Abdominal Aortic Aneurysm (AAA) Post Surgery Care

Abdominal Aortic Aneurysm (AAA) side Surgery CargonIntroductionbreast feeding deal of the patient following study functioning is a complex task, involving holistic trouble of patient wellbeing in the light of several challenges to health and homeostatic stability. This essay sets out to discuss the care of one such patient, following surgery to fixate an ab aortic aneurysm. In assemble to address the issue and provide the senior highest possible standards of individualised care, shields need a considerable know extendge base, gleaned from training, from ongoing updating, from the gettable curtilage, and from their experience as professionals in their field. This essay leave as well as set out to explore how treat knowledge is applied to practice, always time laging the patient as the focus of care, with reference to the underlying physiology which re posthumouss to the patients train.Nursing skills are overly based on knowledge and experience, both the experience of the concord themselves and the experience of those who have taught them, who work with them and who collaborate in the provision of care. While this essay focuses on the nurses role in relation to the case and the client, it is master(prenominal) to remember that nursing care does non take place within a vacuum, and reference will be made to those with whom the nurse must interact and engage as part of this role.The care of a patient following surgical abdominal aortic aneurysm remedy follows the principles of general surgical surgical care, along with specific interventions, varaning and support that are a consequence of the condition and the record of the surgery. The holistic management of this case must also take into account the psycho-social and emotional factors which whitethorn affect the case, condition the life-threatening nature of the condition and the authority complications of the surgery.The CaseDavid Grainger is a 65 year old man, who is retired and who tries to keep himself fit by playing golf. He had a history of recurrent cark underneath his laugh at cage for some month, and had been treating himself for indigestion with limited success. His friends became worried about him and his condition when he appeared to be losing weight, and so eventually David plucked up the courage to visit his GP. He was referred to the local hospital for tests, which eventually led to a diagnosis of abominal aortic aneurysm. David was later admitted to the surgical ward for surgery to repair the aneurysm.On render to the ward David had a family transfusion running and a lesion drain (Redivac) from the abdomen most to the surgical incision site. He had an indwelling Foley catheter with an hourly urine bag, which was changed to free drainage after 12 hours of adequate urine sidetrack, and a PCA (patient controlled analgesia) device in situ. He has a mepore dressing to the abdominal ache site.David has two IVI sites, one in each hand. The air transfusion was running via the left hand, and dominion saline solution (0.9%) was running in the some other, along with the PCA, on a three-way tap. The day following surgery Davids temperature is recorded at 39.6c with an elevated pulse of 90bpm. He repeatedly complains of feeling cold. Discussion with the senior baby and the SHO indicates that David is experiencing a potential pyrexia.Abdominal Aortic Aneurysm.Abdominal Aortic Aneurysm (AAA) is a fairly habitual condition (the 14th leading sustain of death in the US (Birkmeyer and Upchurch, 2007). It is a life-threatening condition (Isselbacher et al, 2005). The greatest risk of an AAA is the risk of rupture, which has a signifi weedt mortality rate attached to it (Birkmeyer and Upchurch, 2007). It is defined as an abnormal localised arterial dilation or ballooning that is greater than one and half times the arterys normal circumference, and must involve all three layers of the vessel skirt (Irwin, 2007). Abdominal aortic aneurysms are those which are located below the diaphragmatic b hallow, and account for 75% of aortic aneurysms (Irwin, 2007). workforce are four to five times more likely to develop the condition, and risk factors include smoking, hypertension and dyslipidemia, prison cellular changes in the tunica media associated with diseases such as Mar fan syndrome, inflammation, and blunt trauma (Irwin, 2007). There is also a family history factor, with increased risk amongst primary relatives of individual with AAA (Irwin, 2007). some other risk factor is atherosceloris, although someone without this condition can develop an aneurysm (Irwin, 2007).Repair is either by open surgical repair, through a large midline incision (Irwin, 2007). The procedure is major surgery, and the aorta is cross-clamped to allow the insertion of a unreal organ transplant which is attached to proximally and distally to health aortic tissue (Irwin, 2007). Another procedure is endovascular repair utilize a p ercutaneous vascular stent (Irwin, 2007 Beese-Bjustrom, 2004). In this procedure, a woven polyester tube covered by a stent is placed inside the aneurismal section of the abdominal aorta, which keeps normal blood flow away from the aneurysm, greatly reducing the risk of dissection and rupture (Bese-Bjustrom, 2004). In this case David underwent open surgery.AssessmentAssessment of the patients condition is the frontmost stagecoach in nursing care picturening and management, forming the basis of nursing finale making (Watson-Miller, 2005). A summary of assessment activities carried out for David can be found in display board 1.Table 1. Nursing Assessment of David on Day 1 Post-Op.ActionRationaleMonitor line of products Pressure, Pulse, Pulse Oximetry RespirationsVital observations indicate changes in underlying condition. Low blood pressure with high pulse, for example, would be suggested of haemorrhage. After aneurysm repair, an elevated BP can stress the graft site and cause g raft ill (Irwin, 2007). This also increases myocardial oxygen demand, and an imbalance between oxygen supply and demand may lead to myocardial ischaemia and lead to MI (Irwin, 2007). Respiratory rate must be monitored post-anaesthetic, and observation of respirations allows the nurse to prepare for preventive measures to reduce the risk of atelectasis or DVT. Four hourly observations are usual from 24 hours postoperatively (Zeitz, 2005).Monitor TemperatureUsually carried out four hourly, to detect potential sings of pyrexia, or reaction to blood transfusion (Jones and Pegram, 2006) or medications. Another complication could be malignant hyperthermia, although this is rare and unlikely to develop this late postoperatively (Neacsu, 2006).Intravenous Monitoring and melted balanceMonitor site for patency and condition monitor fluid intake and rate record fluid balance. IVI pump checked at this time. Urinary output via catheter also recorded.PCA/ trouble oneselfPump check should usuall y be every hour if a controlled medicate is used in the PCA, and recorded on the sequester chart. Pain levels assessed (Manias, 2003).WoundDressing observed for signs of exudates injury observed for signs of healing/infection/dehiscence.Wound drainSite observed for signs of infection drain feeding bottle check for amount and type of exudates fluid balance recorded.Other monitoring specific to AAA repair.Fluid and electrolyte balance neurological status full blood count (elevated white count indicates infection) (Beese-Bjustrom, 2004)Assessment during the rootage 24 hours is usually aimed at establishing physiological equilibrium, managing pain, preventing complications and supporting the patient towards self-care (Watson-Miller, 2005). These are standard post-operative observations, but the care of the person having brookne abdominal aortic aneurysm repair may be somewhat more specific. many of these areas will be dealt with in more detail below, considering the evidence bas e and the nature of nursing knowledge applied to the job. The nursing knowledge applied in the assessment process derives from acquired knowledge (that gleaned during training, and study), and experiential knowledge, from front experiences of applying theoretical knowledge to practice. If the nurse has previously cared for patients with this condition, she will apply that experience to this case. If not, the application of clinical, theoretical and other knowledge (such as colleagues experience) to the scenario, alongside total understanding of physiological principles, should result in effective and grant care. The evidence base must also be utilised.PyrexiaHaving identified a potential problem in relation to temperature regulation, it is important to plan for ongoing monitoring, identification of the cause of increased temperature, treatment of the cause and relief of symptoms. The cause of the temperature is most likely to an infection. Nosocomial infection is a concern after surgery, oddly when the patient has an incision involving any aspect of the vascular system (Irwin, 2007). In order to prevent wound infection, David will be prescribed IV antibiotics, which will then be changed to oral antibiotics at the admit time (Irwin, 2007). Symptomatic relief of the pyrexia can be achieved by fan therapy and the administration of paracetamol, which can be presumption PR if David remains nil by mouth. However, the nurse would ensure this was prescribed and not contraindicated cod to any interactions with Davids other medications. Davids increased temperature may also be due to the development of ischaemic colitis (a complication of abdominal aortic aneurysm repair) and so white cell counts should be checked, as a raised count may be indicative of this (Beese-Bjustrom, 2004). The pyrexia may be in response to the blood transfusion (Jones and Pegram, 2006), although we would expect this to have developed earlier in the treatment.At this point, Davids pyrexi a indicated a potential problem, and may not use up paracetamol or fan therapy. Instead, prevention of the development of infection, and reassurance that his feeling of being cold may be due to raised temperature, may suffice.Blood Pressure focus and Fluid Balance.Keeping Davids blood pressure within the normal range is critical to maintain end organ perfusion, and so both hypertension and hypotension must be prevented in this case (Irwin, 007). In order to prevent hypertension and the complications described higher up, David may be given IV beta blockers, and will be monitored for any cardiovascular changes such as chest discomfort, ST-T quiver changes, or dysrhythmias (Irwin, 2007). Given his stability 24 hours post-operatively, he may be moved from ITU to a high dependency or standard surgical ward, where telemetry may then be stopped.Monitoring mean arterial pressure and maintaining a reading of at least 70 mmHg can ensure proper perfusion of major organs, and this can be su pported by careful infusion of intravenous fluids as described above (Irwin, 2007). In relation to fluid balance (and continuing organ functioning) a urine output of some 50ml/hour would indicate adequate glomerular filtration rate and nephritic perfusion (Irwin, 2007). Any deviations from these ideals would be recorded and report promptly to the appropriate members of the multi-disciplinary team (Irwin, 2007).Pain ManagementWhile Davids pain is being managed efficaciously with the Patient Controlled Analgesia (PCA) device, the use of a PCA is not a long-term means of pain management. Therefore, the planning stage of management of Davids care for the nurse looking after him should involved a collaborative plan for pain management. This may be in collaboration with the medical checkup team, the anaesthetist, and David himself. A range of medications are available for David to use once he has reached a stage of being able to manage without the PCA, but it is also important that hi s pain be properly managed during the postoperative stage, because good pain management will befriend David to mobilise properly and reduce the other postoperative risks, such as those of DVT, PE (Irwin, 2007) and pressure sore development.Another area to address is the prevention of atelectasis. Regardless of the type of surgical procedure, as many as 90% of patients who have a general anaesthetic develop some degree of atlectasis in the postoperative period ( Irwin, 2007 Pruitt, 2006). Pneumonia is another risk (Irwin, 2007). As well as the risks from having an anaesthetic anyway, David is at increased risk because he is more likely to demonstrate postoperative hypoventilation, because pain from abdominal surgery can prevent him from productive ventilation system and coughing which helps prevent atelectasis (Pruitt, 2006). David can be taught to splint the surgical site with a take a breather or roll of blanket, and then carry out these breathing exercises incentive spiromet ry, coughing and deep breathing to help keep his lungs clear (Irwin, 2007). Adopting a good upright position also helps to increase lung content and encourage deeper breaths (Pruitt, 2006), and so good pain management is also important in supporting David to do this (Irwin, 2007). Adequate pain control is also essential to graft patency, because uncontrolled pain causes the release or epinephrine, noreinephrine, and other hormones that active the fight or flight response (Bryant et al, 2002). The consequent vasoconstriction can decrease blood flow through the graft and can increase risk of thrombus formation (Bryant et al, 2002).Alongside a drug therapy plan for pain management, it might also be appropriate to consider nondrug pain management as well (Tracy et al, 2006). Opioids used to manage postoperative pain can cause respiratory depression (Irwin, 2007). virtually of the other advantages of nondrug pain management techniques is that they are readily available, inexpensive, a nd not associated with side effects, but the biggest advantage in this case is that they promote self-care and enhance personal control for ones own health (Tracy et al, 2006). For Davids case, promoting self-care may have a outcome of beneficial effects on him holistically, given that he has belatedly experienced the diagnosis and treatment of a life-threatening condition (Manias, 2003). There is some evidence to suggest that tailored education and support in such therapies can benefit patient outcomes (Tracy et al, 2006), but this would require that the nurse is knowledgeable about the techniques, and that all members of the multidisciplinary team are equally invested and have been prompted to include nondrug pain management in the care plan (Tracy et al, 2006).Prevention of Problems Associated with Aneurysm Repair.There are a number of potential complications of surgical abdominal aortic aneurysm repair, which are in addition to the usual postoperative risks. These include graf t rupture, haemorrhage, and graft occlusion (Irwin, 2007). This is another reason for close monitoring of Davids haemodynamic status, because a drop in blood pressure or urine output, associated with increased heart rate and maybe a change in mental status may indicated shock consequent to blood privation (Irwin, 2007). It is also important to care to the full and frequently assess the abdomen, for pain, distension or increasing girth (Irwin, 2007). bribery occlusion may manifest as coronary ischaemia, MI, cerebral ischaemia or stroke, ischaemic colitis or even spinal cord ischaemia resulting in paralysis (Irwin, 2007). Similarly, occlusion of an abdominal graft can also compromise renal blood flow, causing acute tubular necrosis and renal failure, or compromise peripheral circulation, which might lead to limb loss (Irwin, 2007). Therefore it might be prudent to calculcate ankle/brachial index regularly to evaluate lower extremity perfusion (Irwin, 2007).Nursing IssuesIn an empir ical study of nursing in patients undergoing procedures for abdominal aortic aneurysm repair, Kozon et al (1998) found that patients who undergo the traditional open procedure require more intensive nursing care of lengthier duration, to move them along the illness-wellness spectrum towards self-care and independence. Kozon et al (1998) demonstrate a tailor made model based on the nursing process, which allows nurses to bid the postoperative course for individual patients. They also consider the psychological aspects of care, discussing the state of fear of patients, which is either outwardly visible to the nursing staff or is expressed by the patients themselves (Kozon et al, 1998). This is important in ensuring the holistic management of Davids care. However, Kozon et al (1998) also recommend further nursing research on this area to fully optimise nursing and enable the recognition of the nursing needs of the individual patient. This says much about the nature of nursing knowledg e and the evidence base on this topic, which remains very much focused on the physical and medical aspects of care. Kozon et al (1998) developed a protocol to apply to such cases, but in terms of evidence, larger scale studies are needed to validate this. The high risks of both the procedure and the repair are highlighted in the literature (Bryant et al, 2002), and so a thorough understanding of these is vital in order to back nursing practice and ensure rapid and appropriate prioritisation of care needs, recognition of deviations from the norm and prompt, appropriate referral and treatment.Another issue which the evidence base throws up is the documentation and monitoring of pain management. In a descriptive, retrospective audit of nursing records, Idvall and Ehrenberg (2002) found that there are many shortcomings in content and extensiveness of nurses monitoring and recording of patients pain. This is of particular importance in relation to postoperative care of those patients h aving undergoing surgical repair of abdominal aortic aneurysm, given that pain can indicate a number of complications of the procedure.ConclusionAs can be seen, the care of the patient having an AAA repair is a complex undertaking, requiring a thorough knowledge base on the part of the nurse, and the skills necessary to recognise complications, deviations from clinical parameters, and effects of treatments in order to promptly and appropriately treat and refer the patient (Warbinek and Wyness, 1994). In Davids case, he has presented with a potential complication of his surgery, but the complex nature of his condition could mean that his potential pyrexia is due to a number of causes. Understanding the underlying physiology of his condition is vital in ensuring all his care needs are met and that he is kept in the optimal state of health to promote rapid recovery. This involves an holistic approach, with anxiety paid to his pain management and psychological state as well as his cons iderable medical and physical needs. The evidence base for care is suggestive of the existence of some useful nursing evidence on which to base care, but also suggests the need for more concrete and comprehensive research to underpin practice. Nursing assessment and intervention can be crucial to the survival of patients with this condition (Myer, 1995). Thus nursing knowledge must draw upon their own and others knowledge and experience, and the knowledge and understanding of the patient, and their describe symptoms and feelings, in order to provide the highest standard of care and promote Davids optimal wellbeing and replica to health.ReferencesBeese-Bjustrom, S. (2004) Aortic Aneurysms and dissections. Nursing 34 (2) 36-42.Birkmeyer, J.D. and Upchurch, G.R. (2007) Evidence Based Screening and management of Abdominal Aortic Aneurysm. history of Internal Medicine 146 (10) 749-751.Bryant, C., Ray, C. and Wren, T.L. (2002) Abdominal Aortic Aneurysm Repair a Look at the first 24 Hou rs. Journal of PeriAnaesthesia Nursing 17 (3) 164-169.Idvall, E. and Ehrenberg, A. (2002) Nursing documentation of postoperative pain management. Journal of clinical Nursing.11 734-742.Irwin, G.H. (2007) How to protect a patient with aortic aneurysm. Nursing 37 (2) 36-43.Isselbacher, E.M. (2005) Thoracic and Abdominal Aortic Aneurysms. Circulation111 816-828.Jones, A. and Pegram, A. (2006) Management of pyrexia during blood transfusion. British Journal of Nursing. 15(5) 257.Kozon, V., Fortner, N. and Holzenbein, T. (1998) An empirical study of nursing in patients undergoing two contrary procedures for abdominal aortic aneurysm repair. Journal of Vascular Nursing. 16 (1) (1-5).Manias, E. (2003) Pain and anxiety management in the postoperative gastro-surgical setting. Journal of Advanced Nursing 41 (6) 585-594.Myer, S.A. (1995) Case studies what a difference a nurse makes. Advanced Practice in Acute and Critical Care. 6(4) 576-87.Neacsu, A. (2006) Malignant hyperthermia. Nursing Stan dard 20 (28) 51-57.Pruitt, B. (2006) second your patient combat postoperative atelectasis. Nursing 2006 36 (5) 31-34.Tracy, S., Dufault, M., Kogut, S. et al (2006) Translating Best Practices in Nondrug Postoperative Pain Management. Nursing Research 55 (2S) S57-S67).Warbinek, E. and Wyness, M.A. (1994) Caring for patients with complications after elective abdominal aortic aneurysm surgery a case study. Journal of Vascular Nursing. 12(3) 73-9.Watson-Miller, S. (2005) Assessing the postoperative patient Philosophy, knowledge and theory. International Journal of Nursing Practice. 11 46-51.Zeitz, K. (2005) Nursing observations during the first 24 hours after a surgical procedure what do we do? Journal of Clinical Nursing 14 334-343.