W H Y I T I S D O N E (continued) W H A T I T T E L L S M E (continued)
• Blood urea nitrogen (BUN) and creatinine (Cr): These tests mea sure the amount of nitrogen and chemical waste product in the blood that passes through the kidneys to be fi ltered and eliminated in urine. When mea sured together (in certain ratios), information is obtained about kidney function.
Changes in kidney function may occur with renal artery involvement and/or with hypotension/shock state.
ACTIONS/INTERVENTIONS RATIONALE
Hemodynamic Regulation NIC In de pen dent
Note presence of condition(s) (such as recent thoracic or abdominal aortic surgery, recent aortic rupture or surgical clamping, blood loss, hypovolemia, hypoxemia).
Factors that affect systemic circulation, tissue oxygenation, and organ function.
Observe for changes in level of consciousness or mentation, purposeful movement, and ability to follow commands and to move extremities appropriately
Changes in ce re bral or peripheral circulation and perfusion may reflect state of impairment due to damage from aneurysm or may show postoperative changes, either improvement or impairments from surgical procedure.
Monitor vital signs, especially noting changes/trends in blood pressure, including hypertension or hypotension.
Changes in blood pressure may be subtle or sudden and may be indicative of several things (e.g., increased vascular re sis tance, hyper/hypovolemia, leaking of surgical anastomosis with slow bleeding, or hemorrhage), all complications that require monitoring for prevention or early intervention.
Assess heart sounds, as well as apical and peripheral pulses.
Document dysrhythmias.
Changes in heart sounds and pulses may indicate inad- equate oxygenation or hydration status. Dysrhythmias may be pres ent because of ischemia or surgical changes to the aorta, coronary arteries, or valves.
Note and act upon changes and trends.
Evaluate breathing patterns and respiratory rate outside of acceptable par ameters.
These may indicate oxygen exchange prob lems; postopera- tive changes in the chest (e.g., ventilation or chest tubes);
response to deficient hemoglobin or fluids; or respiratory depression associated with anesthesia/analgesia.
Note reports of difficulty breathing.
Assess lung sounds, noting presence/absence of air move- ment in any area.
Client may have chest tubes in following thoracic surgery.
When drainage has slowed/stopped and air is moving freely in all lung fields, the tube(s) will be removed.
Inspect skin for cyanosis, pallor, mottling, cool or clammy skin, and increased capillary refill time.
Skin can reveal the status of systemic and/or local oxygen- ation and perfusion.
Observe/mea sure all- source output, noting changes, trends, and imbalances.
Client may have preoperative and perioperative conditions associated with the aneurysm, which are affecting postoperative output (e.g., renal vascular involvement) and/or perioperative issues (e.g., hypotension/shock, bleeding, chest tubes) that affect fluid status and organ perfusion.
These postoperative Nursing Diagnoses and Interventions are recommended in conjunction with general surgical inter- ventions. Refer to Care Plan: Surgical Interventions.
N U R S I N G D I A G N O S I S :
risk for in effec tive Tissue Perfusion (Specify: cardiovascular, ce re bral, renal, peripheral)
Possibly Evidenced By
Cardiac perfusion: Cardiovascular surgery; hypertension or hypotension; hypovolemia; hypoxia Ce re bral perfusion: Cerebrovascular impairment; aortic dissection; mechanical prosthetic valve Renal perfusion: Cardiac surgery; vascular embolism; treatment regimen; hypovolemia; hypoxemia Peripheral perfusion: Endovascular trauma or procedure
Desired Outcomes/Evaluation Criteria— Client Will Circulation Status NOC
Maintain BP within individually acceptable range.
Demonstrate stable perfusion as appropriate (e.g., vital signs within client’s normal range; chest pain/discomfort absent or at manageable level; neurological signs within client’s normal range; peripheral pulses pres ent and strong; absence of edema).
CHAPTER 2Cardiovascular: Aortic Aneurysms
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Investigate reports of pain, noting if pain is a new or dif fer ent pain than client reported prior to surgery.
Helps differentiate whether this pain is related to surgical procedure and/or if this pain differs from that experi- enced prior to surgery. Nonsurgical pain may be associ- ated with inadequate systemic or localized tissue oxygenation/organ perfusion.
Perform Doppler assessment of extremity pulses, if needed. In patients who have under gone aortic reconstructions, neither distal pulses nor Doppler signals may be pres ent initially, because of vasoconstriction from hypothermia.
For upper extremities, a Doppler signal is nearly always audible in the wrist in the immediate postoperative period.
Assist with and encourage early ambulation. Enhances circulation and return of normal organ function.
Collaborative
Collaborate in management of under lying conditions, such as bleeding, hypertension, hypovolemia, dysrhythmias, diabetes, COPD, etc.
To correct or manage acute or chronic conditions that would influence organ perfusion and function.
Maintain patent airway. Facilitates air movement.
Provide supplemental oxygen by appropriate route (e.g., ventilator, mask, nasal cannula).
Oxygen may be needed to improve systemic circulation and tissue perfusion.
Administer IV fluids and blood products, as indicated. Maintains circulating volume and supports tissue/organ perfusion.
Administer medi cations, as indicated. Vari ous drugs may be needed to support cardiac function, to promote systemic hemostasis, and/or to prevent or limit risk of perfusion complications (e.g., dysrhythmias, bleeding, thromboembolic phenomena, electrolyte imbalances).
Apply antiembolic hose or sequential compression devises, as indicated.
Prevents venous stasis and promotes circulation.
N U R S I N G D I A G N O S I S :
risk for Bleeding
Possibly Evidenced By Aneurysm
Abnormal blood profile [e.g., altered clotting factors, decreased hemoglobin]
Treatment regimen [e.g., surgery, medi cations, administration of platelet- deficient blood products]
Desired Outcomes/Evaluation Criteria— Client Will Bleeding Loss Severity NOC
Be free of signs of active bleeding such as hemoptysis, hematuria; or excessive blood loss [preoperative, perioperative, and/
or postoperative].
Demonstrate stable vital signs, skin and mucous membranes free of pallor; usual mentation and urinary output.
ACTIONS/INTERVENTIONS RATIONALE
Bleeding Precautions NIC In de pen dent
Note presence of condition(s) (such as recent thoracic or abdominal aortic surgery, recent aortic rupture or surgical clamping, hemorrhage/blood loss, hypovolemia, hypox- emia). Be aware of bleeding risks, both for sudden hemorrhage and for hidden internal blood loss.
Factors that affect systemic circulation, clotting factors, and tissue/organ perfusion. Both aneurysm rupture and open abdomen repair may result in significant blood loss.
Observe for frank bleeding from incisions, tubes, and body orifices. Hematest secretions and excretions as indicated.
Hemorrhage may occur because of an inability to achieve hemostasis in the setting of aortic aneurysm, surgery, or development of a coagulopathy.
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Assess vital signs, including blood pressure, pulse, and respiration, especially when associated by impaired mental status.
Assists in determining intravascular fluid deficits. Tachycar- dia, tachypnea, hypotension, and any change in menta- tion can herald hypovolemia, impending shock.
Monitor hemodynamic mea sure ments (e.g., central venous pressure or arterial blood pressures) where available.
Invasive monitoring lines will be in place in the critically ill patient, whose early postoperative care will be provided in intensive care units.
Monitor skin and mucous membrane color and moisture.
Note increased capillary refill time and poor skin turgor (late sign).
Hypovolemia associated with bleeding may be demon- strated in pale, cool, and clammy skin with dry mucous membranes.
Observe/mea sure all- source output, noting changes, trends, and imbalances.
Client may have preoperative and perioperative conditions associated with the aneurysm, which are affecting postoperative output (e.g., renal vascular involvement) and/or perioperative issues (e.g., hypotension/shock, bleeding, chest tubes), which affect fluid status and organ perfusion.
Investigate reports of pain in specific areas and whether pain is increasing, diffuse, or localized.
Can help locate pos si ble sources of bleeding, especially in setting of falling hemoglobin, and downward trend in vital signs.
Evaluate and mark bound aries of soft tissues (e.g., abdomen, flank, back) if hematomas present/spreading.
Be prepared for emergency interventions. This is a fragile client. Prompt interventions may be needed to prevent/manage complications and save life.
Collaborative
Review laboratory data (e.g., hemoglobin, hematocrit, platelets, and coagulation profiles), as indicated.
Assists in determining intravascular fluid volume, status of blood volume, and bleeding risks.
Administer IV fluids and blood products/specific compo- nents, as indicated.
Restores and maintains circulating volume.
N U R S I N G D I A G N O S I S :
acute Pain
May Be Related To
Physical injury agents (e.g., operative procedure) Possibly Evidenced By
Verbal/coded report; expressive be hav ior (e.g., restlessness, crying)
Changes in physiological par ameters (e.g., blood pressure, heart/respiratory rate; oxygen saturation) Guarding/protective be hav ior; positioning to ease pain
Self- focus
Desired Outcomes/Evaluation Criteria— Client Will Pain Level NOC
Report pain or discomfort is relieved or controlled.
Verbalize nonpharmacological methods that provide relief.
Follow prescribed pharmacological regimen.
ACTIONS/INTERVENTIONS RATIONALE
Pain Management: Acute NIC In de pen dent
Determine and document presence of pos si ble pathophysi- ological causes of pain (e.g., surgical incision(s), tissue trauma, comorbidities such as complication from ischemia or clotting prior to surgery).
Establishes a baseline for pain assessments.
(continues on page 118)
CHAPTER 2Cardiovascular: Aortic Aneurysms
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Evaluate pain in immediate postoperative period and regularly (e.g., hourly, per protocol).
Provides information about need for and effectiveness of interventions. Regular monitoring also permits early recognition of developing complication (such as might occur with abdominal distention associated with internal bleeding).
Consider patient’s age and current situation (e.g., sedated, on ventilator, cognitively impaired), coexisting medical or psychological conditions: size and location of incisions/
drains/tubes, etc.
Many factors affect pain situation and perception. This surgery is complex and often performed on emergent basis on el derly person (although it can be performed on person of any age) with very little time for preoperative preparation of postoperative expectations. Early postop- erative situation is often complex and confusing, filled with medical/nursing interventions and activity.
Determine specifics of pain— location (e.g., incision, deep in abdomen), characteristics (e.g., throbbing, stabbing), and intensity (0 to 10, or similar scale).
Facilitates diagnosis of prob lem and initiation of appropriate interventions. Helpful in evaluating need for/effectiveness of therapy.
Evaluate vital signs on ongoing basis. Changes in blood pressure and heart rate often accompany acute pain (especially in early postoperative period) and may occur before patient reports pain.
Changes in vital signs can also point toward potential complication (e.g., bleeding, infection) causing or exacer- bating pain.
Assess causes of pos si ble discomfort other than operative procedure.
Allows for identification of other discomforts (e.g., nausea, infiltrated IV, chest tube, abdominal distention, need to urinate; anxiety/fear; disorientation), which may require intervention in order to promote overall comfort.
Assist client in determining acceptable level of discomfort. It may not always be pos si ble to eliminate pain; however, patient may be “comfortable” at a level 5 if pain has been a level 10 for a length of time. Or eliminating another discomfort (e.g., nausea) can promote improved analgesia effect.
Collaborate with patient in pain management. Instruct in early reporting of pain and ongoing evaluation of effec- tiveness of current interventions.
Promotes client’s sense of control and maximizes efforts for pain control.
Provide and promote nonpharmacological mea sures for pain relief (such as repositioning; rest in a quiet environment;
family presence; splinting of incision during coughing;
relaxation techniques, such as deep breathing; soft music/other diversion).
Helps relieve muscle and emotional tension. Enhances sense of well- being.
Document effects of pain management (nonpharmacologi- cal mea sures and analgesics).
Pain should be reassessed after each pain management intervention once a sufficient time has elapsed for the treatment to reach peak effect. Reassessment should include whether the patient’s goal for pain relief was met (e.g., pain intensity, effect on function [physical or psychosocial], patient satisfaction with pain relief, whether side effects had occurred and were tolerable).
Collaborative
Administer analgesics by appropriate route (e.g., IV, patient- controlled analgesia [PCA], oral), as indicated.
Pain control is essential to quality patient care. It ensures patient comfort, promotes tissue healing and effective pulmonary toilet.
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Pro cess NIC In de pen dent
Determine client’s circumstances, observing age, functional and cognitive status. Note type of aneurysm repair (e.g., open abdomen or endovascular), whether more than one chronic condition (e.g., COPD, stroke, renal impairment) is pres ent at the same time.
These factors affect how the client/caregiver views and manages postoperative self- care. Elder patients (about 60% in one study) often pres ent with worse comorbidities and severe complications such as myo car dial infarction, pneumonia, and acute renal failure (Raval & Escandari, 2012). In another study, elder patients reported that health- related quality of life after AAA repair was significantly impaired in the early postoperative period (Pol et al, 2012).
Identify immediate care needs, complexity of care needs, care support system, and where convalescence will take place.
When being discharged from acute care, client may continue care in rehabilitation, long- term care, or home.
This is dependent upon client’s discharge status and presence or absence of support systems. This, in turn, determines the type and amount of teaching, support, and care coordination required. For example, client in early postoperative period may need assistance with surgical wound care, blood pressure monitoring, and medi cation safety. Client in later stages of recovery may need more teaching and support in areas of prevention of recurrence (e.g., remaining smoke- free, adhering to medical follow-up monitoring).
Assist client/caregiver in identifying modifiable risk factors, such as smoking, hypertension, and diet high in sodium and saturated fats.
It is appropriate to address preventable or manageable conditions that are known to contribute to cardiovascular disease.
Problem- solve with client/caregiver to identify ways in which appropriate lifestyle changes can be made to reduce modifiable risk factors.
Changing “comfortable or usual” be hav ior patterns can be very difficult and stressful. Support, guidance, and empathy can enhance client’s success in accomplishing his or her health goals.
Discuss importance of eliminating smoking, and assist client in formulating a plan to quit smoking. Refer to smoking cessation program or healthcare provider for helpful medi cations.
Nicotine increases catecholamine discharge, resulting in increased heart rate, blood pressure, and vasoconstriction, interfering with optimal organ perfusion and function.
Note: Several studies have demonstrated that tobacco use is associated with an increased rate of aneurysm expansion (preoperatively) and smoking cessation is likely the most impor tant recommendation that can be made to a patient with AAA (Brady et al, 2004).
N U R S I N G D I A G N O S I S :
in effec tive Health Management
May Be Related To
Complexity of therapeutic regimen Insufficient knowledge
Possibly Evidenced By
Reported difficulty with prescribed regimens
Failure to include treatment regimen in daily living or to take action to reduce risk factors In effec tive choices in daily living for meeting health goal
Desired Outcomes/Evaluation Criteria— Client Will Knowledge: Treatment Regimen NOC
Verbalize understanding of disease pro cess and treatment regimen.
List signs and symptoms that require immediate intervention.
Identify and engage available resources.
Self- Management: Hypertension NOC
Maintain BP within individually acceptable par ameters.
CHAPTER 2Cardiovascular: Aortic Aneurysms
a. Mechanical (e.g., trauma, surgery) or physiological (e.g., hypertension, phlebitis) damage to the vessel wall leads to platelet activation, with platelets adhering to one another and clumping together, forming a thrombus.
b. The thrombus either dissolves over time or grows and becomes large enough to occlude a vessel, which causes blood fl ow to slow, expands the veins to accommodate the increased volume, and causes more clots to form.
I. Pathophysiology: Venous thromboembolism (VTE) results from a combination of hereditary and acquired risk factors, known as thrombophilia or hypercoagulable states.
Also, vessel wall damage, venous stasis, and alterations in the clotting mechanism (Virchow’s triad) remain the fundamental issues in thrombosis (Ozaki & Bartholomew, 2012).
ACTIONS/INTERVENTIONS (continued) RATIONALE (continued)
Instruct in and demonstrate BP self- monitoring technique.
Observe client’s technique in return, and ascertain that client understands blood pressure readings. Evaluate client’s hearing, visual acuity, manual dexterity, and coordination.
Monitoring BP at home is reassuring to client because it provides visual feedback to determine treatment out- comes and helps promote early detection of deleterious changes. Note: Client may be on multiple medi cations with goal of keeping blood pressure at or below 120/80, to reduce flow force in aorta.
Help client develop a simple, con ve nient schedule for taking medi cations.
Individualizing schedule to fit client’s personal habits may make it easier to get in the habit of including medi cations in healthcare management activities.
Explain prescribed medi cations along with their rationale, dosage, expected and adverse side effects, and par tic u lar traits.
Adequate information and understanding about beneficial and expected side effects can enhance client’s commit- ment to the treatment plan.
Explain rationale for prescribed dietary regimen— such as diet low in sodium, saturated fat, and cholesterol.
Excess saturated fats, cholesterol, sodium, alcohol, and calories have been defined as nutritional risks in hypertension.
Encourage client to establish a regular exercise program, within client’s capabilities and potential.
Besides helping to lower BP, aids in toning the cardiovascular system and improves general health and well- being.
Review symptoms that require the client to notify the healthcare provider, such as failure of healing in surgical wound; fever; sudden or continued increase of BP; chest (or other) unrelieved pain; shortness of breath; peripheral or abdominal swelling; and other symptoms as individu- ally appropriate.
Early detection and reporting of potentially developing complications (early or late) allow for timely intervention.
Note: One author reporting on postoperative thoracic aortic aneurysm follow-up stated that “development of another aneurysm postoperatively is not uncommon”
(Tseng & Bush, 2016). Also, patients who have had endovascular aneurysm repair need lifelong radiographic monitoring of graft placement and for developing endoleaks. Note: An endoleak is a common complication of an endovascular aneurysm repair (EVAR) and is found in 30% to 40% of patients intraoperatively and in 20% to 40% during follow-up (Tinkham, 2013).
Provide information regarding community resources for both client and caregiver support. Initiate referrals, as indicated.
Community resources such as stop smoking clinics, stress management classes, home care, caregiver respite, and counseling ser vices may be helpful in efforts to support lifestyle changes and enhance recovery efforts.
POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on client’s age, physical condition and presence of com- plications, personal resources, and life responsibilities)
•Activity Intolerance— generalized weakness, imbalance between oxygen supply and demand
•in effec tive Health Management— complexity of therapeutic regimen, economic difficulties, perceived seriousness
•Self- Care Deficit [specify]— pain/discomfort, weakness, fatigue
•risk for Infection— alteration in skin integrity, decrease in hemoglobin, smoking