Nursing Care Plan for Aortic Aneurysm

Join NURSING.com to watch the full lesson now.

Included In This Lesson

Study Tools

Outline

Pathophysiology

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:

  1. Fusiform: dilation that involves the entire circumference
  2. Saccular: localized outpouching
  3. Dissecting: pressure tears lining of vessel away from outer layer, blood gets trapped between the layers – often decreases distal blood flow
  4. False: clot forms outside the vessel wall

Etiology

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.

Desired Outcome

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

Subjective Data:

  • Chest pain
    • Burning / tearing
    • Radiates to back, shoulder, abdomen, flank, or groin
  • s/s Low CO
    • Weakness
    • Fatigue
  • Shortness of breath

Objective Data:

  • 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.

 


References

Transcript

Hey guys, in this lesson, we’re going to take a look at the care plan for aortic aneurysms. 

 

So, in this lesson, we’ll briefly take a look at the pathophysiology and etiology of an aortic aneurysm. We’re also going to take a look at additional things that would be included in this care plan, like subjective and objective data, as well as nursing interventions and rationales for those interventions. 

 

Okay, so an aortic aneurysm occurs when the aorta is under extreme high pressure, typically from hypertension and this causes the wall of the vessel to weaken causing dilation or outpouching of the vessel that is extremely weak. This causes turbulent flow and creates a very high risk for rupture. Aneurysms are classified by location being either thoracic or abdominal, and there are different types, including fusiform, saccular, dissecting and false. We’ll take a look at those in more detail later. 

 

So most commonly, aortic aneurysms are caused by hypertension, but they also can be related to connective tissue disorders, Marfan syndrome and Ehlers-Danlos Syndrome. So, the desired outcome is to manage the patient’s blood pressure to prevent worsening or rupture of the aneurysm.

 

 Okay, so let’s take a look at some of the subjective and objective data that your patient with an aortic aneurysm may present with. Now, remember subjective data, these are going to be things that are based on your patient’s opinions or feelings. So, for aortic aneurysms, this might include chest pain and they might explain it as a burning feeling that radiates to their back, shoulder, abdomen, flank, or groin. They might say they are weak or fatigued because of low cardiac output and also shortness of breath. 

 

Objective or measurable data includes a visible or palpable pulsating abdominal mass with a systolic bruit. Other objective data includes decreased cardiac output, blood pressure, pulses, level of consciousness and urine output. Objective data that shows an increase would be heart rate. The skin might be cool, pale and diaphoretic, and you might also see a hematoma on the patient’s flank. 

 

Okay, let’s look at some of the necessary nursing interventions for an aortic aneurysm. A full pain assessment is necessary to find out how quickly the pain came on because sudden onset of pain may indicate rupture. Find out if the pain radiates, because aneurysms tend to radiate to the back and abdomen and severe pain may indicate a worsening aneurysm. A full abdominal assessment is also critical as abdominal aortic aneurysms or triple A’s can be seen and felt by a pulsating object in the abdomen and a bruit can be heard. Remember, inspection for a visible pulsation, auscultation for a systolic bruit, and palpation for pulsation and tenderness. 

 

Okay, assessing vital signs and hemodynamics is super important because with aortic aneurysms, cardiac output can be compromised and needs to be watched closely for signs of deterioration in the patients. Remember peripheral perfusion may be decreased, so monitor for cool clammy skin with a slow capillary refill. Managing pain is also an important part of the aortic aneurysm care plan as this issue can create a lot of pain in the patient, which can be described as burning or tearing. So position the patient for comfort, and of course administer any necessary analgesics if needed. 

 

So, in addition to analgesics, antihypertensives are necessary for controlling blood pressure, which is top priority. The goal is to decrease the pressure on the walls of the aorta and maintain a map or mean arterial pressure, which is sufficient enough to perfuse the body, which is typically a value of greater than 65 millimeters of mercury. To monitor for evidence of rupture, assess the patient for sudden severe pain that radiates to the back, flank, or groin, or a hematoma on the flank, and also for signs of shock, which are going to be decreased blood pressure, increased heart rate, decreased pulses, slow capillary refill and cool, pale clammy skin. If a patient has a ruptured aneurysm, they must go to the OR immediately. This is emergence to prevent death from hemorrhage and in other cases, a patient may be sent to the cath lab or the OR for repair. 

 

Okay, guys, here is a look at a completed aortic aneurysm care plan. 

 

Okay. Before we end this lesson, I just wanted to quickly review the different types of aneurysms. A fusiform aneurysm occurs with dilation that involves the entire circumference.  Saccular is indicated by a localized outpouching. Dissecting occurs when pressure tears a lining of the vessel away from the outer light layer and blood gets trapped between the layers and decreases distal blood flow. Okay. Finally, false aneurysms are when a clot forms outside the vessel wall. 

 

Okay. Let’s do a quick review. An aortic aneurysm occurs with weakening of the wall of the aorta causing an outpouching or dilation, turbulent flow and possible rupture. The most common cause is hypertension, connective tissue issues, Marfan syndrome, and Ehlers-Danlos Syndrome. 

 

Subjective data includes radiating chest pain, shortness of breath, weakness, and fatigue. 

 

Objective data includes a visible pulsating mass, systolic bruit, decreased cardiac output BP and increased heart rate. Assess the patient for their onset of pain. Assess the admin for signs of aneurysm. Assess peripheral perfusion because of decreased cardiac output and assess vital signs for a worsening condition. Finally manage the patient’s pain, administer analgesics, antihypertensives and prepare the patient for the OR, or the cath lab to repair the aneurysm if necessary.

 

Okay, guys, that is it on this lesson on the care plan for aortic aneurysms. We love you guys. Go out and be your best self today, and as always, happy nursing!