Nursing Care Plan for Aortic Aneurysm

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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

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