Aneurysm and complications

ANEURYSM 

Overview 

A weakness in a section of a dilated artery that causes a widening or ballooning in the wall of the blood vessel is called an aneurysm.

Aneurysm can occur in two forms. They can be saccular(only affecting one side of the artery) or they can be fusiform(involving the complete circumference of the artery).

Seventy-five percent of aneurysms are abdominal aortic aneurysm. 

Dissecting aneurysm (aortic aneurysm ) can occur when blood accumulates within the artery wall (hematoma ) following a tear in the lining of the artery (usually due to hypertension ). These is a life-threatening condition.

HEALTH PROMOTION AND DISEASE PREVENTION 

• Promote smoking cessation.
• Maintain appropriate weight for height and body frame.
• Encourage a healthy diet and physical activity. 
• Control blood pressure with regular monitoring and medication if needed.

Assessment 

Risk factors 

• Sex(male)
• Atherosclerosis 
• Uncontrolled hypertension 
• Tobacco use
• With age, arterial stiffening caused by loss of elastin in arterial walls,  thickening of intima of arteries,  and progressive fibrosis of media occurs; therefore, older adult clients are more prone to aneurysm and have a higher mortality from aneurysm than younger individuals. 

Subjective and objective data

• Initially, clients are often asymptomatic. 
• Abdominal aortic aneurysm (AAA)- most common related to atherosclerosis 
• Constant gnawing feeling in abdomen; flank or back pain
• Pulsating abdominal mass(do not palpate; may cause rupture)
• Bruit
• Elevated blood pressure (unless in cardiac tamponade or rapture of aneurysm )
• Aortic dissection (often associated with Marfan's syndrome )
• Sudden onset of "tearing ", "ripping ", and "stabbing " abdominal or back pain 
• Hypovolemic shock 
• Thoracic aortic aneurysm 
• Severe back pain
• Hoarseness,  cough, shortness of breath and difficulty in swallowing 
• Decrease in urinary output

Diagnostic procedure 

X-ray 

• X-rays reveal the classic "eggshell " appearance of an aneurysm.  Aneurysm is often discovered when examining a client for some other clinical possibility. 
• Computed tomography (CT) and ultrasonography 
• CT scan and ultrasonography are used to assess the size and location of aneurysm and are often repeated at periodic intervals to monitor the progression of an aneurysm.

Patient-centered care

Nursing care

• Take a vital sings every 15 min until stable,  then every hour. Monitor for an increase in blood pressure. 
• Assess the onset, quality, duration, and severity of pain.
• Assess temperature, circulation, and range of motion of extremities.
• Continuously monitor the cardiac rhythm.
• Monitor ABGs, SaO2, electrolyte and CBC laboratory findings.
• Monitor hourly urine output-greater than 30ml/hr indicates adequate kidney perfusion.
• Administer oxygen as prescribed. 
• Obtain and maintain IV access.
• Administer medication as proscribed. 

MEDICATIONS 

The priority intervention is to reduce systolic blood pressure between 100 and 120 mm Hg during an emergency.  Long term goal includes maintaining systolic blood pressure at or less than 130 to 140 mm Hg.

• Administer antihypertensive agents as prescribed. Often more than one is prescribed (beta-blockers and calcium channel blockers )

SURGICAL INTERVENTION 

 Abdominal aortic aneurysm resection -excision of the aneurysm and the placement of a synthetic graft ( elective or emergency )

• Rupturing aneurysm requires prompt emergency surgery (50% mortality rate)
• Elective surgery is used to manage AAA of 6 cm diameter or greater 
• Risks include significant blood loss and the consequence of reduced cardiac ischemia ( MI, renal failure, respiratory distress, paralytic ileus)

NURSING ACTION 

• Priority interventions include monitoring the arterial pressure, heart rhythm, and hemodynamic findings, as well as monitoring for evidence of graft occlusion or rupture postoperatively. 
• Maintain the head of the bed below 45° to prevent flexion of the graft.
• Report evidence of graft occlusion or rupture immediately (changes in pulse,  coolness of extremity below graft, severe pain, abdominal distension, decreased urine output)
• Monitor and maintain normal blood pressure. Prolonged hypotension can cause thrombi to form within the graft; severe hypertension can cause leakage or rupture at the arterial anastomosis suture line. 
• Maintain a warm environment to prevent temperature-induced vasoconstriction.
• Administer IV fluids at prescribed rates to ensure adequate hydration and kidney perfusion. 
• Monitor bowel sounds and observes for abdominal distension. Maritain nasogastric suction as prescribed. 
• Prevent thromboembolism.
• Monitor any sign of infection 
• Administer antibiotics as prescribed 

COMPLICATION

Rapture

Aneurysm rupture is a life-threatening emergency, often resulting in massive haemorrhage, shock, and death.

Treatment requires simultaneous resuscitation and immediate surgical repair. 

Thrombus formation 

A thrombus may form inside the aneurysm. Emboli may be dislodged, blocking arteries distal to the aneurysm,  which causes ischemia and shuts down other body systems.