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TL AAA
Abdominal Aortic Aneurysm (HESI)
Question | Answer |
---|---|
Define AAA (abdominal aortic aneurysm). | dilatation of the abdominal aorta caused by an alteration in the integrity of its wall |
What is the most common cause of AAA? | Atherosclerosis |
AAA is a late manifestation of what sexually transmitted disease? | Syphilis |
What is the end result of an untreated abdominal aortic aneurysm? | Rupture/death |
What are the most frequent symptoms associated with abdominal aortic aneurysm? | Mostly asymptomatic; abdominal pain; low back pain; feeling one’s heart beating |
Clients taking which type of drug are at increased risk for abdominal aortic aneurysm? | Antihypertensives |
The client is admitted complaining of chest pain and terrible tearing sensation in his chest. What condition might you suspect? | Dissecting aortic aneurysm |
What are the symptoms of a rupture of an aortic aneurysm? | hypovolemic or cardiogenic shock with sudden, severe abdominal pain |
Which assessments are necessary in the first few hours for the patient with a dissecting aortic aneurysm? | Vital signs Q hour, Neurologic vital signs, respiratory status, urinary output, peripheral pulses |
What is the nurse likely to find on assessment of a patient with an abdominal aortic aneurysm? | bruit over the abdominal artery, pulsation in upper abdomen, patient report of abdominal or lower back pain, |
What diagnostic tests could confirm the diagnosis of abdominal aortic aneurysm if the aneurysm is calcified? | abdominal radiograph (aortogram, angiogram, abdominal ultrasound) |
What are several applicable nursing diagnoses for the patient with AAA? | Activity intolerance, Impaired skin integrity, anxiety |
What nursing interventions are required for the patient with an aortic aneurysm (4 important assessments)? | regular assessment of all peripheral pulses and vital signs; look for signs of occlusion after graft; watch for signs of kidney trouble; Observe for postoperative ileaus |
Name all the peripheral pulses that a nurse would regularly check for the patient with abdominal aortic aneurysm. | Radial, femoral, popliteal, posterior tibial, dorsalis pedis |
After the placement of an aortic graft the nurse should observe for signs of occlusion. What are the signs of occlusion? | changes in pulses; severe pain; cool to touch below graft; white or blue extremities |
The kidneys are at risk for damage during grafting of the Aorta because the large arteries are clamped off. What signs would alert the nurse to this potential complication? | Output < 30ml/hr; Dark urine; Elevated BUN and Creatinine |
How often should BUN and creatinine levels be checked post surgery for AAA? | daily |
What are the normal levels for BUN, creatinine, and the ratio of BUN to creatinine? | BUN 10 to 20 mg/dl; creatinine 0.6 to 1.2 mg/dL; BUN:Creatinine = 20:1 |
What is the purpose of an NG tube for 1-2 days after surgical repair of AAA? | prevent postoperative ileus |
What assessment does the nurse perform to monitor for postoperative ileus? - At what frequency? | bowel sounds every shift |