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.
Risk for Ineffective Tissue Perfusion
- Risk for Ineffective Tissue Perfusion
May be related to
- Conditions that increase stress on the arterial wall, leading to risk for dissection
- Defect in the vessel wall, leading to risk for dissection
- Iatrogenic causes
Possibly evidenced by
- [not applicable]
- Client will maintain adequate tissue perfusion as evidenced by strong palpable pulses; warm, dry extremities; BP within norma range for the client; urinary output greater than or equal to 30 ml/hr; alert, normal level of consciousness; normal bowel sounds; absence of abdominal or chest pain.
- Client will have a reduce risk for complications from progressive dissection or rupture s a result of early detection of symptoms and appropriate intervention.
|Assess and monitor the location and characteristic of pain.
||A description of pain can help differentiate the location and determine treatment. More than 90% of clients with abdominal aortic aneurysms have a sudden onset of severe pain described as sharp, tearing, or stabbing in nature.|
|Obtain a thorough history regarding risk factors for dissection or rupture.||Most clients are asymptomatic unless their aneurysm is dissecting or ruptures. History aids in ruling out a cerebrovascular, cardiac, renal, vascular, and occlusive disease. Poorly controlled hypertension increase stress on the aortic wall and its risk for dissection or rupture.|
|Monitor for signs and symptoms indicating progressive dissection.||A high index suspicion can determine the treatment to reduce mortality. Clinical signs and symptoms indicate the site and progression of dissection. Acute aortic dissection usually occurs along the thoracic aorta. Pain is severe and may mimic the pain associated with myocardial infarction. Pain may be located both above and below the diaphragm if the dissection is extensive. Changes in the level of consciousness and diminished carotid pulses are associated with dissection of the aortic arch. Dissection of the abdominal aorta can cause decreased urine output, diminished motor and sensory function in the lower extremities, abdominal pain, and bloody diarrhea.|
|For abdominal aneurysms:|
|Assess the lower extremities for signs of peripheral ischemia and insufficiency (such as paralysis, pain, paresthesia, pallor, pulselessness, and poikilothermia [decreased temperature, coolness]).||Dissection can cause reduced sensory and motor function in the lower extremities.|
|Monitor for abdominal distention, diarrhea, or severe abdominal pain and/or fever.||These signs rule out embolization or decreased perfusion to the mesenteric artery and rupture into the abdominal cavity.|
|Gently palpate the abdomen for a midline mass or pulsation.||An enlarging abdominal aortic aneurysm may present as a midline pulsatile abdominal mass. The pulsations may equal the apical heart rate. The technique for pulsation should be as gentle as possible to avoid trauma to the aneurysm.|
|Monitor urine output.||Decrease urine output may result from the compression of the renal arteries from the infrarenal abdominal aneurysm, cross-clamping of the aorta during surgery or embolization. Urine output may not be affected if the aneurysm is above the renal artery. However, most aneurysms are located below the renal artery.|
|For thoracic aneurysms:|
|Assess the quality of peripheral pulses.||Peripheral pulses assure distal perfusion. A suggested grading system is as follows:
|Assess for respiratory compromise.||Respiratory compromise is a result of compression of the trachea or bronchus.|
|Assess for hemoptysis.||Hemoptysis results from compression of the trachea or lung.|
|Assess for dysphagia.||Dysphagia may be caused by esophageal compression.|
|Monitor BP for hypertension.||Hypertension is a risk factor for rupture. Differential arm BP may be present as a result of compression of the subclavian artery.|
|Assess for upper-extremity and head swelling with cyanosis.||These signs can be caused by the obstruction of the superior vena cava.|
|Anticipate further diagnostic studies:||Tests are required to confirm the diagnosis and delineate anatomy (location, shape, and size of aneurysms).|
|Provide nonpharmacological measures to alleviate pain:
||These measures may be tried initially, but depending on the status of the aneurysm, they may not be effective.|
|Administer antihypertensive medications as indicated: angiotensin-converting enzyme (ACE) inhibitor, beta-blocker.||Bp control is imperative for maintaining tissue perfusion. The goal is to maintain systolic BP less than 120 mm Hg. These medications reduce the stress applied to the arterial walls and may reduce the risk for dissection in hypertensive clients.|
|Administer pain medication as indicated.||Persistent acute pain suggests ongoing dissection or rupture. Surgical intervention may be required to relieve pain.|
|For type A dissections (involving ascending aorta or transverse arch), prepare the client for surgical intervention.||The surgical procedure involves replacement of the ascending aorta to prevent aortic rupture or retrograde progression of the dissection.|
|For type B dissection (involving descending thoracic aorta), anticipate chronic medical treatment, which consists of the following long-term measures:
||The major treatment approach for type B involves a pharmacological regimen to control BP. It may require surgical treatment if hypertension is uncontrollable, persistent pain occurs, compromise to major organ occurs, or the aorta ruptures.|
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:
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