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Tuesday, March 22, 2011

NCP Nursing Care Plan for Abdominal Aortic Aneurysm

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NCP Nursing Care Plan for Abdominal Aortic Aneurysm. Abdominal aortic aneurysm (AAA) is a localized outpouching abnormal dilation in the arterial wall that generally occurs in the aorta between the renal arteries and the iliac branches. Nearly 98% of all abdominal aneurysms are located in the infrarenal aorta. These aneurysms can be fusiform (spindle shaped) or saccular (pouchlike) and develop slowly.
First, a focal weakness in the muscular layer of the aorta (tunica media), resulting from degenerative changes, allows the inner layer (tunica intima) and outer layer (tunica adventitia) to stretch outward (often caused by plaque and cholesterol deposits) and degenerative changes occur. The inner and outer layers of the arterial wall are stretched, and as the pulsatile force of the blood rushes through the aorta, the vessel wall becomes increasingly weak, and the aneurysm enlarges. Abdominal aneurysms can be fatal. More than half of people with untreated aneurysms die of aneurysm rupture within 2 years.

Causes for Abdominal Aortic Aneurysm
The most common cause of Abdominal Aortic Aneurysm is atherosclerosis or arteriosclerosis; the rest, from cystic medial necrosis, trauma, syphilis, and other infections.

Complications for Abdominal Aortic Aneurysm
Hemorrhage and shock from aneurysmal rupture

Nursing Assessment Nursing Care Plan for Abdominal Aortic Aneurysm

  • Patient History most of abdominal aortic aneurysm are asymptomatic and are found incidentally. When the aorta enlarges and compresses the surrounding structures, patient complaints may include flank and back pain, epigastric discomfort, or altered bowel elimination. The pain may be deep and steady with no change if the patient shifts position. If the patient reports severe back and abdominal pain, rupture of the abdominal aortic aneurysm may be imminent
  • Inspection of the patient with an intact abdominal aneurysm usually reveals no significant findings. However, if the patient isn't obese, you may notice a pulsating mass in the periumbilical area. If the aneurysm has ruptured, you may notice signs of hypovolemic shock, such as skin mottling, decreased level of consciousness, diaphoresis, and oliguria. The abdomen may appear distended and an ecchymosis or hematoma may be present in the abdominal, flank, or groin area
  • Palpation of the abdomen may disclose some tenderness over the affected area. A pulsatile mass may be felt; however, avoid deep palpation to locate the mass because this may cause the aneurysm to rupture. Palpation of the peripheral pulses may reveal absent pulses distal to a ruptured aneurysm

Watch for signs that may indicate impending aneurysm rupture. Note subtle changes such as a change in the characteristics and quality of peripheral pulses, changes in neurological status, and changes in vital signs such as a drop in blood pressure, increased pulse, and increased respirations. An abdominal aneurysm can impair flow to the lower extremities and cause what are known as the five Ps of ischemia: pain, pallor, pulselessness, paresthesias, and paralysis

Diagnostic tests for Abdominal Aortic Aneurysm
• Abdominal ultrasonography or echocardiography
• Anteroposterior and lateral X-rays of the abdomen
• Computed tomography scan
• Aortography

Nursing diagnosis Nursing Care Plan for Abdominal Aortic Aneurysm
Common nursing diagnosis found in Nursing Care Plan for Abdominal Aortic Aneurysm

Nursing outcomes Nursing Care Plan for Abdominal Aortic Aneurysm
Nursing Key outcome NCP Nursing Care Plan for Abdominal Aortic Aneurysm, Patient Will:

  • Express feelings of increasing comfort and decreased pain.
  • Verbalize strategies to reduce his anxiety level.
  • Maintain adequate cardiac output.
  • Maintain adequate fluid volume.
  • Maintain adequate ventilation and oxygenation.
  • Maintain joint mobility and muscle strength.
  • Patient's skin will remain intact.
  • Pulses will remain palpable distal to the aneurysm site.
  • Maintain adequate urine output (output will be equivalent to intake).

Nursing interventions Nursing Care Plan for Abdominal Aortic Aneurysm

  • Fluid Management: Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels
  • Hypovolemia Management: Reduction in extracellular and/or intracellular fluid volume and prevention of complications
  • Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume.
  • Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient
  • Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain
  • Environmental Management: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
  • Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger
  • Calming Technique: Reducing anxiety in patient experiencing acute distress
  • Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility
  • Cardiac Care: Limitation of complications resulting from an imbalance between myocardial oxygen supply and demand for a patient with symptoms of impaired cardiac function
  • Circulatory Care: Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps
  • Respiratory Monitoring: Collection and analysis of patient data to ensure airway patency and adequate gas exchange
  • Oxygen Therapy: Administration of oxygen and monitoring of its effectiveness


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