Abdominal Aortic Aneurysm An aneurysm is a localized sac or dilation formed at a weak point in the wall of the aorta.

It may be classified by its shape or form. The most common forms of aneurysms are saccular or fusiform. A saccular aneurysm projects from one side of the vessel only. If an entire arterial segment becomes dilated, a fusiform aneurysm develops. Very small aneurysms due to localized infection are called mycotic aneurysms. Historically, the cause of abdominal aortic aneurysm, the most common type of degenerative aneurysm, has been attributed to atherosclerotic changes in the aorta.. Aneurysms are serious because they can rupture leading to hemorrhage and death. Causes The most common cause of abdominal aortic aneurysm is athero-sclerosis. The condition, which is more common among Caucasians, affects men four times more often than women and is most prevalent in elderly patients (Rutherford, 1999). Most of these aneurysms occur below the renal arteries (infrarenal aneurysms). Untreated, the eventual outcome may be rupture and death. All aneurysms involve a damaged media layer of the vessel. This may be caused by congenital weakness, trauma, or disease. After an aneurysm develops, it tends to enlarge. Risk factors include genetic predisposition, smoking (or other tobacco use), and hyper-tension; more than one half of patients with aneurysms have hypertension. Signs and Symptoms About two fifths of patients with abdominal aortic aneurysms have symptoms; the remainder do not. Some patients complain that they can feel their heart beating in their abdomen when lying down, or they may say they feel an abdominal mass or abdomi-nal throbbing. If the abdominal aortic aneurysm is associated with thrombus, a major vessel may be occluded or smaller distal occlusions may result from emboli. A small cholesterol, platelet, or fibrin emboli may lodge in the interosseous or digital arteries, causing blue toes. Diagnostic Tests The most important diagnostic indication of an abdominal aortic aneurysm is a pulsatile mass in the middle and upper abdomen. About 80% of these aneurysms can be palpated. A systolic bruit may be heard over the mass. Duplex ultrasonography or CT is used to determine the size, length, and location of the aneurysm. When the aneurysm is small, ultrasonography is conducted at 6-month intervals until the aneurysm reaches a size at which surgery to prevent rupture is of more benefit than the possible complications of a surgical procedure. Some aneurysms remain stable over many years of observation. Medical Management An expanding or enlarging abdominal aneurysm is likely to rup-ture. Surgery is the treatment of choice for abdominal aneurysms wider than 5 cm (2 inches) wide or those that are enlarging.

Surgical Management

Open repair is indicated in young patients as an elective procedure, or in growing or large, symptomatic or ruptured aneurysms. It was the main surgical intervention used from the 1950s until other procedures developed. Endovascular grafting involves the transluminal placement and attachment of sutureless aortic graft prosthesis across an aneurysm. This procedure can be performed under local or regional anesthesia. Endovascular grafting of abdominal aortic aneurysms may be performed if the patients abdominal aorta and iliac arteries are not extremely tortuous and if the aneurysm does not begin at the level of the renal arteries. Clinical trials are evaluating endograft treatment of abdominal aortic aneurysms at or above the level of the renal arteries and the thoracic aorta. Potential complications include bleeding, hematoma, or wound infection at the femoral insertion site; distal ischemia or embolization; dissection or perforation of the aorta; graft thrombosis; graft infection; break of the attachment system; graft migration; proximal or distal graft leaks; delayed rupture; and bowel ischemia.

Nursing Management Teach the patient about the disease process, breathing and leg exercises, the surgical procedure, and postoperative routines. Support the patient by encouraging him or her to share fears, questions, and concerns. Keep the incision clean and dry. Inspect the dressing every hour to check for bleeding. Use sterile techniques for all dressing changes. To ensure adequate respiratory function and to prevent complications, assist the patient with coughing and deep breathing after extubation Splint the incision with pillows, provide adequate pain relief prior to coughing sessions, and position the patient with the head of the bed elevated to facilitate coughing. Turn the patient side to side every 2 hours to promote good ventilation and to limit skin breakdown. Vigilant nursing care to prevent and detect postoperative problems, including hemorrhage and infection. Goals are to prevent and monitor for complications, promote comfort, and facilitate his return to normal daily activities after discharge. Close monitoring of BP to ensure that there is end organ perfusion Careful infusion of I.V. fluids such as lactated Ringer's or 0.9% sodium chloride solution or blood products helps stabilize BP. A urine output of 50 mL/hour indicates an adequate glomerular filtration rate and renal perfusion. Meticulously document intake and output and promptly report any discrepancies.

Urosepsis Sepsis is a life-threatening bacterial infection of the blood; urosepsis is sepsis that complicates a urinary tract or prostate infection. Urosepsis requires treatment with antibiotics and may require supportive therapies such as intravenous fluids and oxygen. If undiagnosed or untreated, urosepsis can progress to septic shock, a serious and life-threatening condition complicated by dropping blood pressure, rapid heart and breathing rates, decreasing urine output, and alterations in mental status. The urinary tract consists of the kidneys, ureters, bladder and urethra. The kidneys filter the blood, creating urine, which travels through the ureters to the bladder, where it is stored until it exits the body through the urethra. In the male, the prostate wraps around the urethra as it travels from the bladder to the penis. Most of the time, bacteria that cause urosepsis enter the body through the urethra and make their way to the prostate or kidney before entering the bloodstream. Causes Urosepsis is caused by a bacterial infection of the urinary tract or prostate that spreads into the bloodstream. Even if a person is in general good health, many of the bacteria that cause urosepsis can normally occur in their intestines. Signs and Symptoms Abdominal, pelvic or back pain or cramping Bloody or pink-colored urine (hematuria) Cloudy urine Difficult or painful urination, or burning with urination (dysuria) Fever and chills Foul-smelling urine Frequent urination General ill feeling Pain during sexual intercourse Urgent need to urinate

(Serious signs and symptoms) Change in level of consciousness or alertness, such as passing out or unresponsiveness High fever (higher than 101 degrees Fahrenheit) Low temperature (hypothermia; temperature 96.8 degrees Fahrenheit or lower) Not producing any urine Profuse sweating and unusual anxiety Rapid heart rate (tachycardia) Respiratory or breathing problems, such as shortness of breath, difficulty breathing, labored breathing Severe abdominal, pelvic, or back pain Severe nausea and vomiting Weak pulse Risk Factors Women Elderly or people who have weakened immune systems Diabetics Female incontinence Enlarged prostate, kidney or bladder stones, tumors or urethral scarring Instrumentation of the urinary tract during surgeries, procedures, or catheterization

Diagnosis Diagnosis of urosepsis is based on laboratory studies of the urine and blood cultures to look for bacteria. Obtaining an accurate history from the patient or caregiver is also an important part of making the diagnosis. The early symptoms may be similar to other diseases, making the identification of urosepsis somewhat difficult. Medical Management Prompt intervention is necessary to treat urosepsis adequately. Patients are generally admitted to an intensive care unit where antibacterial medication is typically administered, as well as intravenous fluids to manage low blood pressure and organ perfusion-the adequate passage of fluid through an organ. Mechanical ventilation or kidney dialysis may be necessary if respiratory distress or decreased kidney function occurs. Nursing Management Continuous monitoring by a trained nursing staff

Clear documentation and assessment of subtle changes in the patient's clinical state. Patients with severe sepsis should have observations recorded hourly. Record body temperature, pulse, blood pressure, urine output, CVP, respiratory rate and SpO2 (if available). Accurate fluid balance is essential - insensible losses may be very significant in hot climates