RESOURCE UNIT

ABDOMINAL AORTIC ANEURYSM

Submitted by:
BSN 3-E, GROUP IV
Campos, Julie Ann
Martinez, Ma. Carla
Matalaba, Anne Khriztine
Monleon, Vanessa Mae
Monteron, Rodielyn Mae
Najarro, Marie Kathleen
Natural, Meriam
Obani, Mie
Palmero, Johanna Marie
Palmitos, Angelica
Peñaflor, Pinky
Sumalinog, Jo Anne
Tangkay, Christine
Torrevillas, Gail
Tuang, Jarric

Submitted to:
Ms. Cecilia C. Ramos, RN
Clinical Instructor
 ABDOMINAL AORTIC ANEURSYM

General Objective: After 1 hour of lecture, the BSN IV students will be able to acquire positive attitude, basic knowledge and skills on the concept of abdominal aortic aneurysm.
SPECIFIC CONTENT TIME ALLOTMENT METHODOLOGY RESOURCES EVALUATION
OBJECTIVES
Specifically, the BSN
3E students will be An aneurysm is an area of a localized widening i. Prayer – 2 min. - lecture Human: After an hour of
able to: (dilation) of a blood vessel. (The word BSN 4E students lecture, the BSN 4E
1.Introduction: "aneurysm" is borrowed from the Greek ii. Reading of Objectives students were able to
• Define "aneurysma" meaning "a widening"). – 3 min. Internet: actively participate in
-aneurysm www.medicinenet.c the question and
- aortic aneurysm An aortic aneurysm involves the aorta, one of iii. Lecture – 1 hour om answer portion of the
-abdominal the large arteries through which blood passes www.webmd.com health teaching
aneurysm from the heart to the rest of the body. The aorta iv. Evaluation – 15 min. www.intelihealth.c programme.
• Overview bulges at the site of the aneurysm like a weak om
spot on an old worn tire. www.bestpractice.b
mj.com
Aortic aneurysms can develop anywhere along
the length of the aorta. The majority, however, Books:
are located along the abdominal aorta. Most Textbook Medical
(about 90%) of abdominal aneurysms are Surgical
located below the level of the renal arteries, the Nursing,10th
vessels that leave the aorta to go to the kidneys. Ed.,Smeltzer and
About two-thirds of abdominal aneurysms are Bare.
not limited to just the aorta but extend from the
aorta into one or both of the iliac arteries. Medical Surgical
Nursing Clinical
Abdominal aortic aneurysm (also known as Management for
AAA, pronounced "triple-a") is a localized Positive Outcomes,
dilatation (ballooning) of the abdominal aorta 8th Ed., Black and
exceeding the normal diameter by more than 50 Hawks.
percent. Approximately 90 percent of abdominal
aortic aneurysms occur infrarenally (below the
kidneys), but they can also occur pararenally (at
the level of the kidneys) or suprarenally (above
the kidneys). Such aneurysms can extend to
include one or both of the iliac arteries in the
pelvis.

Abdominal aortic aneurysms occur most

commonly in individuals between 65 and 75
years old and are more common among men and
smokers. They tend to cause no symptoms,
although occasionally they cause pain in the
abdomen and back (due to pressure on
surrounding tissues) or in the legs (due to
disturbed blood flow). The major complication
of abdominal aortic aneurysms is rupture, which
can be life-threatening as large amounts of blood
spill into the abdominal cavity, and can lead to
death within minutes.
2. Enumerate the risk The exact cause is unknown, but risk factors for
factors of AAA’s developing an aortic aneurysm include:

• cigarette smoking not only increases the

risk of developing an abdominal aortic
aneurysm, the chance of aneurysm
rupture (a life-threatening complication
of abdominal aneurysm) is also more
common among active smokers.
• High blood pressure
• High cholesterol
• Male gender
• Emphysema
• Genetic factors- There is a familial
tendency to developing abdominal aortic
aneurysms. Individuals with first-degree
relatives having abdominal aortic
aneurysms have a higher risk of
developing abdominal aortic aneurysm
than the general population. They also
tend to develop the aneurysms at
younger ages and have a higher
tendency to suffer aneurysm rupture
than individuals without family history.
• Obesity

• Age
3. Discuss the etiology. The primary event in the development of an
AAA involves proteolytic degradation of the
extracellular matrix proteins elastin and
collagen. Various proteolytic enzymes,
including matrix metalloproteinases, are critical
during the degradation and remodeling of the
aortic wall.4 Oxidative stress also plays an
important role, and there is an autoimmune
component to the development of AAA, with
 extensive lymphocytic and monocytic
infiltration with deposition of immunoglobulin
G in the aortic wall.4 Cigarette smoking elicits
an increased inflammatory response within the
aortic wall.5 An infectious etiology
with Chlamydia pneumoniae has been proposed
but not proven.4 Increased biomechanical wall
stress also contributes to the formation and
rupture of aneurysms with increased wall
tension and disordered flow in the infrarenal
aorta.4 Finally, 12 to 19 percent of first-degree
relatives, predominantly men, of a patient with
an AAA will develop an aneurysm.6
4. Briefly discuss the The abdomen (commonly called the belly) is
anatomy and the body space between the thorax (chest) and
physiology of the pelvis. The diaphragm forms the upper surface
abdomen and its of the abdomen. At the level of the pelvic
arteries. bones, the abdomen ends and the pelvis
begins.
The abdomen contains all the digestive
organs, including the stomach, small and large
intestines, pancreas, liver, and gallbladder.
These organs are held together loosely by
connecting tissues (mesentery) that allow
them to expand and to slide against each
other. The abdomen also contains the kidneys
and spleen.
Many important blood vessels travel through
the abdomen, including the aorta, inferior vena
cava, and dozens of their smaller branches. In
the front, the abdomen is protected by a thin,
tough layer of tissue called fascia. In front of
the fascia are the abdominal muscles and skin.
In the rear of the abdomen are the back
muscles.
The aorta is the largest artery in the body. It is
connected to the left ventricle of the heart and
has the job of carrying oxygenated blood from
the heart to other parts of the body.
The abdominalaorta is the last portion of the
aorta and is located in the abdominal cavity. It
takes blood from the aorta, through the trunk,
and to the abdominopelvic organs and legs. The
left ventricle and thoracic aorta of the heart lead
to the abdominal aorta which begins at
the diaphragm. This artery then crosses the
diaphragm at the level of the T12 vertebrae.
From there it descends along the posterior wall
of the abdomen in front of the vertebral column,
following the natural curvature of the lumbar
vertebrae and positioned slightly to the left of
the midline of the body. It also lies parallel to
the inferior vena cava, which is located to its
right.

The abdominal aorta branches into three sets of

smaller arteries, becoming narrower as it
descends through the abdominal cavity. These
three sets are known as the visceral, parietal, and
terminal arteries. These branches of the
abdominal aorta and their associated vertebral
levels are defined as follows. From the vertebral
level of T12, the abdominal aorta first branches
into the inferior phrenic and celiac arteries
(T12), superior mesenteric and middle
suprarenal arteries (L1), renal and gonadal
arteries (L2), lumbar artery (L1-L4), inferior
mesenteric artery (L3), and the median sacral
and common iliac arteries (L4). At the L5 level,
the artery then splits to form the two common
 iliac arteries that carry blood to the legs.

The most common ailment involving the

abdominal aorta is an abdominal
aortic aneurysm (AAA). An aneurysm is a
widening (also known as dilation) of a blood
vessel due to a weakness in the vessel. At the
weak portion, the aneurysm bulges and poses a
serious risk of rupture. An AAA is more
common in men, particularly those age 60 and
older. Approximately 5% of men over the age of
60 suffer from abdominal aortic aneurysms. Risk
factors for the development of AAA include
cigarette smoking, hypertension,
highcholesterol (hypercholesterolemia),
and diabetes mellitus. While there are several
possible causes of an AAA, the most common
cause remains arteriosclerosis, or hardening of
the arteries.

5 .Briefly explain the Histologically there is obliteration of collagen

pathophysiology of the and elastin in the media and adventitia, smooth
AAA’s. muscle cell loss with resulting tapering of the
medial wall, infiltration of lymphocytes and
macrophages, and neurovascularization.

Proteolytic degradation of aortic wall connective

tissue: matrix metalloproteinases (MMps) and
other proteases are derived from macrophages
and aortic smooth muscle cells and secreted into
the extracellular matrix. Disproportionate
proteolytic enzyme activity in the aortic wall
may promoto deterioration of structural matrix
proteins. Increased expression of collagenases
MMp-1 and MMP-13 and elastases MMp-2,
 MMP-9, and MMP-12 have been demonstrated
in human AAAs.

Inflammation and immunse responses: an

extensive transmural infiltration by macrophages
and lymphotcytes is present on aneurysm
histology and these cells may release a cascade
of cytokines that subsequently activate many
proteases. Additionally, deposition of IgG into
the aortic wall supports the hypothesis that AAA
formation may be an autoimmune response.
There is currently interest in the role of reactive
oxygen species and antioxidants in AAA
formation.

Biochemical wall stress: elastin levels and the

elastin-collagen ratio decrease progressively
distal down the aorta. Diminished elastin id
associated with aortic dilation and collagen
degradation predisposes to rupture. Additionally,
data supports increased MMP-9 expression and
activity, disordered flow and increase in wall
tension, and relative tissue hypoxia in the distal
aorta.
( See Diagram on the separate page.)
6. Enumerate the CLINICAL MANIFESTATIONS:
clinical manifestations. • mostly asymptomatic
• palpable at about 5 cm in diameter,
except in obese clients
• client's awareness of a pulsating mass in
the abdomen, with or without pain, followed by
abdominal pain and back pain is the most
common
• groin pain and flank pain
• bruits can be heard over the aneurysm
• sometimes mottling of the extremities or
 distal emboli in the feet

Once the aneurysm bursts, symptoms include:

• Severe back or abdominal pain that
begins suddenly
• Paleness
• Dry mouth/skin and excessive thirst
• Nausea and vomiting
• Signs of shock, such as shaking,
dizziness, fainting, sweating, rapid
heartbeat and sudden weakness
7 .List the diagnostic DIAGNOSTIC TOOLS:
procedures to be
performed. • Duplex Ultrasonographyhas about 98%
accuracy in measuring the size of the
aneurysm, and is safe and noninvasive. But
ultrasound cannot accurately define the
extent of the aneurysm and is inadequate for
surgical repair planning.
• Computed Tomography (CT) scan of the
abdomen, is highly accurate in determining
the size and extent of the aneurysm, and its
relation to the renal arteries. However,
computerized tomography uses high doses
of radiation and for evaluation of blood
vessels, requires intravenous dye. This
carries some risk including allergic reaction
to the dye and irritation of the kidneys.
• Arteriogram (real time x-rays) where dye is
directly injected into the aorta to assess its
anatomy, historically was the diagnostic test
of choice. Presently, it's indications may be
limited to use when surgery or stenting is
considered
 • MRI (magnetic resonance imaging) In
patients with kidney diseases, the doctor
may consider an MRA (magnetic resonance
angiography), which is a study of the aorta
and the other arteries using MRI scanning.

8. Discuss the medical The treatment options for asymptomatic AAA

management. are conservative management, surveillance with
a view to eventual repair, and immediate repair.
There are currently two modes of repair
available for an AAA: open aneurysm repair
(OR), and endovascular aneurysm repair
(EVAR). An intervention is often recommended
if the aneurysm grows more than 1 cm per year
or it is bigger than 5.5 cm. Repair is also
indicated for symptomatic aneurysms.

Conservative

Conservative management is indicated in

patients where repair carries a high risk of
mortality and in patients where repair is unlikely
to improve life expectancy. The mainstay of the
conservative treatment is smoking cessation.

Surveillance is indicated in small asymptomatic

aneurysms (less than 5.5 cm) where the risk of
repair exceeds the risk of rupture. As an AAA
grows in diameter the risk of rupture increases.
Surveillance until the aneurysm has reached a
diameter of 5.5 cm has not been shown to have a
higher risk as compared to early intervention.
 Medication

No medical therapy has been found to be

effective at decreasing the growth rate or rupture
rate of asymptomatic AAAs. Blood pressure and
lipids should however be treated like in any
atherosclerotic condition. Studies have suggested
possible protective use effects of therapy with
angiotensin converting enzyme inhibitors, beta-
blockers, and statins. Client should be monitored
for blood pressure. Use opioids to reduce pain;
tranquilizers may also be needed.
9. Discuss the surgical Surgery for an abdominal aortic aneurysm is
management. known as AAA surgery or AAA repair. The
threshold for repair varies slightly from
individual to individual, depending on the
balance of risks and benefits when considering
repair versus ongoing surveillance. The size of
an individual's native aorta may influence this,
along with the presence of comorbidities that
increase operative risk or decrease life
expectancy.

Aneurysm repair

Aneurysm repair is recommended for all

aneurysms greater than 6 cm wide. Elective
repair is also generally recommended for
aneurysms between 4 and 6 cm in clients who
are good surgical risks. The more traditional
surgical technique for aneurysm repair is done
through a midline incision that extends from the
xyphoid process to the symphisis pubis. The
aneurysm is exposed, the aorta is clamped just
above and below the aneurysm to stop the flow
of blood, the aneurysm is open, and a dacron
graft is placed within the aneurysm. The
aneurysm sac is then wrapped around the graft
to protect it.

Endovascular repair

Endovascular repair is generally indicated in

older, high-risk patients or patients unfit for
open repair. Its is also a newer method for non
emergency treatment to repair abdominal aortic
aneurysm.However, endovascular repair is
feasible for only a proportion of AAAs,
depending on the morphology of the aneurysm.
The main advantages over open repair are that
there is less peri-operative mortality, less time in
intensive care, less time in hospital overall and
earlier return to normal activity. Two small
incisions are made in the groin, and a vascular
graft is guided into the aorta. At the tip of the
catheter are a deflated balloon and a tightly
wrapped polyester cloth graft. When properly
positioned, the graft is secured in placed by
inflating the balloon and opening the graft to the
diameter needed to prevent blood flow into the
aneurysm. The balloon is then deflated and
removed along with the catheter. At each end of
the graft are hooks that help secure it to the inner
walls of the aorta. The graft allows blood flow to
continue through the aorta to the arteries in the
pelvis and legs, without filling the aneurysm.
Disadvantages of endovascular repair include a
requirement for more frequent ongoing hospital
reviews, and a higher chance of further
procedures being required. According to the
 latest studies, the EVAR procedure does not
offer any benefit for overall survival or health-
related quality of life compared to aneurysm
surgery, although aneurysm-related mortality is
lower.In patients unfit for aneurysm repair,
EVAR plus conservative management was
associated with no benefit, more complications,
subsequent procedures and higher costs
compared to conservative management alone.
10. Enumerate possible Abdominal aortic aneurysm repair is considered
complications. a major operation, and many specific
postoperative complications can develop.
Complications after abdominal aortic aneurysm
repair are generally caused by coronary artery
disease and chronic obstructive pulmonary
disease. These conditions decrease excretion of
anesthetic, increase the risk of postoperative
atelectasis, and decrease the client's tolerance of
hemodynamic changes from blood loss and fluid
shifts. To reduce the risk of acute myocardial
infarction, one of the most serious
complications, clients may undergo coronary
artery bypass before aneurysm repair.
Prerenal failure can develop for several reasons.
The kidney can sustain ischemia from decrease
aortic blood flow, decreased cardiac output,
emboli, inadequate hydration, or the need for
clamps on the aortic above the renal arteries
during surgery.
Emboli can also develop and lodge in the
arteries of the lower extremities or mesentery.
Clinical manifestations include those of acute
occlusion in the leg. Bowel necrosis is exhibited
as fever, leukocytosis, ileus, diarrhea, and
abdominal pain.
 The spinal cord can also become ischemic,
resulting in the paraplegia, rectal and urinary
incontinence, or loss of pain and temperature
sensation. Spinal cord ischemia tends to occur
more commonly when an abdominal aortic
aneurysm has ruptured.
Changes in sexual function may also develop
following repair of an abdominal aortic
aneurysm. Retrograde ejaculation occurs in
about two thirds of male clients and loss of
potency occurs in one third of males who have
undergone repair of abdominal aortic aneurysm.
11. Prognosis The outlook for an untreated abdominal aortic
aneurysm depends on its size.
• An abdominal aortic aneurysm larger than 7
centimeters in diameter has a 75% chance of
rupturing within 5 years.
• At 6 centimeters, the risk of rupture is 35%
over 5 years.
• Between 5.0 and 5.9 centimeters, the rupture
risk is about 25% over 5 years.
• The risk of rupture is much lower for
aneurysms smaller than 5 centimeters (2 inches).
With successful surgical repair, the prognosis is
good and depends more on the severity of
atherosclerosis affecting other organs, especially
the heart, brain and kidneys.

12. Nursing Surgical repair of an aneurysm is usually

Management performed if the aneurysm is growing rapidly
and/or reaches a size of 5-6 cm or larger or if the
client experiences symptoms. The procedure
often involves the use of a synthetic graft, which
is inserted to replace or support the weakened
vessel.
This care plan focuses on the adult client
hospitalized for surgical repair of an abdominal
aortic aneurysm. Much of the postoperative
information is applicable to clients receiving
follow-up care in an extended care facility or
home setting.

A. Preoperative :
Abdominal aortic surgery is a major
surgery; it last approximately 4 hours.
During the hours under anesthesia, the
patient faces a great risk of pulmonary
and cardiac complications developing.
Three operative assessment must
include:
1. Detection of
concurrent coronary
artery disease and
cerebrovascular
disease.
2. Assessment of all
peripheral pulses for
baseline comparison,
post-operatively.
3. Standard evaluation
for endovascular
repair due to potential
open repair of the
aneurysm.

B. Post-operative:
Following surgery, clients usually return
to an intensive care unit. A
comprehensive postoperative
assessment of the client after open
 surgical repair for abdominal aortic
aneurysm repair is essential. Potential
complications are many, because of the
seriousness of the problem and the
complexity of the repair. Even though
extra corporeal perfusion
(cardiopulmonary bypass) is not needed
for the surgery, arterial flow to tissues
distal to the aneurysm is reduced during
the time required to perform the surgery
because the aorta is clamped.

1. Nursing diagnosis: Risk for

Hemorrhage

Assessment:
Because of the risk of bleeding at the
graft site, the client is at risk for
hemorrhage.

Outcome Criteria:
The nurse will monitor for
manifestations of hemorrhage and notify
the physician if any manifestations
occur.

Intervention:
Assess for changes indicating
hypovolemia:
• Increase pulse rate, decreased
BP
• Clammy skin, pallor,cyanosis
• Anxiety, restlessness,
decreasing levels of
consciousness
• Thirst, oliguria (urine output
 less than 0.five ml/kg/hr)
• Increased abdominal girth,
increased chest tube output
>100 ml/hr for 3 hours.
• Back pain (from retroperitoneal
bleeding)
• Central venous pressure, left
atrial pressure, pulmonary artery
pressure, and pulmonary
capillary wedge pressure
continuously.

2. Risk for Impaired Gas Exchange:

The large abdominal incision impairs
deep inspiration and usually reduced
effective coughing

Outcomes:
The client will have improved gas
exchange as evidenced by oxygen
saturation >95% increasing
effectiveness in coughing and clearing
of lung sounds.

Interventions:
Monitor settings on the ventilator to
ensure that the client is adequately
oxygenated.

• Assess lung sounds every 1 to 2

hours, report any adventitious
lung sounds.
• Monitor oxygen saturation
continuously, report any
desaturation.
• After extubation, assist with
 coughing by using incentive
spirometry, provide splinting
pillows before coughing,
encouraging ambulation, and
providing adequate analgesia.

3. Risk for Ineffective tissue Perfusion:

During the operation, the aorta is
clamped to stop bleeding while the graft
placed. During that time, distant
peripheral tissues are not perfused. The
graft site can also become occluded
with thrombus. In addition, the client
often has free-existing arterial disease.

Outcomes:
The client will maintain adequate tissue
perfusion as evidenced by pedal pulses,
warm feet, capillary refill of less than 5
seconds, absence of numbness or
tingling, and availability to dorsiflex and
plantiflex both feet equally.

Interventions:
Assess dorsalis pedis and posterior tibial
pulses every hour for 24 hours. Report
changes in pulse quality or absent
pulses.

• Assess dorsiflexion and

plantiflexion and sensation
every hour for 24 hours.
• Inspect lower extremeties for
mottling, cyanosis, coolness, or
numbness every 4 hours.
4.Acute Pain
Abdominal aortic anuersym repair
necessitates a long incision.

Outcomes:
The client will have increased comfort
as evidenced by self-report of
decreasing levels of pain, use of
decreasing amount of opioid analgesics
for pain control, and ambulating or
coughing without extreme pain.

Interventions:
Opioids are usually provided via a
patient-controlled analgesia system or
through an epidural catheter.

• Assess the degree of pain often

and record the baseline level of
pain and the degree to which
pain is reduced by medications
or other interventions.
• When changing to an oral route
for pain management, plan to
pretreat the pain with oral
medications 30 minutes or more
before discontinuing the
infusion.

FIVE: Risk for Ischemia of the Bowel

If the client undergoes extensive aortic
procedures that involve clamping the
mesenteric vessels, ischemic colitis can
develop. In addition, the inferior
 mesenteric artery can emobolize. The
lack of blood supply can lead to
ischemia and ileus.

Outcomes:
The nurse will monitor the client for
abdominal distention, diarrhea, severe
abdominal pain, sudden elevations in white
blood cell count and bowel sounds.

Interventions:

• Assess bower sounds every 4 hours.

• Keep the client nothing by
mouth( NPO ) and provide oral care
every 2 to 4 hours.
• Provide routine nasogastric ( NG ) tube
care.
• Assess nares for tissue impairment.
• Perform guaiac tests of NG drainage
every hours or bleeding is suspected
( i.e.,drainage has dark, coffee-ground
appearance or is bright red).

6.Risk for Spinal Cord Ischemia

A rare but devastation effect of aortic
abdominal aneurysm repair is spinal cord
ischemia leading to paralysis, with or without
bowel and bladder involvement. It appears to be
most common in clients who have suprarenal
aortic reconstruction.

Outcomes:
The nurse will monitor for
manifestations of spinal cord damage
and report any abnormal data.
Interventions:
• Monitor ability to move lower
extremities( dorsiflexion and
plantar flextion) and sensation
in both legs every 1 to 2 hours.
• Report any changes from
basesline.
 Abdominal Aortic
Aneurysm

Proteolytic degradation
Inflammation and
of aortic cell wall Biochemical wall stress
immune responses
connective tissue

Disproportionate
Release of cytokines that Decrease elastin-collagen
proteolytic enzyme
activate proteases ratio
activity in the aortic wall

Obliteration of collagen
and elastin in tunica
media and tunica
adventitia