital signs to monitor for deterioration.
- Assess peripheral perfusion
Since cardiac output can be compromised, peripheral perfusion may be decreased. Monitor for diminished pulses, cool, pale, clammy skin, and slow cap refill.
- Manage Pain
- Administer analgesics
- Position of comfort
Aortic aneurysms are often accompanied by pain that radiate to the back. It can even be burning or tearing pain. We need to manage this with analgesics as well as encouraging the patient to be in their position of comfort. For some, this might be side-lying, while others may prefer to be on their backs.
- Administer antihypertensives
Controlling blood pressure is a top priority with an aortic aneurysm. The goal is to decrease the pressure on the walls of the aorta while still maintaining a MAP sufficient enough to perfuse the rest of the body. Usually this means a MAP > 65 mmHg.
- Monitor for evidence of rupture
Larger aortic aneurysms are at high risk for rupture. This would be evidenced by sudden, severe pain that radiates to the back, flank, or groin, a hematoma on the flank (retroperitoneal bleed), and signs of shock (↓ BP, ↑ HR, ↓ pulses, slow cap refill, cool, pale, clammy skin)
- Prepare patient for emergency surgery if needed
Ruptured aneurysms need to go to the OR emergently for repair to prevent death from hemorrhage. Other patients may need their aneurysm repaired in the OR or in the cath lab (EVAR) to prevent complications.
- Gulanick, M. & Myers, J. (2007). Nursing care plans: Nursing diagnosis and intervention, 6th ed. St. Louis, MO: Mosby Elsevier.
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell