Aortic aneurysm (Abdominal Aneurysm; Dissecting Aneurysm; Thoracic Aneurysm;) is a localized, circumscribed, blood-filled abnormal dilation of an artery caused by disease or weakening of the vessel wall.
True aneurysms involve dilation of all layers of the vessel wall. The two types of true aneurysms are: (1) saccular, which is characterized by a bulbous out-pouching of one side of the artery resulting in localized stretching in localized stretching of the artery wall, and (2) fusiform, which is characterized by a uniformly shaped dilation of the entire circumference of the artery. True aneurysms are asymptomatic and are typically diagnosed by physical examination or a diagnostic ultrasound or computed tomography (CT) scan. The natural history of an aneurysm is enlargement; as a rule, the larger it is, the greater the chance of rupture. Aneurysms are most commonly seen in the abdominal aorta. Abdominal aortic aneurysm (AAAs) account for about 75% and thoracic aneurysms for about 25% of all cases. They occur more often in men than in women. Risk factors include smoking and familial history of aneurysms. When an aneurysm becomes large enough for risk for rupture, it can be repaired by open surgical repair or a less-invasive endograft-covered stent repair.
Dissecting aneurysms occur when the inner layer of the blood vessel wall tears and splits, creating a false channel and cavity of blood between the intimal and adventitial layers. They are typically classified according to the location. According to the Stanford classification, type A involves the ascending aorta and its transverse arch and type B involves the descending aorta. A dissecting AAA is the most catastrophe involving the aorta, and it has a high mortality rate if not detected early and treated with surgery. More than 90% of clients present with sudden onset of severe pain which is usually described, as sharp, tearing, or stabbing in nature. Symptoms depend on the size and location of the dissection or rupture. Risk factors for dissection include congenital, inflammatory, hypertension, pregnancy, trauma, and Marfan syndrome.
Nursing Care Plans
Nursing care plan for clients with an aortic aneurysm is to modify risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing the occurrence of a rupture.
May be related to
- New medical problem
- Unfamiliarity with surgical procedure and hospital care
Possibly evidenced by
- Expressed need for information
- Multiple questions
- Client or significant others verbalize understanding of disease process, treatment options, and goals of therapy.
|Assess the client’s knowledge of the disease and treatment options.||This information provides an important starting point in education.|
|Instruct medically treated clients about the following:
||Clients treated medically need to maintain goal BP levels and comply with scheduled CT scans to monitor the size of the aneurysm. Knowledge of early warning signs facilitates rapid treatment. These may include pain in the chest, back, groin, abdomen; decreased urine output; cool, pale extremities.|
|Instruct surgical clients about the following:
||Discharge instructions guide clients regarding self-care measures; Heavy lifting of more than 5 to 10 pounds is restricted for 4 to 6 weeks after surgical repair of an aortic aneurysm. These restrictions reduce strain on suture lines until they are completely healed; Clients need to be aware of the warning signs that warrant medical attention.|
|Instruct endograft clients about the need for follow-up CT scans at 1 and 6 months and yearly for the rest of their lives.||The endograft may incur a leak; ongoing evaluation is needed so appropriate treatment can be initiated.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans for hematologic and lymphatic system disorders:
- Anaphylactic Shock | 4 Care Plans
- Anemia | 4 Care Plans
- Aortic Aneurysm | 4 Care Plans
- Deep Vein Thrombosis | 5 Care Plans
- Disseminated Intravascular Coagulation | 4 Care Plans
- Hemophilia | 5 Care Plans
- Leukemia | 5 Care Plans
- Lymphoma | 3 Care Plans
- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans