Primary Nursing Diagnosis

Risk for fluid volume deficit related to hemorrhage

OUTCOMES. Fluid balance; Circulation status; Cardiac pump effectiveness; Hydration

INTERVENTIONS. Bleeding reduction; Fluid resuscitation; Blood product administration; Intravenous therapy; Circulatory care; Shock management

^ PLANNING AND IMPLEMENTATION Collaborative

PREOPERATIVE. The treatment of choice for AAA 6 cm or greater in size is surgical repair. When aneurysms are smaller, some controversy exists regarding treatment. Some authorities suggest the smaller aneurysm should just be evaluated frequently by ultrasound examination or CT scan, with surgical intervention only if the aneurysm expands. There is increasing evidence suggesting that beta blockade, particularly propranolol, may decrease the rate of AAA expansion, and blood pressure control as well as smoking cessation is important. Others suggest elective surgical repair regardless of aneurysm size. If the aneurysm is leaking or about to rupture, immediate surgical intervention is required to improve survival rates.

SURGICAL. The type and extent of surgery depend on the location of the aneurysm. Typically, an abdominal incision is made, the aneurysm is opened, clots and debris are removed, and a synthetic graft is inserted within the natural arterial wall and then sutured. During this procedure, the aorta is cross-clamped proximally and distally to the aneurysm to allow the graft to take hold. The patient is treated with heparin during the procedure to decrease the clotting of pooled blood in the lower extremities.

POSTOPERATIVE. Patients will typically spend 2 to 3 days in the intensive care setting until their condition stabilizes. Monitor their cardiac and circulatory status closely, and pay particular attention to the presence or absence of peripheral pulses and the temperature and color of the feet. Immediately report to the physician any absent or diminished pulse or cool, pale, mottled, or painful extremity. These signs could indicate an obstructed graft. Ventricular dysrhythmias are common in the postoperative period because of hypoxemia (deficient oxygen in the blood), hypothermia (temperature drop), and electrolyte imbalances. An endotracheal tube may be inserted to support ventilation. An arterial line, central venous pressure line, and peripheral intravenous lines are all typically ordered to maintain and monitor fluid balance. Adequate blood volume is supported to ensure patency of the graft and to prevent clotting of the graft as a result of low blood flow. Foley catheters are also used to assist with urinary drainage, as well as with accurate intake and output measurements. Monitor for signs of infection; watch for temperature and white blood cell count elevations. Observe the abdominal wound closely, noting poor wound approximation, redness, swelling, drainage, or odor. Also report pain, tenderness, and redness in the calf of the patient's leg. These symptoms may indicate thrombophlebitis from clot formation. If the patient develops severe postoperative back pain, notify the surgeon immediately; pain may indicate that a graft is tearing.

EXPERIMENTAL THERAPY. Several medical centers are using an experimental graft that is inserted through a groin artery into the area of the aneurysm. Intravascular stents covered with prosthetic graft material such as Dacron are expandable and carry blood past the weakened portion of the aneurysm. The procedure can be performed without extensive surgery, and although in limited use, patients have had positive short-term (approximately 4 years) results.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Morphine

1-10 mg IV

Opioid analgesic

Relieves surgical pain

Fentanyl

50-100 mcg IV

Opioid analgesic

Relieves surgical pain

Antihypertensives and/or diuretics

Varies by drug

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