CASE STUDY

Abdominal Aortic Aneurysm

Krystle Pereira Wendy Cheung

Mr. Adams is a 65 year old male, who came into the ER complaining of back and stomach painrating the pain 7/10. He informed staff that he was baking a cake for his daughter when he felt the intense pain in his abdomen and back. Patient states I had the pain since last week, but it got worst today. Took a few Advil, believing that it may help with alleviating the pain. The medicine didnt work. Past medical history includes hypertension and hypercholesterolemia. Patient states that his father died from a heart attack. Had a heart valve replacement surgery in 2009, and an atrial ablation 10 years ago. His mother had diabetes, cancer and hypertension. Grandfather and brother died from a ruptured abdominal aneurysm. Mr. Adams is currently taking Statins and Niacins for his hypercholesterolemia, and Beta Blockers for his hypertension. Patient admitted that he smoked 1 pack a day x 40 years. He also admits to drinking a few beers and 2 glasses of red wine a day. Diet is consistent of McDonalds. Patient states that he cant live without it. Prefer to eat food that is fried. Patient state that he had a heart valve surgery in 2009.

Case Scenario

Past medical history? Hypertension, hypercholesterolemia. Past family history? My father died from a myocardial infarction; my mom had diabetes, cancer and hypertension. My grandfather and brother died from a ruptured aneurysm. Please describe the pain. I had the pain since last week, but it got worst today. Took a few Advil, believing that it may help with alleviating the pain. The medicine didnt work. The pain is in the abdomen and back. Please rate the pain (0=no pain, 10=worst pain) I would say a 7. What were you doing when you experience the intense pain? I was baking a cake for my daughter. Currently taking any medications? With all of my heart problems, I have been on Statins and Niacin for my cholesterol since my 40s. I am also taking beta blockers.

Health History

Smoke cigarettes? How many per day? 1 pack x 10 years Do you drink? How much? Yes, drink like a few beers and 2 glasses of red wine a day. I love alcohol. Describe your diet. I like to food from McDonalds; cant live without it. I also eat a lot of food that is fried. I rarely eat any vegetables. Describe your bowel movement? I usually have to strain to get my bowel moving and very irregular. It very hard to get them out. They come out like pebbleshard and small. Previous surgeries? I have had a heart valve replacement surgery in 2009. I also had atrial fibrillation about 10 years ago and had an ablation to resolve the problem.

Health History

90 Hypertension, Abdominal aortic aneurysm

89 hypercholesterolemia

69, smoking, drinking, cancer

80 No Disease

87 Obesity & HTN

69 MI

80 Obesity, Cancer, diabetes, HTN

89 A/W

60 Abdominal Aortic Aneurysm

65 Hypertension, hypercholesterolemia, Abdominal Aortic Aneurysm, heart valve replacement surgery, atrial fibrillation ablation

Patient Genogram

Key: = Female = Male = Patient (Mark Adams) A/W = Alive and well = dead

Obtain vital signs Careful palpation or feeling of the Auscultating with a stethoscope Ultrasound of the abdomen CT scan

Physical Assessment

 Abnormal Vital signs: increase in heart rate, rapid & shallow breathingdue to pain, decrease in b/p caused by hemorrhage or rupture of the aneurysm, SpO2 <95%, diaphoretic Careful palpation or feeling of the abdomen reveal the a >4.5 cm wide pulsation of the abdominal aorta

Auscultation reveals a bruit or abnormal sound from turbulence of blood within the aneurysm.
Based on the risk factors that the patient possessed (previous history, past family history, diet, etc) a CT scan and ultrasound is done, which resulted in a >4.5 cm aneurysm in the abdominal aorta.

Objective Data

Abdominal Aortic Aneurysm

Medical Diagnosis

Aneurysm is believed to be caused by inflammatory and immune responses, lipid accumulation in foam cells, extracellular free cholesterol crystals, calcification, thrombosis, ulcerations, and ruptures of the vessel layers (Huether, 2008). These factors can lead to plaques developing in the vessels and decrease the elasticity of the blood vessels. As the elasticity of the arteries decreases, a budge may develop to manage the high pressure that is within in the aorta. During a physical assessment, a pulsation greater than 4 cm can be noted as one develops an abdominal aorta aneurysm.

What is AAA?

 People with arteriosclerosis can weaken the aortic wall Genetic or hereditaryThere is an increased risk of developing AAA for individuals with first degree relatives who also developed AAA. Genetic disease, such as Ehlers-Danlos syndrome and Marfans syndrome Post-physical trauma to the aorta. Arteritis: Inflammation of blood vessels as occurs in Takayasu disease, giant cell arteritis, and relapsing polychondritis. Fungal infection resulting from IV drug abuse, syphilis, and heart surgeries

Possible causes of AAA

 Men who are Caucasian, older than 60 years old, smokes, have other cardiovascular disease, and has a family history of developing AAA

Who is at risk?

 Mostly asymptomatic As an abdominal aortic aneurysm develops, symptoms may include: pulsation noted during a physical exam, pain in the back, abdomen, or groin. The pain may be consistent and can not be relieved with position change or medications. It is believed that the pain is caused by pressure from the vessels on certain tissue. In a ruptured aneurysm, a person may develop: sudden, severe pain, loss of consciousness, diaphoretic, increase heart rate, decrease in blood pressure.

Clinical manifestations of AAA

Ultrasound: sound waves are transmitted across tissues and the echoes recorded to generate an image which allows health care providers to measure and locate an aneurysm. It can measure the size of the aneurysm without invasive procedures. A disadvantage of the ultrasound is the inability to define the extent of the aneurysm. CT scans: This is also known as computed tomography. An image of a cross-section of the body is created through the use of X-ray and computers. The image will be able to show calcium deposits in the aneurysm walls. This test is highly accurate in determining the size and extent of the aneurysm. A disadvantage of this test is the exposure to radiation. Contrast dyes will also be used, which can cause an allergic reaction in some people. Magnetic resonance imaging (MRI): Utilizes magnetic waves to produce images. People who has any metal in their bodies can be a MRI done. Angiogram: Contrast dyes are injected into the blood vessels for viewing the structure of it. Some people are unable to have this test because of allergic reaction to the dye.

How is AAA diagnosed?

 Open surgical repair: To repair a ruptured AAA, a synthetic tube that resembles the aorta will be replaced in the removed area. Endovascular surgery: This is a less invasive surgery, in which a stent will be inserted into a blood vessel. Medical management or non-surgical management includes stop smoking, control blood pressure, lower high blood cholesterol, use of beta-blockers, and close monitoring of the aneurysm size with ultrasound or CT scan every 6-12 months.

Treatment options for AAA

 Beta blockers. Beta blockers lower your blood pressure by slowing your heart rate. Examples of beta blockers include metoprolol (Lopressor, Toprol-XL), atenolol (Tenormin) and bisoprolol (Zebeta).
Angiotensin II receptor blockers. Your doctor may also prescribe these medications if beta blockers aren't enough to control your blood pressure. These medications are recommended for people who have Marfan syndrome, even if they don't have high blood pressure. Examples of angiotensin II receptor blockers include losartan (Cozaar), valsartan (Diovan) and olmesartan (Benicar). Statins. These medications can help lower your cholesterol, which can help reduce blockages in your arteries and reduce your risk of aneurysm complications. Examples of statins include atorvastatin (Lipitor), lovastatin (Mevacor), simvastatin (Zocor) and others.

Drug Therapy

 Age 65yrs Smoker Male Caucasian High blood pressure High serum cholesterol Diabetes mellitus

A family history of abdominal aneurysm

Patient Risk Factors R/T History

Deficient Fluid volume R/T 1. Hypermetabolic state. 2. Fluid loss during surgery. 3. Presence of indwelling tubes.

Nursing Diagnoses #1

Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness

Defining Characteristics

Short term: Maintain urine output more than 1300 mL/day (or at least 30 mL/hr) by the end of shift Maintain normal blood pressure, pulse, and body temperature by the end of shift Maintain elastic skin turgor; moist tongue and mucous membranes; and orientation to person, place, and time by the end of shift Long term: Be able to explain measures that can be taken to treat or prevent fluid volume loss

Patient Goals

Watch for early signs of hypovolemia, including thirst, restlessness, headaches, and inability to concentrate. Thirst is often the first sign of dehydration (Scales & Pilsworth 2008). EB: A study of healthy volunteers who experienced a fluid restriction of up to 37 hours reported symptoms of headache, decreased alertness, and inability to concentrate (Shirreffs et al, 2004). Monitor pulse, respiration, and blood pressure of clients with deficient fluid volume every 15 minutes to 1 hour for the unstable client, every 4 hours for the stable client. Vital sign changes seen with fluid volume deficit include tachycardia, tachypnea, decreased pulse pressure first, then hypotension, decreased pulse volume, and increased or decreased body temperature (Scales & Pilsworth, 2008). EB: A systematic review demonstrated that hypotension and tachycardia, and occasionally fever, are clinical signs of dehydration (Ferry, 2005). Note skin turgor over bony prominences such as the hand or shin. Monitor for the existence of factors causing deficient fluid volume (e.g., vomiting, diarrhea, difficulty maintaining oral intake, fever, uncontrolled type 2 diabetes, diuretic therapy). Early identification of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume.

Nursing Interventions & Rationales

Observe for dry tongue and mucous membranes, and longitudinal tongue furrows. These are symptoms of decreased body fluids. Recognize that checking capillary refill may not be helpful in identifying fluid volume deficit. Capillary refill can be normal in clients with sepsis, increased body temperature dilates peripheral blood vessels, and capillary return may be immediate (Scales & Pilsworth, 2008). EBN: A systematic review found capillary refill not helpful to determine hypovolemia (Dufault et al, 2008).

Weigh client daily and watch for sudden decreases, especially in the presence of decreasing urine output or active fluid loss. Body weight changes reflect changes in body fluid volume (Kasper et al, 2005). EB: Systematic reviews demonstrated that measurement of body mass change is a safe technique to assess hydration status (Armstrong, 2005; Wakefield, 2008).
Monitor total fluid intake and output every 8 hours (or every hour for the unstable client). Recognize that urine output is not always an accurate indicator of fluid balance. A urine output of less than 30 mL/hr is insufficient for normal renal function and indicates hypovolemia or onset of renal damage (Scales & Pilsworth, 2008). Hydrate the client with ordered isotonic intravenous (IV) solutions if prescribed. Isotonic intravenous fluids such as 0.9 normal saline or lactated Ringer's allow replacement of in-travascular volume (Fauci et al, 2008).

Nursing Interventions & Rationales

 Instruct the client to avoid rapid position changes, especially from supine to sitting or standing.
Teach the client and family how to measure and record intake and output accurately. Teach the client and family about measures instituted to treat hypovolemia and to prevent or treat fluid volume loss. Instruct the client and family about signs of deficient fluid volume that indicate they should contact health care provider.

Client/Family Teaching and Discharge Planning

Deficient Knowledge R/T 1. Surgical procedure. 2. Immediate post-op care. 3. Discharge instruction.

Nursing Diagnosis #2

Long term: Explain disease state, recognize need for medications, and understand treatments Incorporate knowledge of health regimen into lifestyle List resources that can be used for more information or support after discharge
Short term: Be able to describe the rationale for at least one therapy/treatment options by the end of shift.

Patient Goals

 Consider the client's ability and readiness to learn (e.g., mental acuity, ability to see or hear, existing pain, emotional readiness, motivation, and previous knowledge) when teaching clients. EB: Each client is unique, and client motivation, beliefs, and expectations will influence learning (Price, 2008). EBN: Learning readiness changes over time based upon situational, physical, and emotional challenges. The nurse assumes the role of authority, guide, motivator, mentor, and consultant depending on the learning readiness of the client (Olinzock, 2008).
Monitor how clients process information over time. EBN: Clients are unique in how they process information. Some clients will be more uncertain than others and may need more educational intervention over time (Suhonen, Valimaki, & Leino-Kilpi, 2008). Use individualized approaches that support client priorities, preferences, and choice. EBN: Individualized educational interventions have a positive effect on client outcomes (Suhonen, Valimaki, & Leino-Kilpi, 2008).

Nursing Interventions & Rationales

Engage client as a partner in the educational process. EBN: A nursing approach that is collaborative and that uses encouragement and support to increase self-efficacy resulted in client satisfaction, empowerment, and confidence (Hannula, Kaunonen, & Tarkka, 2008). EB: Low literacy clients who were active and participated in the development of educational materials became more involved in the process of learning (Seligman et al, 2007).

Provide information to support self-efficacy, self-regulation, and self-management. EB: Knowledge of disease management alone does not directly result in behavioral change. Enhancing self-efficacy and confidence in one's ability to problem-solve and make decisions should be included in self-management education (Effing et al, 2007).
Assess the client's literacy skill when using written information. EBN: Health care professionals may overestimate reading and comprehension levels of their clients. Education for those with low literacy should be as least threatening as possible (Schaefer, 2008). EB: Multiple educational strategies including picture, digital, and telephone follow-up have proven effective in reducing complications in those with chronic conditions (DeWalt et al, 2006: Hoffmann & McKenna, 2006).

Nursing Interventions & Rationales

Provide visual aids to enhance learning. EB: Visual aids such as pictures and simple word captions have proven to be effective when used to highlight important information, especially when working with clients with low literacy (Houts et al, 2006).
Consider coordinated, multifaceted methods of disbursing information. EB: Coordinated efforts using a combination of written and verbal information, regular review, and a written action plan have proven beneficial for self-care behavioral change (Glazier et al, 2006; Sheard & Garrud, 2006). Help the client appropriate follow-up resources for continuing information and support. EBN: Advocating for client's participation using a community-based case management program has demonstrated improved clinical and financial outcomes for clients with complex chronic conditions (Chow et al, 2008).

Consider using a problem-solving group educational program. EB: Group care that uses a discovery and problem-solving approach and tailors learning to individual information needs has proven more effective than standard one-to-one teaching in empowering individuals (Deakin et al, 2006). EB: More intensive one-to-one attention may be needed for socially disadvantaged populations (Glazier et al, 2006).

Nursing Interventions and Rationales

 Abdominal Aortic Aneurysm. (2012). Cleveland Clinic. Retrieved February 1, 2012, from http://my.clevelandclinic.org/disorders/aneurysms/hic_abdominal_aortic _aneurysm.aspx Abdominal Aortic Aneurysm. (2012). MedicineNet. Retrieved February 1, 2012, from http://www.medicinenet.com/abdominal_aortic_aneurysm/article.htm Huether, S. E., RN, PhD., & Kathryn, M. L., RN, PhD. (2008). Alterations of Musculoskeletal Function. In Understanding Pathophysiology (pp. 1036-1042). St. Louis Missouri: Mosby, Inc., an affiliate of Elsevier Inc. Michaels, J. A. (2005). Screening for abdominal aortic aneurysm (AAA) reduced AAA mortality in Danish men 64 to 73 years of age. ACP Journal Club, 143(2), 39.

References