Question

A client with an abdominal aortic aneurysm complains of sudden lower back pain. What is the nurse's initial action? A. Place the client in the prone position B. Measure the client's abdominal girth C. Assess the peripheral pulses D. Administer morphine sulfate \(6 \mathrm{mg}\)

Short answer

Answer: The best initial action for a nurse to take in this situation is to assess the peripheral pulses. This assessment provides crucial information about perfusion and circulation, which can help detect any complications related to the abdominal aortic aneurysm's rupture or impending rupture.

Step-by-step solution

Understand AAA and its complications

An abdominal aortic aneurysm is a weakening and bulging in the wall of the abdominal aorta, which is the largest blood vessel in the body. A sudden lower back pain in a client with AAA may signal a rupture or imminent rupture, which is a life-threatening medical emergency. We need to prioritize the actions that will help identify a rupture and ensure the client's safety.

Evaluate Option A - Place the client in the prone position

Placing the client in the prone position may potentially increase the pain or worsen the condition. We should always assess the client before making any positional adjustments. This option is not the best initial action.

Evaluate Option B - Measure the client's abdominal girth

Measuring the client's abdominal girth could provide some information about the potential growth of the aneurysm. However, this measurement will not provide immediate information about a rupture, which is the primary concern. This option can be considered, but for now, let's evaluate the other options.

Evaluate Option C - Assess the peripheral pulses

Assessing the peripheral pulses can provide valuable information about perfusion and circulation, which can be indicative of a rupture or impending complication. This action is important, as it can help identify any abnormalities related to the aneurysm. This option is a strong contender for the initial action.

Evaluate Option D - Administer morphine sulfate \(6 \mathrm{mg}\)

Although morphine sulfate may relieve the client's pain, administering medication without first assessing the client or understanding the cause of the pain is not an appropriate initial step. We should assess and evaluate the situation before administering any medications. This option is not the best initial action.

Select the best initial action

Based on the evaluations of the given options, the nurse's initial action should be to assess the peripheral pulses (Option C). This assessment will provide crucial information about perfusion and circulation, which can help detect any complications related to the abdominal aortic aneurysm's rupture or impending rupture. Understanding these potential issues is crucial for the client's safety and well-being.

Key concepts

AAA Emergency Management

An abdominal aortic aneurysm (AAA) is a serious condition that can have life-threatening consequences if not managed promptly and effectively. During an AAA emergency, the nurse's response is crucial for the patient's survival. Management begins with promptly recognizing the signs and symptoms of a rupture, which include sudden and severe lower back pain, shock, hypotension, and a pulsatile abdominal mass.

Emergency management prioritizes ensuring cardiovascular stability and rapid transfer to surgical intervention. Nurses must act swiftly to assess the situation, beginning with the ABCs (Airway, Breathing, and Circulation). While surgical repair is the definitive treatment, the nursing team's immediate goal is to stabilize the patient's condition and prevent further complications. This entails monitoring vital signs, administering IV fluids, and preparing the patient for surgery or further diagnostic procedures like an urgent CT scan.

Due to the urgency, it's important not to waste time on interventions that won't provide rapid assessment or stabilization, such as placing the patient in a particular position (e.g., prone) without a clear indication. The initial focus should aim at identifying life-threatening complications and facilitating the necessary interventions to preserve life.

Assessing Peripheral Pulses

Assessing peripheral pulses is an essential component of the cardiovascular assessment, particularly in the context of an abdominal aortic aneurysm. It helps to evaluate the adequacy of blood flow to the limbs, which can be compromised if the aneurysm affects circulation.

In the case of suspected AAA rupture, a decrease or absence of peripheral pulses can indicate that blood flow has been significantly impeded. This can be due to internal bleeding or dissection causing a decrease in cardiac output. It is critical to compare the pulses bilaterally, as differences between the extremities may reveal important information about the location and extent of the vascular compromise.

For accurate assessment, palpate major pulse points such as the radial, brachial, femoral, popliteal, posterior tibial, and dorsalis pedis pulses. Note not just the presence or absence of these pulses, but also their quality; are they weak, thready, or bounding? Changes in the quality and symmetry of pulses can be an early red flag that requires immediate attention and possible escalation of care.

Nursing Assessment for AAA

A comprehensive nursing assessment for AAA is crucial in identifying risks, preventing rupture, and managing complications. A complete assessment should include a thorough patient history and physical examination. The nurse should be alert for symptoms suggesting an imminent rupture such as sudden and severe back or abdominal pain, a rapid drop in blood pressure, or signs of internal bleeding.

Physical assessment focuses on the abdominal examination, feeling for pulsatile masses and listening for bruits over the aorta. While a significant sign, abdominal girth measurements are less immediate and are typically taken periodically to identify the aneurysm's growth rate over time, rather than during an emergency situation.

Additionally, a nurse will monitor for potential complications such as renal failure or bowel ischemia by assessing urine output, renal function tests, and bowel sounds. The nurse's role includes educating patients with known AAAs about recognizing symptoms of a potential rupture and when to seek immediate medical attention. This combined approach of vigilant monitoring and patient education underlines the importance of a comprehensive nursing assessment for AAA.