Learn to recognize the early signs of abdominal aortic aneurysm
Consider possible aneurysm in patients presenting with abdominal, back, or hip pain.
Nurses need to be proactive in recognizing abdominal aortic aneurysms, says Judy Selfridge-Thomas, RN, MSN, CEN, FNP, a nurse practitioner in the department of emergency medicine at St. Mary Medical Center in Long Beach, CA. "They're an easy diagnosis to miss," she stresses. "If a patient comes in complaining of abdominal, back, or hip pain, aneurysm is one of the things you should be thinking about."
Here are some tips to consider when assessing patients for abdominal aortic aneurysms:
Know risk factors. Abdominal aneurysms occur primarily in the sixth or seventh decade of life, and occur in males 10 times as often as females.1 Risk factors include smoking and a sedentary lifestyle. "You need to keep a high index of suspicion in patients with these risk factors, even if there are no obvious symptoms," stresses Selfridge-Thomas. "If you don't have that suspicion, the diagnosis may very well get missed, because not all people with aneurysms come in hypovolemic."
An aortograph or CT scan is needed to make a definitive diagnosis, but good nursing assessment skills facilitate that process, says Selfridge-Thomas. "If you notice a difference in blood pressure or pulses, aneurysm is one of the things you think of at that point, but you've got to consider it first," she explains.
Realize symptoms may not be severe. If the aneurysm hasn't ruptured or started to leak, the patient may come in complaining of back, abdominal, or pelvic pain. "If the patient hasn't started to dissect at all, you may not get differences in blood pressure or pulses, which would be more telling. In that scenario, aneurysm should be part of your overall thought process. Ask yourself, could it possibly be something other than just back pain?" advises Selfridge-Thomas.
Trend blood pressures. Assess right and left upper extremity blood pressures and note any differences. "If there is no noticeable difference, then you just trend blood pressures. But you want to document that from the beginning," recommends Donna York, RN, MS, CFRN, chief flight nurse, nurse manager, Life Flight Medical Transport Program, Stanford University Hospital, UCSF-Stanford Health Care (CA).
Realize that severity of pain varies widely. "Just having an aneurysm itself does not necessarily produce severe pain," notes Selfridge-Thomas. "The patient will have pain when the tearing of the vessel wall occurs. If the patient has cardiovascular risk factors, consider that an aneurysm may be causing the problem rather than some of the more obvious things."
When one patient presented with hip pain, it was difficult to ascertain the cause. "He didn't look shocky, he hadn't fallen, and we had taken X-rays, and nothing showed up. But the medicines we gave him just couldn't get rid of this nagging pain," says Selfridge-Thomas. "We finally sent him over to CT scan, and there was an aneurysm."
Realize that the location of an aneurysm may vary. Symptoms will vary depending on the location of the aneurysm. "You can have an aneurysm anywhere on the aorta," notes York. "It can be up on the aortic arch or in the thoracic area or abdomen."
If the aneurysm is in the thoracic area, the patient may complain of hoarseness, bad cough, and neck or back pain, says York. "But if it's abdominal, you will usually have pain mid-abdomen, pulsating mass, nausea or vomiting, compression of the nerves, radicular pain," she notes. "And, if the aneurysm is right on the renal artery, on the border between abdominal and thoracic, you might start having renal failure."
Don't overlook symptoms. "You need to have the patient be as descriptive as possible about their about symptoms," says York. "We tend to feel that if it's in the gut it's not important, but the key thing is not to minimize the patient's symptoms."
Recognize signs of rupture. If the patient has low blood pressure, or signs of hypoperfusion, that may be a sign that the aneurysm has ruptured. "In that case, we probably want to give fluids with the goal of trying to keep their mean arterial pressure at least 60, and if blood is available, to transfuse blood after they have already received 2 L of fluid," says York.
It's important to give the correct amount of fluid. "Because the hypothesis is that the aneurysm has ruptured, you want to reinstate their volume," notes York. "But you don't want to make them hypertensive, because you don't want to pop the balloon if it hasn't already popped."
Don't mistake an aneurysm for an MI. Occasionally, aortic abdominal aneurysms are mistaken for MIs. "Nurses may mistake an aneurysm for an MI, and the patient may not be transferred to a high-risk cardiovascular center," says York. "The nurse needs to do a head-to-toe assessment, listen to what the patient is saying, record the vital signs, take a big step back and look at what is going on. Does the data fit the parameters of the MI or are there outliers? If there are outliers, they should be perceived as red flags."
Manage pain. Although assessment is important, the patient's pain should not be overlooked. "Management of pain is sometimes lacking, because people get distracted by what's going on, but nobody should have to suffer through this," says York. "Probably intravenous pain control is most efficacious."
Send x-rays with a transferred patient. "If you do transfer a patient with these sort of symptoms to another hospital, make sure you send films with the patients, not just reports, but the actual pictures," York advises. "That will help smooth the diagnostic process."
Reference
1. Black JM. Medical-Surgical Nursing. 5th ed. Black J, Matassarin-Jacobs E, eds. Philadelphia: WB Saunders; 1997:1425.
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