Therapeutics Manual, 2007 3rd ed. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. Twinsburg Family Health and Surgery Center offers specialty services ranging from Cardiology to Urology and more, as well as a 24-hour emergency department. CT scan and ultrasound don’t give a direct view of the vessels and don’t yield as accurate a diagnosis as the arteriogram. Because of the client’s unstable condition, he is in the intensive care unit where visitors are limited to the family. Which of the following conditions is linked to more than 50% of clients with abdominal aortic aneurysms? An arteriogram accurately and directly depicts the vasculature; therefore, it clearly delineates the vessels and any abnormalities. Abdominal Aortic Aneurysm Nursing Care Plan & Management, People know you for what you've done, not for what you plan to do. The client insists on having a visit from a medicine man whom the family visits regularly. Which of the following sounds is distinctly heard on auscultation over the abdominal region of an abdominal aortic aneurysm client? Assess the condition of output / dischart out; number, color, and odor from the operation wound. Answers A and C are incorrect because they occur with rupture of the aneurysm. Intermitted lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. Upon examination, his blood pressure is 190/100, pulse is 118, and hematocrit and hemoglobin are both low. Removal of the aneurysm and restoration of vascular continuity with a graft (resection and bypass graft or endovascular grafting) is the goal of surgery and the treatment of choice for abdominal aortic aneurysms larger than 5.5 cm (2 inches) in diameter or those that are enlarging. Abdominal pain is most common symptom resulting from impaired circulation. Headache and diaphoresis aren’t associated with abdominal aortic aneurysm. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. Check peripheral circulation, including pulses,temperature, and color. Intensive monitoring in the critical care unit is required. The purpose of the School is to graduate individuals prepared for registered nurse (RN) licensure and competent for entry-level practice in a variety of healthcare settings. If this activity does not load, try refreshing your browser. Instruct the client that if severe back or abdominal pain or fullness, soreness over the umbilicus, sudden development of discoloration in the extremities, or a persistent elevation of BP occurs to notify the physician immediately. Expected Outcome Risk for Ineffective After Coping Related to implementation Depression in of nursing care, response to stressors client will associated with verbalize feelings childbirth and with the parenting significant other and health care provider throughout the postpartum period. ADAM for images Ms. Sy undergoes surgery and the abdominal aortic aneurysm is resected and replaced with a graft. Provision of holistic care requires that the client’s belief system is honored. What is the definitive test used to diagnose an abdominal aortic aneurysm? This mostly occurs people who are older, overweight or inactive following abdominal surgery. With which of the following disorders is jugular vein distention most prominent? The patient will be admitted to the day surgery unit for sclerotherapy. Description. Your doctor may recommend a surgical procedure where a surgeon operates to push the protruding muscle back into place. How should the nurse interpret this request? Assess risk factors for the arterial disease process. Once you are finished, click the button below. Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing If loading fails, click here to try again. For the same reason, the RBC count is decreased – not increase. Citizens School of Nursing, founded in 1913, is sponsored by Allegheny Valley Hospital. The portion of the aorta distal to the renal arteries is more prone to an aneurysm because the vessel isn’t surrounded by stable structures, unlike the proximal portion of the aorta. The presence of a pulsating mass in the abdomen is an abnormal finding, usually indicating an outpouching in a weakened vessel, as in abdominal aortic aneurysm. When to seek immediate medical attention. Question the client regarding the sensation of palpation in the abdomen. When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most commonly palpated? If you leave this page, your progress will be lost. Inspect the skin for the presence of vascular disease or breakdown. Diminished pedal pulses, a sign of poor circulation to the lower extremities, are associated with an aneurysm but isn’t life threatening. Checking on the VS especially the RR, which detects need for oxygenation, is a priority to help detect its progress and provide for prompt management before the occurrence of complications. The nurse’s priority should be : Shock is characterized by reduced tissue and organ perfusion and eventual organ dysfunction and failure. Midline lower abdomen to the right of the midline, Middle lower abdomen to the left of the midline. The WBC count increases as cell migrate to the site of injury. Angina is associated with atherosclerosis of the coronary arteries. The aorta lies directly left of the umbilicus; therefore, any other region is inappropriate for palpation. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. In which of the following areas is an abdominal aortic aneurysm most commonly located? Continuous pressure on the vessel walls from hypertension causes the walls to weaken and an aneurysm to occur. The client with an abdominal aortic aneurysm frequently complains of pulsations or "feeling my heart beat" in the abdomen. Severe lower back pain, decreased BP, decreased RBC, decreased WBC, Intermittent lower back pain, decreased BP, decreased RBC, increased WBC, Lower back pain, increased BP, decreased RBC, increased WBC, Severe lower back pain, decreased BP, decreased RBC, increased WBC. Atherosclerosis accounts for 75% of all abdominal aortic aneurysms. Active-listen and identify clients Pulsatile flow reduced by medications that reduce cardiac contractility, such as propanolol. Which of the following blood vessel layers may be damaged in a client with an aneurysm? Medicine men are not approved by the hospital as legitimate health care providers. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. Also, this page requires javascript. When ruptured occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Which of the following complications of an abdominal aortic repair is indicated by detection of a hematoma in the perineal area? No other appropriate treatment options currently exist. Get surgery. Which of the following groups of symptoms indicates a ruptured abdominal aortic aneurysm? Plaques build up on the wall of the vessel and weaken it, causing an aneurysm. Dullness is heard over solid organs, such as the liver. Lower back pain, increased blood pressure, decreased re blood cell (RBC) count, increased white blood (WBC) count. Instruct the client on the importance of regular physician visits to follow the size of the aneurysm. Please visit using a browser with javascript enabled. Rupture of the aneurysm is a life-threatening emergency and is of the greatest concern for the nurse caring for this type of client. Because no bleeding occurs with rapid expansion of the aneurysm, a hematoma won’t form. Ineffective breathing pattern related to: Strict control of blood pressure and reduction in pulsatile flow. Unlock the full document with a free trial. Patients from infancy to the elderly are cared for by our exceptional team of surgeons, anaesthetists, health … The goal of treatment is to limit the progression of the disease by modifying risk factors , controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture. The aneurysm can be located anywhere along the abdominal aorta. An adult client has continued slow bleeding from the graft after repair of an abdominal aortic aneurysm. According to Dr. Kingsley at UPMC, you should call your primary care physician if mild pain lasts more than a couple of days, or if the severe stomach pain is accompanied by other symptoms. The WBC count increases as cells migrate to the site of injury. Talk with your doctor about surgery options. Lower back pain, not upper, is a common symptom, usually signifying expansion and impending rupture of the aneurysm. 6535 N Charles St Ste 510 , Towson, MD, 21204 (410) 821-6260 $ John L. Flowers, MD, is the chairman of the Department of Surgery at GBMC. Retroperitoneal rupture at the repair site. A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. You have not finished your quiz. Severe lower back pain, decreased blood pressure, decreased RBC count, increased WBC count. Abdominal pain is the most common symptom resulting from impaired circulation. A common complaint of the client with an abdominal aortic aneurysm is: Loss of sensation in the lower extremities. 50–100 mcg IV of opioid analgesic (Fentanyl) to relieve surgical pain. The principle of justice prohibits giving one client a privilege that other clients are not permitted. Hypertension should be avoided and controlled because it can cause the weakened vessel to rupture. An abdominal aneurysm would only be visible on an X-ray if it were calcified. Distal to the iliac arteries, the vessel is again surrounded by stable vasculature, making this an uncommon site for an aneurysm. A bruit, a vascular sound resembling heart murmur, suggests partial arterial occlusion. The media has more smooth muscle and less elastic fibers, so it’s more capable of vasoconstriction and vasodilation. ... Complicatios for patients not requiring surgery. He earned his Doctor of Medicine degree from the Hahnemann University College of Medicine. Abdominal pain in a client with an abdominal aortic aneurysm results from the disruption of normal circulation in the abdominal region. Medical or surgical treatment depends on the type of aneurysm. Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump. Instruct the client with a thoracic aneurysm to report immediately the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness. Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? Rationale. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Notes. Patient-reported outcomes tool for hernia surgery helps physicians improve care New care model helps primary-care practices treat obesity COVID-19 treatment protocol developed in … Maternal and Child Health Nursing (NCLEX Exams), Medical and Surgical Nursing (NCLEX Exams), Pharmacology and Drug Calculation (NCLEX Exams), Abdominal Aortic Aneurysm Repair Nursing Care Plan, Surgery (Perioperative Client) Nursing Care Plans, Contact Dermatitis Nursing Care Plan & Management. 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Saunders, Comprehensive Review for the NCLEX_RN Exam , 2005 ed He completed his residency in General Surgery at the University of Maryland and was the first ever Fellow in Surgical Laparoscopy and Endoscopy there. If hemorrhage were present, the abdomen would be tender and firm. Diabetes mellitus doesn’t have direct link to aneurysm. ... and the use of an Asthma Care Plan. Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? Choose the letter of the correct answer. Duplex ultrasonography or computed tomography (CT), Risk for fluid volume deficit related to hemorrhage, Acute pain related to surgical tissue trauma, Anxiety related to threat to health status, Deficient knowledge (preoperative and postoperative care) related to newly identified need for aortic surgery. Lower back pain results from expansion of the aneurysm. Compliance with the regime of monitoring the size of the aneurysm by computed tomography over time is essential. This rupture is most commonly caused by leakage at the repair site. Lower back pain results from expansion of the aneurysm. Blood pressure decreases due to the loss of blood. Abdominal Aortic Aneurysm Nursing Care Plan & Management. The child has a highlight platelet count of 20,000/mm3. For the same reason, the RBC count is decreased – not increased. The expansion applies pressure in the abdomen, and the pain is referred to the lower back. Good luck! Antihypertensives and/or diuretics for rising BP may stress graft suture lines. Chest pain usually is associated with coronary artery or pulmonary disease. The patient will be admitted to the surgical unit and resection will be scheduled. Please wait while the activity loads. The interna and externa are generally no damaged in an aneurysm. A pulsating abdominal mass usually indicates which of the following conditions? Answer B is incorrect because back pain is not affected by changes in position. Neither an enlarged spleen, gastritis, nor gastic distention cause pulsation. What is the most common symptom in a client with abdominal aortic aneurysm? Obtain information regarding back or abdominal pain. 1. There is no area adjacent to the aortic arch, which bends into the thoracic (descending) aorta. A 76 year old man enters the ER with complaints of back pain and feeling fatigued. Nursing Intervention for Cesarean Section Postoperative. Femoral hernia: When part of the intestine causes a bulge in the upper part of the thigh, close to the groin. Cardiac arrhythmias aren’t directly linked to an aneurysm. Prominent, pulsating mass in abdomen, at or above the umbilicus. Severe lower back pain, decreased blood pressure, decreased RBC count, decreased RBC count, decreased WBC count. Friction rubs indicate inflammation of the peritoneal surface. Only 1% of clients with syphilis experience an aneurysm. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Systolic pressure maintained at 100 to 120 mm Hg with antihypertensive drugs, such as nitroprusside. The nurse palpates the abdomen which is soft, non-tender and auscultates an abdominal pulse. What is the most common cause of abdominal aortic aneurysm? The patient will be admitted to the medicine unit for observation and medication. Faith healers do not meet the standards for clergy exemption from visitation rules. Nursing Diagnosis. The expansion applies pressure in the abdominal cavity, and the pain is referred to the lower back. Which of the following groups of symptoms indicated a ruptured abdominal aneurysm? Any items you have not completed will be marked incorrect. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Our hottest nursing game is out now in the App Store. Announcement!! A nurse is planning care for a 6-year-old child who is receiving chemotherapy. An aortic aneurysm is an abnormal dilation of the arterial wall caused by localized weakness and stretching in the medial layer or wall of an artery. When to Seek Medical Help. The client’s spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. Scribd members can read and download full documents. ... for a broad range of medical problems, such as hernia repair and gall bladder removal. The factor common to all types of aneurysms is a damaged media. Although the other conditions are related to the development of an aneurysm, none is a direct cause. For a rupture aneurysm, prognosis is poor and surgery is performed immediately. Incisional hernia: When the intestine protrudes through the abdominal wall at the site of a previous surgery. An MI, if severe enough, can progress to heart failure; however, in and of itself, an MI doesn’t cause jugular vein distention. The most likely diagnosis is: The symptoms exhibited by the client are typical of an abdominal aortic aneurysm. The most significant sign is the audible pulse in the abdominal area. Instruct the client regarding the procedure for monitoring BP. As a university-affiliated program, the Surgical Program offers a range of care and procedures from thoracic and general surgery to gynaecology, ophthalmology and urology. When rupture occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. A patient comes to the emergency department with abdominal pain. Jugular vein distention isn’t a symptom of abdominal aortic aneurysm or pneumothorax. Chest radiograph, angiogram, transesophageal echocardiography, and magnetic resonance imaging(MRI). Location,intensity,and frequency of pain,and the factors that relieve pain, Appearance of abdominal wound (color,temperature,intactness,drainage), Evidence of stability of vital signs,hydration status,bowel sounds,electrolytes, Presence of complications: Hypotension, hypertension, cardiac dysrhythmias, low urine out- put,thrombophlebitis,infection,graft occlusion,changes in consciousness,aneurysm rupture, excessive anxiety,poor wound healing. Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity.