Askep Aneurisma (Kelompok) Fix

ASUHAN KEPERAWATAN TN.
H DENGAN ANEURISMA AORTA
DI RUANG WISNUMURTI RSUP DR. SARDJITO
Disusun untuk Memenuhi Tugas Praktik Klinik
Keperawatan Medikal Bedah
Disusun Oleh :
Rizka Amelia Afriliani (P07120520015)

Galuh Ayu Nur Widati (P07120520016)
PROGRAM STUDI PENDIDIKAN PROFESI NERS

POLITEKNIK KESEHATAN KEMENTRIAN KESEHATAN YOGYAKARTA
JURUSAN KEPERAWATAN
2021
- Nyeri yang terasa
dalam, biasanya terjadi
di tengah perut, dan
sering menjalar ke
belakang, konstan dan
dapat dikurangi dengan
mengubah posisi
- Pulsasi menonjol yang
dirasakan dengan
meraba kedua sisi aorta Tanda dan gejala Aneurisma adalah
di garis tengah perut kantong lokal/dilatasi
- Nyeri tekan pada Pengertian yang terbentuk di titik
abdomen lemah pada dinding
- Suara abnormal dari arteri.
turbulensi aliran darah
dalam aneurisma saat
auskultasi - Riwayat keluarga
- Distensi abdomen dengan aneurisma
apabila terjadi ruptur Aorta
- Riwayat merokok
- Hipertensi
- Fusiform aortic - Hiperkolesterolemia
Faktor risiko
aneurysm : bentuknya - Aterosklerosis
lebih baik, dilatasinya - Jenis Kelamin
simetris pada sekeliling - Overweight
dindig aorta, dan - Etnis (kaukasia/
bentuknya lebih sering Aneurisma Aorta amerika)
ditemukan. - Umur
- Saccular aortic
aneurysm : berbentuk
seperti kantong yang Aneurisma terjadi karena pembuluh
menonjol keluar dan darah kekurangan elastin, kolagen,
berhubungan dengan dan matriks ekstraseluler yang
Menurut morfologi menyebabkan melemahnya dinding
dinding aorta melalui
leher yang sempit. aorta. Kekurangan komponen
- Pseudoaneurysm or tersebut bisa disebabkan oleh faktor
false aortic aneurysm : inflamasi (aterosklerosis). Sel radang
merupakan akumulasi pada dinding pembuluh darah yang
dara ekstravaskuler mengalami aterosklerosis
disertai disrupsi ketiga mengeluarkan matriks
lapisan pembuluh metalloproteinase. Matriks
darah. Dindingnya metalloproteinase akan
Patofisiologi
merupakan trombus menghancurkan elastin dan kolagen,
dan jaringan yang sehingga persediaannya menjadi
Klasifikasi
berdekatan. berkurang. Selain matriks
metalloproteinase, faktor lain yang
berperan terjadinya aneurisma adalah
- Abdominal aortic plasminogen activor, serin elastase,
aneurysm (AAA) : dan katepsin. Suplai darah ke
lokasinya pada aorta pembuluh darah melalui vasa
abdominalis vasorum diduga dapat terganggu
- Thoracic aortic pada usia lanjut, memperlemah
aneurysm (AAT) : tunika media dan menjadi faktor
lokasinya pada aorta predisposisi terbentuknya aneurisma.
toraks Menurut tempatnya
- Thoracoabdominalis
aortic aneurysm
(AATA) : lokasinya pada
aorta desendens yang
secara bersamaan
melibatkan aorta
abdominalis.
WOC Aneurisma
Arteri media melemah
Membuat peregangan pada arteri intima &

advertisia
Tekanan pada dinding arteri meningkat

Nyeri
Aneurisma membesar Risiko Perdarahan
Terjadi ruptur
Terjadi perdarahan Hipovolemia
Shock Hipovolemi
RENCANA ASUHAN KEPERAWATAN
No Diagnosa Keperawatan Tujuan Keperawatan Intervensi Keperawatan

1 Nyeri akut b.d agen Setelah dilakukan asuhan keperawatan Manajemen nyeri:
pencedera fisik selama 3x24 jam, nyeri berkurang dengan
(Aneurisma aorta) kriteria hasil: Observasi:
- Keluhan nyeri menurun - Identifikasi karakteristik, durasi, frekuensi, kualitas dan
(D.0077. SDKI, hal 172) - Ekspresi menahan nyeri menurun intensitas nyeri
- Gelisah menurun - Indentifikasi skala nyeri
- Frekuensi nadi membaik - Identifikasi respon non verbal
- Pola nafas membaik - Identifikasi faktor yang memperberat/ memperingan nyeri
- Tekanan nafas membaik - Monitor keberhasilan terapi komplementer yang telah
diberikan
- Monitor efek samping penggunaan analgetik
Terapeutik:
- Berikan teknik non-farmakologis untuk mengurangi rasa
nyeri (nafas dalam, terapi musik, distraksi, guided imagiery)
- Kontrol lingkungan yang memperberat rasa nyeri
- Fasilitasi istirahat dan tidur
Edukasi :
- Jelaskan penyebab, periode dan pemicu nyeri
- Jelaskan strategi meredakan nyeri
- Ajarkan teknik non farmakologi untuk meredakan nyeri
Kolaborasi:
- Kolaborasi pemberian analgetik
2 Risiko Perdarahan b.d Setelah dilakukan asuhan keperawatan Pencegahan Perdarahan:
kondisi aneurisma selama 3x24 jam, tingkat perdarahan
menurun dengan kriteria hasil: Observasi:
(D.0012. SDKI, hal 42) - Kelembapan membran mukosa - Monitor tanda dan gejala perdarahan
meningkat - Monitor nilai hematokrit/hemoglobin
- Kelembapan kulit meningkat - Monitor TTV
- Hematemesis menurun - Monitor koagulasi
- Distensi abdomen menurun Terapeutik:
- Hemoglobin membaik - Pertahankan bedrest
- Tekanan darah membaik - Batasi tindakan invasive, jika perlu
- Hematokrit membaik -
Edukasi:
- Jelaskan tanda dan gejala perdarahan
- Meningkatkan makanan yang mengandung vitamin K
- Menghindari aspirin atau antikoagulan
- Anjurkan segera melapor jika terjadi perdarahan
Kolaborasi:
- Kolaborasi pemberian produk darah, jika perlu
3 Hipovolemi b.d Setelah dilakukan asuhan keperawatan Manajemen Syok Hipovolemia:

kehilangan cairan aktif selama 3x24 jam, status cairan membaik
dengan kriteria hasil: Observasi:
(D.0023. SDKI, hal 64) - Frekuensi nadi membaik - Monitor status kardiopulmonal
- Tekanan darah membaik - Monitor status oksigenasi
- Tekanan nadi membaik - Monitor status cairan
- Membran mukosa membaik - Monitor tingkat kesadaran
Terapeutik:
- Berikan posisi trendelenberg
- Pasang jalur IV
- Pertahankan jalan nafas paten
- Berikan oksigen untuk mempertahankan
- Pasang katotor urin untuk menilai luaran urin
- Ambil sampel AGD
Kolaborasi:
- Kolaborasi pemberian infus kristaloid 1-2 L pada dewasa
- Kolaborasi pemberian transfusi darah
POLITEKNIK KESEHATAN KEMENKES YOGYAKARTA PROGRAM STUDI
PROFESI NERS
JURUSAN KEPERAWATAN
Hari/Tanggal : Selasa 02 Februari 2021

Jam : 09.00 WIB
Tempat : Wisnumurti PJT RSUP dr Sardjito
Oleh : Rizka Amelia Afriliani
Galuh Ayu Nur Widati
Sumber data : Pasien, Rekam medik
Metode :Observasi, wawancara, pemeriksaan fisik, dan dokumentasi
A. PENGKAJIAN
1. Identitas
a. Pasien
1) Nama Pasien : Tn H
2) Tempat Tgl Lahir : 03-04-1974
3) Umur : 48 tahun
4) Jenis Kelamin : Laki laki
5) Agama : Islam
6) Pendidikan : SLTA
7) Pekerjaan : Wiraswasta
8) Suku / Bangsa : Jawa
9) Alamat : Mantrijeron, Yogyakarta
10) Diagnosa Medis : Anuerisma Aorta Abdominalis
11) No. RM : 01958XXX
12) Tanggal Masuk RS : 01/02/2021
b. Penanggung Jawab / Keluarga

1) Nama : Tn. K
2) Umur : 40 tahun
3) Pendidikan : SLTA
4) Pekerjaan : Wiraswasta
5) Alamat : Gunungkidul
6) Hubungan dengan pasien : Adik
7) Status perkawinan : Kawin
POLKESYO TAHUN AKADEMIK 2020-2021

2. Riwayat Kesehatan
a. Kesehata Pasien
1) Keluhan Utama saat Pengkajian
Klien mengeluh nyeri dibagian perut bawah kiri, dan badan terasa
lemas , mual dan muntah.
2) Riwayat Kesehatan Sekarang
a) Alasan masuk RS :
Pada bulan desember 2020 pasien mengeluh nyeri perut
bawah kiri dan BAK sakit, BAB sulit , kemudian dilakukan
pemeriksaan di poli di Boyolali, krmudian dicurigai adanya
gangguan di saluran kencing lalu di rujuk kembali ke dr sp
Urologi di Boyolali namun seteah di USG tidak ada tanda
tanda gangguan saluran kencing , nyeri pasien dirasa tambah
berat akhirnya di rujuk kembali ke poli dr Sp Bedah dengan
curiga adanya usus buntu, setelah di USG didapatkan hasil
adanya gangguan di Aorta kemudia di rujuk ke RSUP
Sardjito untuk dilakukan tindakan lebih lanjut dengan keluhan
nyeri perut kiri bawah, nyeri pinggang dan mual.
b) Riwayat Kesehatan Pasien :
Pasien mengeluh nyeri perut kiri bawah, nyeri pinggang,mual
dan muntah.
3) Riwayat Kesehatan Dahulu
Pasien mengatakan sebelum masuk di bangsal wisnumurti pasien
masuk dari IGD RSUP Sardjito lalu di rawat di ruang ICCU.
Pasien tidak memiliki riwayat hipertensi , pasien merupakan
perokok aktif dan memiliki riwayat diabetes sudah 1 tahun.
4) Riwayat Kesehatan Dahulu

a) Penyakit yang pernah diderita
Pasien mengatakan tidak memiliki riwayat penyakit hipertensi
Pasien mengatakan memiliki riwayat diabetes melitus.
b) Riwayat Hospitalisasi
Pasien sebelum masuk di bangsal wisnumurti sudah pernah
masuk di ICCU RSUP Sardjito.
c) Riwaya Injury
Pasien sudah pernah memiliki riwayat jatuh sbelumnya.
d) Riwaya Imunisasi
Pasien mengatakan tidak mengetahui secara pasti imunisasi
yang dilakukan lengkap atau tidak.
b. Riwayat Kesehatan Keluarga
1) Genogram
Ny.W Tn.B Ny.P Tn.T
Ny. S Ny. T Tn.W Tn.H Tn.K
NnM Nn.Y
Keterangan :
Keterangan :
: Laki-laki : Tinggal Serumah : Pasien
: Perempuan : Meninggal
: Garis Menikah : Garis Keturunan

2) Riwayat Kesehatan Keluarga
Pasien mengatakan tidak ada anggota keluarga yang menderita penyakit sama
dengan pasien.

3. Kesehatan Fungsional (11 Pola Gordon)
1) Nutrisi- metabolik
a. Sebelum sakit
Pasien makan 3x sehari dengan porsi penuh tanpa adanya pantangan
makanan lainnya. Pasien biasa makan dirumah dengan cara makan
dikunyah lama. Pasien minum air putih 8 gelas sehari (1600 ml/ hari).
b. Selama sakit
Pasien saat makan dan nafsu makan tidak berkurang. Pasien mendapat diit
bubur halus selama sakit dengan porsi yang disedikan dari RS, namun
tidak dimakan karena pasien merasa mual , pasien hanya menghabiskan ½
potong buah pisang. Pasien lebih banyak minum sehingga habis 1 botol air
putih sehari. Pada tangan kiri pasien terpasang selang infus.
2) Eliminasi
a. Sebelum sakit
Klien bisa BAB, dengan frekuensi 1 hari sekali.
Klien BAK kurang lebih 3-4 kali per hari dan bisa mandiri.
b. Selama sakit : Selama di rumah sakit klien baru 2x BAB. Pasien memakai
selang kateter untuk membantu eliminasi urine dengan frekuensi urin
sebanyak 100 ml . Pasien mengatakan urinnya kuning, bau khas urine,
serta tidak bercampur darah.
3) Aktivitas /latihan
a. Keadaan aktivitas sehari – hari

a. Sebelum sakit
Pasien biasanya melakukan aktivitas dasar seperti makan, minum,
toileting, berpakaian dengan mandiri tidak menggunakan alat bantu. Pasien
tidur selama ± 8 jam sehari. Pasien biasa tidur dalam keadaan gelap dan
tidak pernah minum obat tidur.
b. Selama sakit
Kemampuan untuk aktivitas sehari-hari tidak dapat dilakukan sendiri
dengan bantuan orang lain.

b. Keadaan pernafasan
a. Sebelum sakit
Pasien tidak memakai obat-obat / O2 untuk melancarkan
pernapasan.Selama sakit
b. Setelah sakit
Pasien tidak menggunakan alat bantu pernapasan yaitu O2 sebanyak 3
lpm.
c. Keadaan Kardiovaskuler
a. Sebelum sakit
Pasien mudah lelah saat melakukan aktivitas berlebihan, pasien memiliki
riwayat gangguan kardiovaskular.
b. Setelah sakit
Pasien merasa cepat lelah karena ketika beraktifitas mobilisasi
(1) Skala ketergantungan
KETERANGAN
AKTIFITAS 0 1 2 3 4
Bathing √
Toileting √
Eating √
Moving √
Ambulasi √
Walking √
Keterangan :
0 = Mandiri/ tidak tergantung apapun
1 = dibantu dengan alat
2 = dibantu orang lain
3 = Dibantu alat dan orang lain
4 = Tergantung total

4) Istirahat – tidur
a. Sebelum sakit
Klien tidur dengan nyaman kurang lebih 7-8 jam perhari.
b. Selama sakit
klien merasa kesulitan tidur dan frekuensi tidur berkurang. Klien sering merasa
pusing dan tidak nyaman untuk tidur. Klien tidur dengan posisi miring ke kanan.
5) Persepsi, pemeliharaan dan pengetahuan terhadap kesehatan
a. Sebelum sakit : klien mengatakan bahwa sakit merupakan kondisi yang tidak
mengenakan sehingga klien selalu berusaha untuk menjaga kesehatannya.
b. Selama sakit : ketika merasa sakit, klien langsung berobat dan memeriksakan diri
ke rumah sakit.
6) Pola Toleransi terhadap stress-koping
Klien mempunyai koping yang maladaptif , dalam menghadapi sakitnya klien merasa
dirinya terpuruk sehingga sering tampak bingung dan cenderung disorientasi. Namun
tetap mengikuti anjuran dokter maupun perawat. Klien juga mematuhi program
pengobatan penyakitnya.
7) Pola hubungan peran
Klien menjalani hubungan yang baik dengan keluarganya dan juga menjalankan
perannya sebagaimana mestinya. Klien juga selalu mendapat dukungannya dari
keluarga dan mendoakan agar cepat sembuh.
8) Kognitif dan persepsi
Status mental klien sadar, bicara lancar tidak ada gangguan, penglihatan normal, tidak
terdapat gangguan pada pendengaran, pasien tidak menggunakan kaca mata atau lensa
kotak.
9) Persepsi diri-Konsep diri
a. Gambaran Diri
Pasien merasa dirinya mengalami sakit sehingga membutuhkan pertolongan
medis.
b. Harga Diri
Pasien merasa minder karena merasa sakitnya sudah terlalu lama dengan
keadaan yang dialami sekarang dan tampak selalu kooperatif terhadap perawat
yang merawatnya
c. Peran Diri

Selama ini pasien berperan sebagai suami dan ayah dari anak nya , pasien juga
berperan membantu perekonomian keluarganya.
d. Ideal Diri
Pasien mengatakan ingin segera sembuh sehingga bisa melakukan aktifitas
seperti biasa dan kembali berkumpul dengan keluarga.
e. Identitas Diri
Pasien mengenali dirinya berharap bisa menjadi seorang ayah yang baik untuk
anaknya dan tidak membuat repot.
10) Reproduksi dan kesehatan.
Klien sudah menikah. Klien berjenis kelamin laki laki dan tidak mempunyai
penyakit kelamin.
11) Keyakinan dan Nilai
a. Sebelum sakit
Pasien mengatakan terkadang melaksanakan ibadah terkadang tidak
b. Setelah sakit
Pasien mengatakan merasa ibadahnya kurang sebelumnya.

4. Pemeriksaan Fisik
a. Keadaan Umum
1) Kesadaran : Composmentis
2) Status Gizi :TB = 163 cm
BB = 60 Kg
IMT = 23 kg/m2 = (Gizi baik)
3) Tanda Vital : TD = 124/77 mmHg. Nadi = 97x/menit
Suhu = 36,8°C RR =22 x/menit

Saturasi O2 =97
%
4) Pengkajian Nyeri PQRST =

Provoking incident = mobilisasi
Quality = seperti tertusuk - tusuk
Region = perut bawah sebelah kiri
Scale = 4
Time = hilang timbul
b. Pemeriksaan Secara Sistematik (Cephalo – Caudal)

1) Kulit
Turgor kulit lembab, turgor kembali < 2 detik, warna sawo matang.
2) Kepala
a. Kepala : Simetris, bentuk mesocephal, warna rambut hitam kecoklatan,
tidak terdapat lesi .

b. Mata : konjungtiva tidak anemis, sklera tidak ikteris, pupil isokor, kesan
mata tampak terlihat sembab, fungsi penglihatan baik.
c. Hidung : simetris, terpasang alat bantu nafas O2 3 lpm , tidak terpasang
NGT, fungsi penciuman baik.
d. Mulut : membran mukosa bibir tampak kering, mulut terlihat bersih,
keadaan lidah merah, tidak ada kelainan, kemampuan bicara baik.
e. Telinga : simetris, tampak bersih .
3) Leher
Tidak ada pembengkakan kelenjar tiroid, ada pembengkakan vena jugularis
5+2 cmH2O, nadi karotis teraba
4) Tengkuk
Kaku kuduk
5) Dada
a. Paru- Paru
a) Inspeksi
Bentuk dada simetris, tidak ada lesi, tidak ada bekas jahitan.
b) Palpasi
Tidak ada nyeri tekan, vokal fermitus kanan kiri sama.
c) Perkusi
Sonor
d) Auskultasi
Terdengar suara vesikuler.
b. Jantung
a) Inspeksi
Ictus cordis tidak tampak
b) Palpasi
tidak ada nyeri tekan
c) Perkusi
pekak
d) Auskultasi
Bunyi jantung S1/S2 normal tidak ada suara tambahan,
6) Punggung
Bentuk tulang punggung normal tidak ada kelaianan bentuk tulang punggung,
tidak terdapat lesi.
7) Abdomen
a) Inspeksi
Bentuk simetris, tidak ada lesi, tidak ada bekas jahitan.
b) Auskultasi
Bising usus 18 x/menit.
c) Perkusi
Terdengar suara timpani.
d) Palpasi
ada nyeri tekan dibagian inguinalis sinistra abdomen
8) Anus dan Rectum

Tidak terkaji
9) Genetalia
Jenis kelamin laki laki , terpasang kateter urin.
10) Ekstremitas
a) Atas
Tidak ada lesi terpasang infus NS 0,9% 20 tpm pada tangan kiri.
b) Bawah
Tidak adanya krepitasi dan fraktur, tidak tampak adanya edema.
Kekuatan otot : Keterangan :
5 = normal
4 = mampu melakukan gerakan
Tangan Tangan normal tetapi tidak mampu
kanan kiri melawan tahanan maksimal
4 4 pemeriksa
Kaki Kaki 3 = mampu melakukan gerakan
kanan kiri mengangkat dua sendi atau lebih,
4 4 tidak bisa melawan tahanan
sedang
2 = mampu melakukan gerakan
dua sendi atau lebih, tidak bisa
melawan tahanan minimal.
1 = hanya bisa menggerakan ujung
jari
0 = tidak bisa menggerakan sama
sekali

Pengkajian VIP score (Visual Infusion Phlebithis) Skor visual
flebitis pada luka tusukan infus :
Tanda yang ditemukan Skor Rencana Tindakan

Tempat suntikan tampak sehat 0 Tidak ada tanda flebitis
- Observasi kanula
Salah satu dari berikut jelas: 1 Mungkin tanda dini flebitis
 Nyeri tempat suntikan - Observasi kanula
 Eritema tempat suntikan
Dua dari berikut jelas : 2 Stadium dini flebitis
Nyeri sepanjang kanula - Ganti tempat kanula
Eritema
Pembengkakan
Semua dari berikut jelas : 3 Stadium moderat flebitis
 Nyeri sepanjang kanula  Ganti kanula
 Eritema  Pikirkan terapi
 Indurasi
Semua dari berikut jelas : 4 Stadium lanjut atau awal
tromboflebitis
Nyeri sepanjang kanula
Eritema  Ganti kanula
Indurasi  Pikirkan terapi
Venous cord teraba
Semua dari berikut jelas : 5 Stadium lanjut tromboflebitis
 Nyeri sepanjang kanula  Ganti kanula
 Eritema  Lakukan terapi
 Indurasi
 Venous cord teraba
 Demam
*)Lingkari pada skor yang sesuai tanda yang muncul

Pengkajian risiko jatuh (Morse)
NO PENGKAJIAN SKALA Skorin Skoring 2

g1
02/02/2 03/02/2021
021
1. Riwayat jatuh: apakah pasien pernah Tidak 0 0 0
jatuh Ya 25
dalam 3 bulan terakhir?
2. Diagnosa sekunder: apakah pasien Tidak 0 15 15
memiliki Ya 15
lebih dari satu penyakit?
3. Alat Bantu jalan: 0 0
- Bed rest/ dibantu perawat 0
- Kruk/ tongkat/ walker 15
- Berpegangan pada benda-benda di 30
sekitar
4. Terapi Intravena: apakah saat ini Tidak 0 20 20
pasien Ya 20
terpasang infus?
5. Gaya berjalan/ cara berpindah: 10 10
- Normal/ bed rest/ immobile (tidak 0
dapat bergerak sendiri)
- Lemah (tidak bertenaga) 10
- Gangguan/ tidak normal (pincang/ 20
diseret)
6. Status Mental 0 0
- Pasien menyadari kondisi dirinya 0
- Pasien mengalami keterbatasan daya 15
ingat
Total Nilai 45 45
Paraf & Nama Petugas yang Menilai
Keterangan :
Tingkatan Risiko Nilai MFS Tindakan
Tidak berisiko 0 - 24 Perawatan dasar
Risiko rendah 25 - 44 Pelaksanaan intervensi pencegahan jatuh standar
Risiko tinggi ≥ 45 Pelaksanaan intervensi pencegahan jatuh risiko tinggi

5. Pemeriksaan Penunjang
a. Pemeriksaan Patologi Klinik
Tabel 3.4 Pemeriksaan laboratorium Tn H di Ruang Wisnumurti
di Rumah Sakit RSUP dr Sardjito Yogyakarta Tanggal 02/01/2021
PEMERIKSAAN HASIL SATUAN NILAI

RUJUKAN
Hematologi
Leukosit 13,9 10^3/uL 4.5 – 11.5
Eritrosit 5,27 10^3/uL 4,00 – 5,40
Hemoglobin 14,5 g/dL 12.0 – 15.0
Hematokrit 43,1 % 35,0 – 49,0
Trombosit 633 10^3/uL 150 – 450
Hemostatis
APTT 45,5 detik 31,4 – 40.8
INR 1,29
Hitung Jenis
Kimia Klinik
Diabetes
Glukosa Darah Sewaktu 122 mg/dl 70-200
Fungsi Ginjal
BUN 15,5 mg/dl 10 – 50
Creatinin Darah 1,51 mg/dl 0.9 -1.3
Kalium 5,02
Natrium 131
Fungsi Hati
SGPT 16 u/L 0.0 – 42.0
SGOT 8 u/L 0.0 - 37.0
(Sumber Data Sekunder : RM Pasien )

Tabel 3.5 Hasil Pemeriksaan EKG
Pasien Tn H di Ruang Wisnumurti RSUP dr Sardjito Tanggal 02/02/2020
(Sumber Data Sekunder : RM Pasien)

6. Terapi
Tabel 3.6 Pemberian Terapi Pasien Tn H di Ruang Wisnumurti RSUP dr Sardjito
NO Terapi 02/02/2021 03/02/2021 04/02/2021

1. Infus Ns 0,9% (16 tpm) Ns),9% (16 tpm) Ns 0,9% (16 tpm)
2. Injeksi Ranitidin /12 jam Ranitidin /12 jam Ranitidin /12 jam
Ondansentron (ekstra) Ondansentron (ekstra) Ondansentron (ekstra)
Metil prednisolon Metil prednisolon Metil prednisolon
3. Oral Captopril Captopril Captopril
Paracetamol 500mg Paracetamol 500mg Paracetamol 500mg
Azparzolam 0.5mg Azparzolam 0.5mg Azparzolam 0.5mg
Acarbose 3 x 50g Acarbose 3 x 50g Acarbose 3 x 50g
Metainamide Metainamide Metainamide
Bisoprolol /24 jam Bisoprolol /24 jam Bisoprolol /24 jam
(Sumber Data Sekunder : RM Pasien)

ANALISA DATA
Tabel 3.7 Analisa Data
Pasien Ny S di Ruang Wisnumurti PJT RSUP dr Sardjito Tanggal 02/02/2021
No Tanggal/jam Data fokus Etiologi Masalah

keperawatan
1 02/02/2021 DS : Agen Nyeri Akut
07:30 - Klien mengatakan mengeluh pencedera (D.0077)
nyeri pada perut bagian bawah fisiologis
kiri
- Pengkajian nyeri :
P = karena tidak bisa
digerakkan dibagian kaki serta
adanya luka di tangan
Q = seperti tertusuk tusuk
R = perut bagian bawah sebelah
kiri
S=4
T = hilang timbul
DO :
- Pasien tampak meringis
menahan nyeri
- Paien tampak kesulitan tidur
- Pasien sedikit gelisah
2 02/02/2021 DS : Kelemahan Intoleransi
07.30 - Pasien mengatakan lemas aktivitas
apalagi jika bergerak (D.0056)
DO :
- Pasien tampak lemah
- Diaphoresis
- Heart rate meningkat setelah
beraktifitas
3 02/02/2021 DS : Krisis Koping tidak
07.30 - Pasien mengatakan tidak tau situasional efektif (
apa yang dipikirkan D.0096)
- Pasien mengatakan tidak mau
makan nasi
- Pasien mengatakan sering
mimpi bertemu ibunda yang
sudah meninggal
DO :
- Pasien tampak bingung
- Pasien tidak bisa menentukan
pilihan
- Pasien tampak kurang
partisipasi sosial
4. 02/02/2021 DS : Kondisi Distres

07.30 - pasien mengeluh hidupnya penyakit Spiritual
kurang beribadah dan lemes kronis (D.0082)
tidak berdaya
DO :
- pasien koping tidak efektif
- pasien masih kesulitan untuk
beribadah
- pasien tampak lemas
- pasien tampak murung
- pasien menangis
5 02/02/2021 DS : Perubahan Risiko
07.30 - pasien mengatakan merasa irama jantung Penurunan
kelelahan Curah Jantung
DO : (D.0011)
- pasien tampak dispnea setelah
beraktifitas
- pasien tampak kelelahan dan
lemas
- adanya peningkatan JVP
B. DIAGNOSA KEPERAWATAN BERDASAR PRIORITAS
1. Nyeri Akut berhubungan dengan agen pencedera fisiologis ditandai

dengan mengeluh nyeri, sulit tidur, tampak meringis, gelisah,
diaphoresis.
2. Intoleransi Aktifitas berhubungan dengan kelemahan ditandai dengan

mengeluh lelah, merasa lemah dan lemas.
3. Koping tidak efektif berhubungan dengan krisis situasional ditandai

dengan tidak mampu memenuhi kebutuhan dasar, partisipasi sosial
kurang, kekhawatiran kronis.
4. Distress spiritual berhubungan dengan kondisi penyakit kronis ditandai

dengan merasa tidak berdaya, mengeluh hidupnya kurang bermakna,
koping tidak efektif.
5. Risiko penurunan curah jantung faktor risiko perubahan irama jantung

C. PERENCANAAN KEPERAWATAN
Nama Pasien / NO CM : Tn H / 01958XXX Ruang: Wisnumurti

Hari/ No DIAGNOSA PERENCANAAN
Tgl/ Jam Dx KEPERAWATAN
TUJUAN RENCANA TINDAKAN TTD
Selasa 1. Nyeri Akut b/d Setelah dilakukan asuhan keperawatan Manajemen Nyeri RIZKA
02/02/2021 agen pencedera selama 3 x 24 jam diharapkan nyeri akut Observasi : AMELIA DAN
10.00 fisiologis (L.08066) menurun dengan kriteria - Identifikasi lokasi, karakteristik, durasi, GALUH AYU
hasil: frekuensi, kualitas, intensitas nyeri
1. Keluhan nyeri (menurun) - Identifikasi skala nyeri
2. Meringis (menurun) Terapeutik :
3. Kesulitan tidur (menurun) - Berikan teknik nonfarmakologis untuk
4. Gelisah (menurun) mengurangi rasa nyeri
Edukasi :
- Ajarkan teknik non farmakologis untuk
mengurangi rasa nyeri
Kolaborasi :
- Kolaborasi pemberian analgetik.
Selasa 2. Intoleransi Setelah dilakukan asuhan keperawatan Manajemen Energi RIZKA
02/02/2021 Aktifitas selama 3 x 24 jam diharapkan toleransi Observasi : AMELIA DAN
10.00 berhubungan aktivitas (L.05047) meningkat dengan - Identifikasi penggunaan energi penyebab GALUH AYU
dengan kelemahan kriteria hasil: kelelahan
1. Keluhan lelah cukup menurun - Monitor pola dan jam tidur
2. Perasaan lemah menurun Terapeutik :
3. Frekuensi nadi menurun - Sediakan lingkungan yang nyaman dan
4. Kemudahan dalam melakukan rendah stimulus
aktifitas sehari-hari Edukasi :
- Anjurkan melakukan aktifitas secara
bertahap
Kolaborasi :
Kolaborasi dengan ahli gizi tengtang cara
meningkatkan pola asupan makanan
Selasa 3. Koping tidak Setelah dilakukan asuhan keperawatan Dukungan Pengambilan keputusan RIZKA
02/02/2021 efektif selama 3 x 24 jam diharapkan status Observasi : AMELIA DAN
10.00 berhubungan koping (L.09086) membaik dengan - Identifikasi persepsi mengenal masalah GALUH AYU
dengan krisis kriteria hasil: Terapeutik :
situasional 1. Verbalisasi kemampuan - Fasilitasi melihat situasi secara realistik
mengatasi masalah cukup - Fasilitasi hubungan antara pasien,
meningkat keluarga dan tenaga kesehatan lainnya.
2. Perilaku koping adaptif cukup Edukasi :
meningkat - Berikan informasi yang diminta pasien
3. Partisipasi sosial meningkat Kolaborasi :
- Kolaborasi dengan tenaga kesehatan lain
dalam memfasilitasi pengambilan
keputusan.
Selasa 4. Distress spiritual Setelah dilakukan asuhan keperawatan Dukungan Spiritual RIZKA
02/02/2021 berhubungan selama 3 x 24 jam diharapkan status Observasi : AMELIA DAN
10.00 dengan kondisi Spirutual (L.09091) membaik dengan - Identifikasi perasaan khawatir, kesepian, GALUH AYU
penyakit kronis kriteria hasil: ketidakberdayaan
1. Verbalisasi perasaan tenang Terapeutik :
cukup meningkat - Berikan kesempatan mengekspresikan
2. Kemampuan beribadah cukup perasaan tentang penyakitnya
membaik - Fasilitasi melakukan kegiatan ibadah
3. Interaksi dengan orang terdekat Edukasi :
cukup membaik - Anjurkan berinteraksi dengan keluarga,
4. Perasaan takut cukup menurun teman, dan atau orang lain
Kolaborasi :
- Atur kunjungan dengan rohaniawan
Selasa 5. Risiko penurunan Setelah dilakukan asuhan keperawatan Perawatan jantung RIZKA
02/02/2021 curah jantung selama 3 x 24 jam diharapkan curah Observasi : AMELIA DAN
10.00 faktor risiko jantung (L.02008) meningkat dengan - Identifikasi tanda dan gejala primer GALUH AYU
perubahan irama kriteria hasil: penurunan curah jantung
jantung. 1. Tekanan darah cukup membaik - Identifikasi tanda dan gejala sekunder
2. Pucat cukup menurun penurunan curah jantung
3. Kelelahan cukup menurun - Monitor tekanan darah
4. Gambaran EKG aritmia cukup - Monitor EKG 12 Lead
menurun Terapeutik :
- Posisikan pasien semi fowler
- Berikan dukungan spiritual dan emosional
- Berikan oksigen untuk mempertahankan
saturasi oksigen >94%
Edukasi :
- Anjurkan beraktifitas fisik secara perlahan
Kolaborasi :
- Kolaborasi pemberian anti aritmia
- Rujuk ke program rehabilitasi jantung

D. PELAKSANAAN DAN EVALUASI KEPERAWATAN
Nama Pasien / NO CM : Tn H/ 01958XXX Ruang: Wisnumurti

Hari
KODE
/ PELAKSANAAN EVALUASI/RESPON TTD
Tgl/ DX
Jam
Selasa DX 1. Melakukan identifikasi lokasi, karakteristik, DS : RIZKA
02/02/20 1 durasi, frekuensi, kualitas, intensitas nyeri, - Klien mengatakan mengeluh nyeri pada AMELIA
21 skala nyeri secara komprehensif perut bagian bawah kiri DAN
08:00 - Pengkajian nyeri : GALUH
P = jika melakukan aktifitas AYU
R = perut bawah kiri
S=4
T = hilang timbul
DO :
- Pasien tampak meringis menahan nyeri
- Pasien tampak lemas
2. Mengajarkan teknik non farmakologis DS :
untuk mengurangi rasa nyeri Pasien mengatakan mengerti dengan terknik
(Napas dalam, Relaksasi, Distraksi) yang diajarkan
DX RIZKA
08:05 1 DO : AMELIA
Pasien tampak mencoba melakukan teknik DAN
yang diajarkan dan bisa melakukan secara GALUH
mandiri. AYU
DS : -

3. Melakukan kolaborasi pemberian analgetik DO :
DX Paracetamol 500 mg. - Paracetamol 500 mg masuk melalui
08:30 1 peroral RIZKA
- Tidak ada reaksi alergi. AMELIA
DAN
GALUH
AYU
4. Kolaborasi pemberian terapi lanjutan DS: -

1. Metil Prednisolon DO:
- obat masuk via oral :
Metil Prednisolon
- tidak ada tanda- tanda alergi RIZKA
DX AMELIA
2 DAN
GALUH
AYU
5. Mengidentifikasi penggunaan energi DS:

penyebab kelelahan - Pasien mengatakan merasa lelah dan RIZKA
DX lemas karena nyeri di perutnya AMELIA
2 DO : DAN
- Pasien tampak lemah GALUH
- ADL pasien dibatu keluarga AYU
- Derajat kekuatan otot
4 4
4 4
DX
2 6. Memonitor pola dan jam tidur DS:
- pasien mengatakan tidak bisa tidur RIZKA
DO : AMELIA
- wajah pasien tampak layu DAN

- jam tidurpasien berkurang GALUH
- pasien sering terbangun AYU
DX
5
DS : - RIZKA
09:15 7. Menyediakan lingkungan yang nyaman dan DO : AMELIA
rendah stimulus - pasien di posisikan sesuai kenyamanan DAN
pasien GALUH
- kelurga tampak paham dengan AYU
penjelasan modifikasi lingkungan yang
DX nyaman.
5
8. Mengidentifikasi Identifikasi tanda dan DS: RIZKA
gejala primer dan sekunder penurunan - pasien mengatakan merasa lemas AMELIA
curah jantung DO : DAN
DX - pasien tampak kelelahan GALUH
5 - kulit pasien tampak pucat AYU
- adanya distensi vena jugularis 5+2
cmH2O
9. Melakukan monitoring EKG 12 Lead

09:25 DS : - RIZKA
DO : hasil pemeriksaanEKG menunjukkan AMELIA
DAN
GALUH
DX AYU
1,2.3,4,5 10. Melakukan monitoring tanda tanda vital DS: -
DO : RIZKA
- hasil pemeriksaan tanda – tanda vital AMELIA
TD: 124/77 mmHg. DAN
Suhu : 36,8 C GALUH
Nadi : 971 x/menit AYU
RR : 22 x/menit

SPO2 : 97%
09.55
DX
3 11. Mengidentifikasi persepsi mengenal DS: RIZKA
masalah perasaan khawatir, kesepian, - pasien mengatakan sakitnya tidak AMELIA
ketidakberdayaan sembuh sembuh, dan merasa kurang DAN
dalam beribadah GALUH
DO : AYU
- pasien tampak khawatir
- pasien tampak murung
- pasien terlihat melamun
- ADL dibantu
DX
3,4 12. Memfasilitasi melihat situasi secara DS : RIZKA
realistik - Pasien mengatakan memikirkan “ibu” AMELIA
yang sudah meninggal dan sering DAN
melihat dan bermimpi GALUH
DO : AYU
- Pasien tampak sedih
- Pasien tampak murung
- Pasien paham dengan penjelasan
perawat terkait hal hal yang realistik dan
tidak realistik
- Pasien tampak menganggukkan kepala
DX
3,4,5 13. Memberikan kesempatan mengekspresikan DS : RIZKA
perasaan tentang penyakitnya - - AMELIA
DO : DAN
- Pasien tampak menangis GALUH
AYU

14. Menganjurkan berinteraksi dengan DS:
keluarga, teman, dan atau orang lain - Keluarga pasien (kakak) mengatakan RIZKA
- memfasilitasi dengan memotivasi terkahir cerita dengan saya ketika di AMELIA
hubungan antara pasien, keluarga dan ruang ICCU DAN
tenaga kesehatan lainnya. DO : GALUH
- memberikan edukasi dukungan keluarga - Pasien tampak kurang bersosialisasi AYU
terkait penyampaian perasaan , bercerita, dengan keluarga
dan dukungan spiritual - Pasien lupa dengan nama keluarga dan
kerabatnya
- Pasien masih tampak bingung
- Keluarga pasien tampak paham dengan
penjelasan dan motivasi dukungan sosial
secara psikologis dan spiritual .
Rabu
03/02/20 DX 1. Melakukan identifikasi lokasi, karakteristik, DS : RIZKA
20 1 durasi, frekuensi, kualitas, intensitas nyeri, - Klien mengatakan mengeluh nyeri pada AMELIA
skala nyeri secara komprehensif perut bagian bawah kiri DAN
- Pengkajian nyeri : GALUH
P = karena tidak bisa digerakkan AYU
dibagian kaki serta adanya luka di tangan
R = perut bawah kiri
S=4
T = hilang timbul
DO :
- Pasien tampak meringis menahan nyeri
- Pasien tampak lemas
DX 2. Mengajarkan kembali teknik non DS : RIZKA

1 farmakologis untuk mengurangi rasa nyeri Pasien mengatakan sudah mengerti dan AMELIA

(Napas dalam, Relaksasi, Distraksi) mempraktekkan secara mandiri DAN
DO : GALUH
Pasien tampak mengulangi melakukan teknik AYU
pengurangan nyeri yang diajarkan dan bisa
melakukan secara mandiri.
3. Melakukan kolaborasi pemberian analgetik DS : - RIZKA

Paracetamol 500 mg DO : AMELIA
- Paracetamol 500 mg masuk melalui DAN
peroral GALUH
- Tidak ada reaksi alergi. AYU
4. Memonitor kembali pola dan jam tidur
DS:
- pasien mengatakan masih kesulitan tidur RIZKA
DO : AMELIA
- wajah pasien tampak layu DAN
- jam tidurpasien berkurang GALUH
- pasien sering terbangun AYU
5. Menganjurkan melakukan aktifitas secara DS :

bertahap - pasien mengatakan merasa lemas dan RIZKA
lelah setelah bergerak sedikit berkurang AMELIA
DS : DAN
- pasien tampak rileks GALUH
- pasien masih tampak lemas AYU
DS : RIZKA
6. Memposisikan pasien dengan posisi semi - pasien mengatakan pasien merasa AMELIA
fowler nyaman dengan posisinya DAN
DO : GALUH
- pasien masih tampak lemah AYU

- pasien tampak lebih nyaman degan set
posisi yang diberikan
DS : - RIZKA
7. Memonitor pemberian oksigen untuk DO : AMELIA
3 mempertahankan saturasi oksigen >94% - oksigen terpasang dengan nasal kanul 3 DAN
18:00 lpm GALUH
- SpO2 : AYU
DS :-
8. Memonitor tanda – tanda vital pasien DO :
TD : 114/86 RIZKA
Nadi :94 AMELIA
Suhu: 36,2 DAN
RR: 22 GALUH
SpO2 : 95% AYU
DS : -
DO : RIZKA
9. Melakukan kolaborasi pemberian terapi - Obat masuk via oral AMELIA
pada pasien : - Acarbose 50g DAN
1.Acarbose 50g - Tidak ada tanda tanda alergi GALUH
AYU
DS :
- Pasien mengatakan masih memikirkan
10. Memberikan dukungan spiritual dan ibunya yg sudah meninggal, sudah mulai RIZKA
emosional mengerjakan sholat dengan posisi tidur AMELIA
DO : DAN
- Pasien tampak memegang tasbih GALUH
- Pasien tampak melaksanakan shalat AYU
berjamaah dengan anaknya

DS :
11. Mengobservasi keadaan umum dan - pasien mengatakan mual tidak mau RIZKA
keluhan pasien makan bubur AMELIA
DO: DAN
- makanan dari instalazi gizi tampak tidak GALUH
dimakan AYU
- pasien tampak hanya mau memakan
buah pisang
DS : -
12. Melakukan kolaborasi pemberian terapi : DO : RIZKA
1. Ondansentron 4mg - obat masuk via iv Ondansentron 4mg AMELIA
- tidak ada tanda tanda alergi DAN
GALUH
AYU
DS :
13. Melakukan kolaborasi dengan ahli gizi - pasien mengatakan mau makan roti atau
tengtang cara meningkatkan pola asupan buah RIZKA
makanan DO : AMELIA
- pasien tampak mau makan buah pisang, DAN
melon dan roti tawar yang diberikan oleh GALUH
ahli gizi AYU
DS : -
14. Melakukan kolaborasi pemberian obat : DO :
1. Captopril 50 mg - obat masuk via oral RIZKA
2. Metil prednisolon 1. Captopril 50 mg AMELIA
2. Metil prednisolon DAN
- tidak ada tanda tanda alergi GALUH
AYU
DS:

15. Menganjurkan kembali untuk berinteraksi - pasien mengatakan keadaannya sudah RIZKA
dengan keluarga, teman, dan atau orang lain lumayan sehat AMELIA
- memfasilitasi dengan memotivasi DO : DAN
hubungan antara pasien, keluarga dan - Pasien sudah bisa bersosialisasi dengan GALUH
tenaga kesehatan lainnya. keluarga AYU
- memberikan edukasi dukungan keluarga - Pasien sudah mrnginat gnama keluarga
terkait penyampaian perasaan , bercerita, dan kerabatnya
dan dukungan spiritual - Pasien sudah tidak tampak kebingungan
Kamis 1. Mengobservasi keadaan umum dan keluhan DS: RIZKA

04/02/20 pasien - Pasien mengatakan keadaannya AMELIA
20 membaik , nyeri perut berkurang , sudah DAN
tidak mual lagi GALUH
DO : AYU
- Pasien tampak lebih rileks
- Pasien tampak tidak pucat
2. Mengobservasi tanda- tanda vital klien DS : -

DO : RIZKA
- Tanda tanda vital pasien AMELIA
TD : 101/71 DAN
Nadi : 65 GALUH
Suhu : 36,4 AYU
RR : 20
SpO2 : 96%
3. Melakukan kolaborasi rujukan ke program DS: RIZKA
rehabilitasi jantung - mengetakan selesai di rehabilitasi AMELIA
merasa lebih segar DAN
DO : GALUH
- pasien tampak lebih rileks AYU

E. CATATAN PERKEMBANGAN
Nama Pasien/No. C.M Ny S/ 019583xx Ruang: Cendana 2
HR/
JAM EVALUASI
TGL/ Dx. PELAKSANAAN (S O A P) TTD
(WIB)
JAM/ Kep
SHIF
02/02/20 DX 13:00 Manajemen Nyeri S: RIZKA
21 1. Melakukan identifikasi lokasi, - Klien mengatakan mengeluh nyeri pada perut AMELIA
karakteristik, durasi, frekuensi, bagian bawah kiri DAN
kualitas, intensitas nyeri, skala - Pengkajian nyeri : GALUH
nyeri secara komprehensif P = jika melakukan aktifitas AYU
2. Mengajarkan teknik non Q = seperti tertusuk tusuk
farmakologis untuk mengurangi R = perut bawah kiri
rasa nyeri (Napas dalam, S=4
Relaksasi, Distraksi)\ T = hilang timbul
3. Melakukan kolaborasi - Pasien mengatakan teringat “IBU”.
pemberian analgetik O:
Paracetamol 500 mg. - Pasien tampak meringis menahan nyeri
4. Kolaborasi pemberian terapi - Paien tampak kesulitan tidur
lanjutan Metil Prednisolon - Pasien sedikit gelisah
Intoleransi Aktifitas - Pasien tampak lemas
1. Mengidentifikasi penggunaan - Kolaborasi analgetik
energi penyebab kelelahan Paracetamol 500 mg masuk melalui peroral
2. Memonitor pola dan jam tidur Tidak ada reaksi alergi.
3. Menyediakan lingkungan yang - Kolaborasi terapi lanjut obat masuk via oral :
nyaman dan rendah stimulus Metil Prednisolon
Koping tidak efektif tidak ada tanda- tanda alergi
1. Mengidentifikasi persepsi - Pasien tampak lemah
mengenal masalah perasaan - ADL pasien dibatu keluarga
khawatir, kesepian, - Derajat kekuatan otot
ketidakberdayaan 4 4
2. Memfasilitasi melihat situasi 4 4
secara realistik - wajah pasien tampak layu
3. Memberikan kesempatan - jam tidur pasien berkurang
mengekspresikan perasaan - pasien sering terbangun
tentang penyakitnya - pasien di posisikan sesuai kenyamanan pasien
Risiko penurunan curah jantung - kelurga memahami penjelasan modifikasi
1. Mengidentifikasi Identifikasi lingkungan yang nyaman.
tanda dan gejala primer dan - pasien tampak kelelahan
sekunder penurunan curah - kulit pasien tampak pucat
jantung - adanya distensi vena jugularis 5+2 cmH2O
2. Melakukan monitoring EKG 12 - Hasil pemeriksaan tanda tanda vital :
Lead TD :124/77 mmHg.
3. Melakukan monitoring tanda Suhu : 36,8 C
tanda vital Nadi : 78 x/menit
Disstres Spiritual RR : 22 x/menit
1. Menganjurkan berinteraksi SPO2 : 97%
dengan keluarga, teman, dan atau - hasil pemeriksaan EKG menunjukkan
orang lain - pasien tampak khawatir, murung, melamun ,
- memfasilitasi dengan bingun dan sedih
memotivasi hubungan antara - Pasien tampak menangis
pasien, keluarga dan tenaga - Pasien paham dengan penjelasan perawat terkait
kesehatan lainnya. hal hal yang realistik dan tidak realistik
- memberikan edukasi dukungan - Pasien tampak kurang bersosialisasi dengan
keluarga terkait penyampaian keluarga
perasaan , bercerita, dan - Pasien lupa dengan nama keluarga dan kerabatnya
dukungan spiritual - Keluarga pasien tampak paham dengan penjelasan
dan motivasi dukungan sosial secara psikologis
dan spiritual
A:
- Nyeri Akut berhubungan dengan agen pencedera
fisiologis
- Intoleransi Aktifitas berhubungan dengan
kelemahan
- Koping tidak efektif berhubungan dengan krisis
situasional
- Distress spiritual berhubungan dengan kondisi
penyakit kronis
- Risiko penurunan curah jantung
faktor risiko perubahan irama
jantung
P : Lanjutkan intervensi
1. Manajemen nyeri
- Melakukan identifikasi lokasi, karakteristik, durasi,
frekuensi, kualitas, intensitas nyeri, skala nyeri
secara komprehensif
- Mengajarkan kembali teknik non farmakologis
untuk mengurangi rasa nyeri
(Napas dalam, Relaksasi, Distraksi)
- Melakukan kolaborasi pemberian analgetik
Paracetamol 500 mg
- Mengobservasi keadaan umum dan keluhan pasien
- Melakukan kolaborasi pemberian terapi
Ondansentron 4mg
2. Manajemen energi
- Memonitor kembali pola dan jam tidur
- Menganjurkan melakukan aktifitas secara bertahap
- Perawatan jantung
- Memposisikan pasien dengan posisi semi fowler
- Memonitor pemberian oksigen untuk
mempertahankan saturasi oksigen >94%
- Memonitor tanda – tanda vital pasien
- Melakukan kolaborasi dengan ahli gizi tengtang
cara meningkatkan pola asupan makanan
- Melakukan kolaborasi pemberian terapi pada
pasien :
Acarbose 50g
Captopril 50 mg
Metil prednisolon
3. Dukungan spiritual
- Memberikan dukungan spiritual dan emosional
- Menganjurkan kembali untuk berinteraksi dengan
keluarga, teman, dan atau orang lain
- memfasilitasi dengan memotivasi hubungan
antara pasien, keluarga dan tenaga kesehatan
lainnya
4. Dukungan pengambilan keputusan
- Memberikan edukasi dukungan keluarga terkait
penyampaian perasaan , bercerita, dan dukungan
spiritual
03/02/20 Nyeri akut DS RIZKA
21 1. Melakukan identifikasi lokasi, - Klien mengatakan mengeluh nyeri pada perut AMELIA
karakteristik, durasi, frekuensi, bagian bawah kiri DAN
kualitas, intensitas nyeri, skala - Pengkajian nyeri : GALUH
nyeri secara komprehensif P =ketika beraktifitas AYU
2. Mengajarkan kembali teknik non Q = seperti tertusuk tusuk
farmakologis untuk mengurangi R = perut bawah kiri
rasa nyeri S=4
3. (Napas dalam, Relaksasi, T = hilang timbul
Distraksi) - pasien mengatakan masih kesulitan tidur
4. Melakukan kolaborasi - pasien mengatakan merasa lemas dan lelah setelah
pemberian analgetik bergerak sedikit berkurang
Paracetamol 500 mg - Pasien mengatakan masih memikirkan ibunya yg
5. Mengobservasi keadaan umum sudah meninggal, sudah mulai mengerjakan sholat
dan keluhan pasien dengan posisi tidur
6. Melakukan kolaborasi pemberian - pasien mengatakan mual tidak mau makan bubur
terapi : - pasien mengatakan mau makan roti atau buah
Ondansentron 4mg
Manajemen energi DO :
1. Memonitor kembali pola dan jam - Hasil pemeriksaan tanda vital :
tidur TD : 114/86
2. Menganjurkan melakukan Nadi :94
aktifitas secara bertahap Suhu: 36,2
Perawatan jantung RR: 22
1. Memposisikan pasien dengan SpO2 : 95%
posisi semi fowler - Pasien tampak meringis menahan nyeri
2. Memonitor pemberian oksigen - Paien tampak kesulitan tidur
untuk mempertahankan saturasi - Pasien sedikit gelisah
oksigen >94% - Pasien tampak lemas
3. Memonitor tanda – tanda vital - Paracetamol 500 mg masuk melalui peroral
pasien - Tidak ada reaksi alergi.
4. Melakukan kolaborasi pemberian - pasien tampak rileks
terapi pada pasien : - pasien masih tampak lemas
a. Acarbose 50g - Pasien sudah bisa bersosialisasi dengan keluarga
5. Melakukan kolaborasi dengan - Pasien sudah mrnginat gnama keluarga dan
ahli gizi tengtang cara kerabatnya
meningkatkan pola asupan - Pasien sudah tidak tampak kebingungan
makanan A:
6. Melakukan kolaborasi pemberian - Nyeri Akut berhubungan dengan agen pencedera
obat : fisiologis
a. Captopril 50 mg - Intoleransi Aktifitas berhubungan dengan
b. Metil prednisolon kelemahan
Dukungan spiritual - Koping tidak efektif berhubungan dengan krisis
1. Memberikan dukungan spiritual situasional
dan emosional - Distress spiritual berhubungan dengan kondisi
Manajemen pengambilan keputusan penyakit kronis
1. Menganjurkan kembali untuk - Risiko penurunan curah jantung
berinteraksi dengan keluarga, faktor risiko perubahan irama
teman, dan atau orang lain jantung
2. Memfasilitasi dengan
memotivasi hubungan antara
pasien, keluarga dan tenaga P:
kesehatan lainnya. - Lanjutkan intervensi
3. Memberikan edukasi dukungan 1. Mengobservasi keadaan umum dan keluhan
keluarga terkait penyampaian pasien
perasaan , bercerita, dan 2. Mengobservasi tanda- tanda vital klien
dukungan spiritual 3. Melakukan kolaborasi rujukan ke program
rehabilitasi jantung
Kamis Manajemen Nyeri dan manajemen S: RIZKA
04/02/20 energi - Pasien mengatakan keadaannya membaik , nyeri AMELIA
21 1. Mengobservasi keadaan umum perut berkurang , sudah tidak mual lagi, masih DAN
dan keluhan pasien sedikit lemas GALUH
Perawatan jantung O: AYU
1. Mengobservasi tanda- tanda vital - Tanda tanda vital pasien
klien TD : 101/71
2. Melakukan kolaborasi rujukan ke Nadi : 65
program rehabilitasi jantung Suhu : 36,4
RR : 20
SpO2 : 96%
- Pasien tampak lebih rileks
- Pasien tampak tidak pucat
- mengetakan selesai di rehabilitasi merasa lebih
segar
A:
- intoleransi aktivitas
- Risiko penurunan curah jantung
P:
- lanjutkan intervensi
HHS Public Access
Author manuscript
J Vasc Nurs. Author manuscript; available in PMC 2021 February 01.
Author Manuscript
Published in final edited form as:

J Vasc Nurs. 2020 June ; 38(2): 36–65. doi:10.1016/j.jvn.2020.01.004.
Society for Vascular Nursing Endovascular Repair of Abdominal

Aortic Aneurysm (AAA) Updated Nursing Clinical Practice
Guideline
Debra Kohlman-Trigoboff, RN, MS, ACNP-BC, CVN1, Kathleen Rich, PhD, RN, CCNS, CCRN-
CSC, CNN2, Anne Foley, MSN, RN, AGACNP, CDE3, Karen Fitzgerald, MSN, RN, NP, CVN4,
Dianne Arizmendi, MSN, CRNP, CWS5, Carolyn Robinson, MSN, RN, CANP, CVN6, Rebecca
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Brown, MEd, MN, RN7, Diane Treat-Jacobson, PhD, RN, FAHA, MSVM, FAAN8, Society for
Vascular Nursing Practice and Research Committee
1Duke University Medical Center, Division of Cardiology, Duke Heart and Vascular, Durham,
North Carolina.
2Critical Care Administration, Franciscan Health-Michigan City, Michigan City, Indiana.
3Department of Vascular Surgery, Hospital of The University of Pennsylvania, Philadelphia,
Pennsylvania.
4The Vascular Group, PLLC, Albany Medical Center Hospital, Albany, New York.
5Corporal Michael Crescenz VA Hospital, Philadelphia, Pennsylvania.
6Minneapolis VA Health Care System, Minneapolis, Minnesota.
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7NationalInstitutes of Health’s National Center for Advancing Translational Sciences, University of

Minnesota School of Nursing, Minneapolis, Minnesota.
8NursingResearch for Improved Care, University of Minnesota School of Nursing, Minneapolis,
Minnesota.
1. Introduction
1.1 Purpose and Scope:
The purpose and scope of this document is to update the 2009 Society for Vascular
Nursing’s (SVN) Endovascular Abdominal Aortic Aneurysm (AAA) Repair Practice
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Guideline [1] to reflect current evidence-based changes.
1.2 Assessment of Scientific Evidence

A comprehensive literature search of studies published in the English language from 1991–
2019 was conducted. Earlier studies were included if clinically relevant. Search terms were:
Abdominal Aortic Aneurysm, Endovascular Abdominal Aortic Aneurysm Repair (EVAR),
Percutaneous Endovascular Aneurysm Repair (pEVAR), Fenestrated EVAR (FEVAR),
Aortic Aneurysm Surgery, Stent Graft, Endograft and combinations thereof. The databases
dktrigoboff@yahoo.com.
Kohlman-Trigoboff et al. Page 2
searched: CINAHL, The Cochrane Library, Elsevier Science Direct, Ovid, MEDLINE,
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PubMed, BMJ Clinical Evidence, National Guidelines Clearinghouse, MD Consult, and

Nursing Consult. Textbooks and review articles were also included. Recommendations for
nursing practice were based upon the data grading system proposed by Melnyk and Finout-
Overholt. [2]
The SVN clinical practice guideline uses the following classification:
1. Class I: Randomized control trial without significant limitations, systematic

reviews or meta-analysis
2. Class II: Randomized control trial with important limitations (e.g.,

methodological flaws or inconsistent results), observational studies (e.g., cohort
or case-control)
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3. Class III: Qualitative studies, case study, or series
4. Class IV: Evidence from reports of expert committees and/or expert opinion of
the guideline panel, standards of care and clinical protocols, animal studies
1.3. History of Endovascular AAA Repair

In the 1960s and American radiologist, Dr. Charles Dotter invented balloon angioplasty. [3]
In 1978, Dr. Palmaz (a vascular radiologist) used this technique to develop the first balloon
mounted arterial stent. [4] In 1990, Dr. Juan Parodi (a vascular surgeon) along with Dr.
Palmaz performed elective repair of five patients with AAA using a custom-made Dacron
tube endoprosthesis fixed with a balloon-expandable stent inserted transfemorally. [5] Since
1991, endovascular repair for AAA has become widely accepted and available due in part to
advances in stent-graft design to accommodate various anatomic features. [6] Bifurcated
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endografts were initially implanted in 1994. [7] Aorto-uni-iliac or aorto-uni-femoral grafts,

reported in 1997, required occlusion of the contralateral common iliac artery and femoral-
femoral bypass grafting. [8, 9] For ruptured AAA, endovascular treatment[10, 11] is
considered the best option. The first reported endovascular treatment of a ruptured AAA was
in 1994 by Yusuf, et al. [12] Four years later, the modular design of the current endografts
was first developed by May, et al, 1998. [13]
1.4 Rationale for Guideline:

Ruptured AAA is ranked as the 13th leading cause of mortality in the United States, which is
approximately 15,000 deaths per year. The incidence of AAA rupture, ranging from 1 to 21
cases per 100,000 persons, is on the rise despite increased AAA diagnosis. [14] Men have a
2–6 times greater frequency of AAA than women, and AAA are found more frequently in
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Caucasians compared to non-Caucasians. [15] There is no known treatment to induce

regression once the AAA has formed. Most current therapies are aimed at limiting further
aneurysmal expansion.
Therefore, the primary goal is to diagnose and treat AAA prior to rupture as the mortality of
ruptured AAA is 80–90%. Thirty to 50% of individuals with ruptured AAA die before
reaching a hospital and 30–40% of those with ruptured AAA die after reaching the hospital.
[16]

1.5 Clinical Practice Guideline Purpose and Goals

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This evidence-based clinical practice guideline was developed by vascular clinical nurse
experts who are members of the Society for Vascular Nursing Practice and Research
Committee. The purpose of this guideline is to assist nurses in delivering the optimal
evidence-based care for the patient undergoing Endovascular AAA Repair (including
discussion regarding surgical cut down for EVAR, Percutaneous access for pEVAR, and
Fenestrated endovascular repair for FEVAR). This document should be tailored to the needs
of the practice setting as well as the values and preferences of the patient.
The goals of care for this patient population are:
1. Ensure optimal nursing care is based on recommended clinical practice

guidelines.
2. Provide a safe and caring environment throughout each phase of the patient’s
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experience before, during and after endovascular AAA repair.
3. Assess, plan, implement, and evaluate individualized patient care effectively.
1.6 Review of Abdominal Aorta Anatomy and Physiology

The aorta is the major blood vessel in the body that carries blood from the heart to the other
major bodily organs. The aorta is divided into thoracic and abdominal sections. The
abdominal aorta begins at the diaphragm and ends at the top of the bifurcation into the iliac
arteries. The aorta lies in the posterior wall of the abdomen, anterior to the vertebral column.
It follows the curvature of the lumbar vertebrae, causing it to convex anteriorly. The aorta
runs parallel to the inferior vena cava (IVC). The abdominal aorta supplies blood to the
intestines (via the superior mesenteric artery (SMA), celiac artery and the inferior
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mesenteric artery (IMA), abdominal organs, kidneys (via renal arteries), lumbar region,
pelvis and legs. [17]
All arteries have three distinct tissue layers: tunica intima (also known as the endothelium),
tunica media and tunica adventitia. The tunica intima is the innermost arterial layer that is in
contact with the blood. The tunica media, which is the middle layer, consists of smooth
muscle cells surrounded by elastin, collagen and proteoglycans that provide elastic
properties of the artery. The tunica adventitia is the outermost layer and consists mainly of
collagen but also contains fibroblasts, immunomodulatory cells, and adrenergic nerves and
acts as a support. [18]
Typically, the diameter of the aorta decreases from its thoracic section to the abdominal and
infrarenal (below the renal artery) portions. In a normal aorta the medial elastin layers,
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elastin and collagen content decrease from the thoracic to the abdominal portion. The elastic
fibers in the aorta contract following each heartbeat to help propel blood away from the heart
and toward organs and tissues.
1.7 Pathogenesis of Abdominal Aortic Aneurysm

An AAA is a focal dilation 50% greater than the normal abdominal aortic diameter of 2 cm,
and by definition is greater than 3 cm in diameter. The infrarenal abdominal aorta is the most

common site of true arterial aneurysmal formation. [19] Risk factors associated with the
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development of AAA include advanced age, male gender, Caucasian race, a positive family
history (15–25% have a first-degree relative with the same type of aneurysm), smoking, and
the presence of other large vessel aneurysms. Atherosclerosis has also been associated with
AAA. [11, 20]
AAAs tend to progressively dilate over time. Expansion rates for AAA vary, however large
aneurysms generally expand at a faster rate than small aneurysms. [11, 20] The main risk
factors associated with expansion and rupture of AAA are somewhat different from those
that contribute to the development of AAA and include large aneurysm diameter, rapid
expansion, smoking, hypertension, elevated peak wall stress, a history of cardiac or renal
transplant, decreased forced expiratory volume, and female gender. [11, 20]
The mechanisms for the development, expansion, and rupture of AAA have been validated
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in animal models. Aneurysmal degeneration of the abdominal aorta is a multifactorial

systemic process due to alterations in vascular wall biology thought to be caused by
inflammation, smooth muscle cell apoptosis, and extracellular matrix degradation. AAAs are
characterized by transmural inflammatory changes in the tunica media, causing loss of
elastin and smooth muscle cells and abnormal collagen remodeling and cross-linking
resulting in progressive thinning and weakening of the aortic wall with enlargement of the
aortic diameter. [21]
Aneurysm location/classification definitions [22]:
• Suprarenal (visceral) – The aneurysm originates above the renal arteries.
• Pararenal – The aneurysm involves the aorta at the level of the renal arteries, i.e.,
the renal artery originates from an aneurysmal aorta.
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• Juxtarenal – The aneurysm originates at the level of the renal arteries but the
aorta at the renal arteries is normal.
• Infrarenal – The aneurysm originates below the renal arteries.
Most AAAs are infrarenal, however approximately 15% are juxtarenal. [23]
Peripheral Artery Disease (PAD) has been associated with AAA. According to the 2016
PAD Guidelines, the prevalence of AAA was higher in patients with symptomatic PAD than
in the general population and in patients with atherosclerotic risk factors. The prevalence of
AAA in patients with PAD increased with age, beginning in patients ≥55 years of age, and
was highest in patients ≥75 years of age. To date, there are no data on AAA screening in
patients with asymptomatic PAD. Screening duplex ultrasound for AAA is a class IIA
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recommendation for patients with symptomatic PAD. [10]
1.8 Aneurysm Screening:

Screening for AAA is associated with a reduction in AAA rupture, mortality and emergency
surgery. Screening men ages 65–75 years is uniformly agreed upon in clinical practice
guidelines, while screening women is controversial as data is lacking. The European Society
for Vascular Surgery [24] does not recommend screening for women and the United States

Preventative Services Task Force [25] recommends reimbursement for screening men only.
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However, screening women may be more cost-effective. Though the prevalence of AAA in
non-smoking women is low, AAA prevalence is higher in women who smoke and the rate of
AAA rupture in general is higher. [11, 26]
The following recommendations are from the Society for Vascular Surgery [11]:
• One-time abdominal ultrasound screening for AAA in patients 65–75 years with
a history of smoking. [11]
• Abdominal ultrasound screening for AAA in first degree relatives of patients

with a AAA between age 65–75
• Abdominal aortic aneurysms >2.5-<3 cm should have AAA duplex every 10

years
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• Abdominal aortic aneurysms 3.0–3.9 cm should have AAA duplex every 3 years
• Abdominal aortic aneurysms 4.0–4.9 cm should have AAA duplex every year
• Abdominal aortic aneurysms 5.0–5.4 cm should have AAA duplex every 6

months
• CT scan in patients with known AAA with recent onset abdominal or back pain
in the presence of an abdominal pulsatile mass. [11]
1.9 Selection Criteria for Endovascular AAA Repair and Summary of Evidence
1.9.1—Nonruptured AAA:
Most AAAs are asymptomatic and often diagnosed incidentally. Aneurysm rupture is the
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most feared complication, and is associated with high morbidity and mortality (refer to 1.4).
The AAA transverse diameter is the best predictor of rupture risk; the bigger the aneurysm,
the more likely it is to rupture. Symptoms suggesting acute AAA growth include back or
abdominal pain which is steady, gnawing in quality, and not affected by movement. Other
rare complications of untreated AAA include aneurysm thromboembolism and thrombosis,
which can lead to acute limb ischemia. [27]
Elective AAA repair is not advised until the risk of rupture exceeds the risks associated with
repair. Repair is recommended for AAA diameter exceeding 5.5 cm, [11, 28] symptomatic
patients, patients who have evidence of embolization or rupture, or when the AAA that has
expanded by more than 0.5 cm within a six-month interval or >10 mm over a year. [28]
Rapid expansion of an AAA is thought to increase the risk for rupture. Women have a higher
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rupture rate and mortality (3 times higher) than men since current evidence that suggests that
AAA in women may grow at a faster rate and may rupture at a smaller size (4.5–5.0 cm).
[29]
• Elective repair is recommended for low or acceptable procedural risk patients

with a fusiform (spindle-like shape that is wide in the middle and tapers at both
ends) AAA that is ≥5.5cm. [11]

• Elective repair in women with AAA between 5.0 and 5.4 cm is recommended.
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[11]
Procedural selection criteria rely on careful assessment of factors that influence rupture risk,
procedural mortality and life expectancy. Other factors such as the patient’s age, rate of
aneurysm expansion, and the presence of PAD or peripheral aneurysm are also important to
consider when determining when to proceed with elective AAA repair. [30]
When elective AAA repair is indicated, the choice between open surgical and endovascular
AAA repair is debatable.
• Elective EVAR repair is associated with lower rates of perioperative (30-day)

morbidity and mortality compared with elective open repair (<2% versus
approximately 5 %), long-term outcomes are similar to open AAA repair
(Chaikof 2018). Of those undergoing EVAR, pEVAR has shown less morbidity
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and mortality, shorter hospital stay and lower cost than surgical cut down EVAR.
[31, 32]
• Open or endovascular repair of infrarenal AAA and/or common iliac aneurysms

is indicated in patients who are good surgical candidates (Class I). [28]
• Open AAA repair is reasonable to perform in patients who are good surgical
candidates but who cannot comply with the periodic long-term surveillance
required after endovascular repair (Class III). [28]
• Endovascular repair of infrarenal aortic aneurysm in patients who are high risk
from a surgical or anesthetic perspective, as determined by the presence of
coexisting severe cardiac, pulmonary, and/or renal disease is of uncertain
effectiveness (Class II).[28]
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1.9.2—Ruptured AAA (rAAA):
Rupture of an abdominal aortic aneurysm (AAA) occurs in approximately 15,000 patients

per year in the United States. Ruptured AAA is nearly always fatal without repair. When a
ruptured AAA is identified, repair should be undertaken emergently to give the patient the
best chance for survival. Timeliness of rAAA repair affects outcomes and the goal should be
for intervention in less than 90 minutes employing the 30-30-30-minute framework (namely
30 minutes to evaluate and diagnose, 30 minutes to transfer from rural to tertiary facility, and
30 minutes to intervention).[11]
• When anatomically feasible, EVAR is recommended over open repair for

ruptured AAA. [11]
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• Emergency EVAR was associated with a significantly reduced perioperative (30-

day) mortality risk relative to open repair (pooled odds ratio [OR] 0.62, 95% CI
0.52–0.75). However, not all institutions are equipped to treat ruptured AAAs
using minimally-invasive technology. Although 70% of patients may be
candidates for EVAR, ruptured AAA is more often repaired with open surgical
techniques since there are limited number of centers available to perform
emergency EVAR. The patients who are anatomically suited to EVAR, but high

risk for open repair (systolic blood pressure <80 mmHg, advanced age (>80
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years), cardiac arrest/myocardial infarction, loss of consciousness, creatinine

>1.3mg/dL on admission, female sex, and hemoglobin <9.0, dialysis
dependence, colonic ischemia), should be considered for transfer to a vascular
center suited for emergency EVAR if the patient is hemodynamically stable. [11]
1.9.3—Specific anatomical requirements/considerations for endovascular AAA repair [30]:
• Adequate length of normal aorta below the renal arteries for device attachment
• Shape and angulation of AAA neck that does not prohibit device fixation
• Characteristics of the iliac arteries to allow catheter and device access (i.e., need
adequate diameter and length, minimal calcification and tortuosity)
• Associated renal and visceral artery involvement

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• Patient comorbidities, body habitus, age
1.9.4—Advantages/Disadvantages of EVAR
Advantages of Endovascular AAA Repair [30]:
• Lower short-term rates of death and complications
• Decreased mortality especially among the elderly population
• Abdominal incision avoided for high risk for patients who have severe
cardiopulmonary disease, advanced age, morbid obesity, or hostile abdomen
• Reduction in cardiopulmonary complications

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• Reduced length of hospital stay
• Eliminates sequelae of laparotomy such as hernia or bowel obstruction
Disadvantages of Endovascular AAA Repair [33]:
• Renal complications related to contrast dye or graft related ischemia
• Proximal or distal attachment failure, graft migration or endovascular stent graft

leaks (endoleak) (refer to 4.3.1)
• Need for long-term surveillance imaging
1.9.5—Estimation of Operative Risk:

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• Operative risk and life expectancy can be estimated using the Vascular Quality
Initiative (VQI) Risk Calculator [34] is used to assess preoperative mortality [11]
• Since EVAR does not require intrathoracic or intraabdominal exposure of the

aorta, or aortic cross-clamping, perioperative morbidity and mortality are
reduced compared with open repair. Also, EVAR has made treatment possible for
some patients with comorbidities who might not otherwise be candidates for
aortic repair. [35]

• Unlike open AAA repair, EVAR and pEVAR can be performed under local
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anesthesia which carries a reduced risk of surgical morbidity and mortality. [36]
1.10 Simplified Procedural Technique for Endovascular AAA Repair

1.10.1—EVAR is a multimodal procedure. It may be performed by a vascular surgeon,
cardiothoracic surgeon, vascular and interventional radiologist or interventional cardiologist
or combination thereof. The procedural location depends upon the treating physician and
may be done in a standard operating room or specialized hybrid room. Other locations
include the Interventional Radiology (IR) or Cardiac Catheterization Laboratory. The use of
high-quality fluoroscopy and angiographic equipment is required to assist in optimal stent-
graft deployment. [37] If the procedure is being performed in the IR or Cardiac
Catheterization Lab, the assisting nursing personnel should have additional education
specific to the interventional laboratory, as well as training in moderate sedation
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administration, and Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS)
(Class IV). [38]
1.10.2—Stent-graft selection is dependent upon physician preference and patient anatomic

characteristics as determined by pre-procedure imaging results. There are no studies
available that evaluate direct comparisons of different aortic stent-graft types. [39] General
EVAR stent graft characteristics include full support throughout the graft and all are self-
expanding. In addition, all have a method of fixation that is designed to prevent graft
migration after deployment. [40] Most aortic stent-grafts are modular with several
components, and typically includes a main body, contralateral and ipsilateral limbs. [41]
Figure D depicts an example of a modular aortic stent-graft.
1.10.3—Anesthesia options include local, regional or general anesthesia as determined by

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physician preference, patient co-morbidities and body habitus. Regional techniques may
include paravertebral, spinal, continuous spinal and epidural. If local or regional anesthesia
is used, the concomitant administration of intravenous sedation is included. (Class I). [42]
Locoregional anesthesia has been shown to reduce operative time, postoperative
complications, hospital stay, and reduced need for intensive care. [36]
1.10.4—Bilateral common femoral artery access for the EVAR delivery system may be
obtained via an open (surgical cut down) or pEVAR with a suture-mediated closure device.
[41, 43] Ultrasound guided access is recommended to optimize arterial access and reduce
access site complications. [44] In addition to reducing operative time and hospital stay,
pEVAR has been shown to reduce wound complications compared to surgical cut down
EVAR. [32] If an open cut down approach is chosen, transverse incisions are typically used
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to expose the femoral arteries. This is associated with a lower rate of wound complications
in comparison to vertical incisions. [45] However, if significant femoral disease is present, a
vertical incision allows for additional femoral exposure. [37] Post-procedure wound
infections are minimized by keeping the incision above the femoral crease. [37] The patient
is heparinized. The iliofemoral artery introducer sheath size ranges from 6F to 20F. The
selected introducer size is dependent upon the femoral and external iliac artery diameter,
stent graft selected, and the presence of iliofemoral occlusive disease. If the external iliac

artery is small, retroperitoneal exposure of the iliac artery may be necessary and a synthetic
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graft sutured onto the common iliac artery. The EVAR delivery system is deployed through
this conduit. [42]
1.10.5—After bilateral femoral artery access has been attained, a guidewire is advanced
retrograde through the contralateral femoral artery up to the proximal thoracic aorta under
fluoroscopy. A marker pigtail catheter is then inserted over the guidewire to the level of L1-
L2. The main body of the stent graft is advanced over a stiff wire through the ipsilateral
femoral artery with proximal placement below the renal arteries. The position of the
contralateral graft opening (known as the gate) on the main body is verified through
fluoroscopy before insertion and during device advancement. Once the main body of the
endograft is positioned, proximal deployment begins. [37] When the proximal end of the
stent graft main body is placed, deployment of the remaining stent graft body continues until
the contralateral gate is in place.
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1.10.6—From the contralateral femoral artery, a guide wire is advanced over the marker
pigtail catheter. This catheter assists in verifying appropriate cannulation of the contralateral
gate. Retrograde cannulation of the contralateral gate of the stent graft is undertaken to
deploy the contralateral iliac graft limb. The deployment is performed so there is overlap
with the limb and the main body contralateral gate. Ipsilateral iliac limb placement follows
the same approach as described above. A completion arteriogram is done for placement
verification, patency and to assess for endoleaks (refer to 4.3.1). [37, 41] The catheters/
guidewires are removed. Arteriotomy closure is via cardiovascular sutures. Deep and
superficial tissues are re-approximated with sutures of the physician choice. If a
percutaneous approach is utilized, a vascular closure device may be included. [46]
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1.11 Endovascular Techniques Used for Complex Abdominal Aortic Aneurysms (aka
Parallel Graft-Endovascular Aneurysm Repair (pg-EVAR)
1.11.1—Although not the focus of this guideline, a brief overview of endovascular
techniques for complex AAAs is included here. Thirty to 40% of patients have unsuitable
anatomy for standard EVAR repair often due to short aortic neck (normal aorta below the
renal arteries). [47] Advanced endovascular techniques have been developed for some
complex aneurysm patients with the benefit of avoiding an open aortic repair in high-risk
patients. Due to their complexity, these techniques are often associated with higher doses of
contrast material and radiation exposure compared to standard EVAR. Physicians also report
a significant learning curve with these newer techniques. [48]
• Ullery [47] reports the two most common methods are fenestrated EVAR
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(FEVAR) and the snorkel/chimney EVAR technique (sometimes called branched

or parallel grafts). Use of these practices allows for cranial extension of the
proximal seal zone to the suprarenal aorta with preservation of visceral and renal
vessel patency.
• Patients with hostile visceral segments (e.g., calcified visceral segments or severe
neck angulations) are not candidates.

• Although all successful EVAR insertions require planning, Eagleton [49] cites
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the need for additional rigor in these complex cases. These include expert
knowledge of device construction and ancillary tools/devices, the ability to
obtain, interpret, and manipulate three-dimensional work stations.
• These procedures are much more challenging for the physician and misalignment
of branch vessel grafts or fenestrations can lead to target vessel occlusion.
• A National Surgical Quality Improvement (NSQIP) database analysis from

2005–2012 comparing EVAR to FEVAR, showed that FEVAR was associated
with longer median operative time and a significant increase in postoperative
transfusions and complications; these included a significant increase in
procedural site infection, and a trend toward increased cardiac complications,
postoperative dialysis, and longer hospital stay. [50]
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• Like any repair of the paravisceral aorta, renal failure is one of the most frequent
complications and complex endovascular repair is no exception. Although a
major FEVAR study reported a 0 % rate of acute renal injury at 30 days (despite
a high rate of renal infarction), a more recent study of FEVAR/branched grafts
noted an acute renal failure rate as high as 25%. [49]
• Most large series report favorable technical success rates of >95% for complex
aortic aneurysm repair using the two techniques described. [49] Like traditional
EVAR, secondary interventions are required to maintain graft patency and
address endoleak (refer to 4.3.1) development. Long-term durability of these
techniques is not yet known. [47]
1.11.2—Fenestrated Stent Grafts:

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• In 2012, the Zenith Fenestrated stent graft was commercially approved for
endovascular repair of short necked AAAs in the United States. [51]
• A FEVAR procedure typically requires larger sheath sizes and more catheter and
wire exchanges than EVAR. [50]
• Fenestrations are circular or elliptical holes intentionally designed within the

proximal main body and are usually customized for each patient. [47] Scallops or
U-shaped gaps are commonly employed in the same proximal main body to
allow perfusion to renal or visceral vessels. See Figure F.
• The Zenith device consists of three modular parts that are inserted retrograde via
the femoral arteries. Rarely, the left brachial approach is also required in cases of
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difficult vessel catheterization.
• Small fenestrations are usually stented to allow for proper alignment of the
visceral segment. [47]
• Since most fenestrated grafts are custom made, there is a delay of 4–6 weeks in
obtaining the graft thus prohibiting use in urgent situations. Some off the shelf
fenestrated grafts are now being manufactured and may be suitable for up to 70%
of FEVAR candidates. [49]

1.11.3—Chimney/Snorkel Configuration:
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• In contrast, the chimney or snorkel configuration utilizes an antegrade approach

(usually the brachial artery) to facilitate placement of a covered stent into one or
more branch vessels in a parallel course outside the main aortic stent graft (latter
placed retrograde via transfemoral route). [47]
• The proximal portion of the chimney/snorkel stent(s) extends beyond the

proximal edge of the main aortic stent graft, thereby extending the proximal seal
zone. See Figure G. This type of configuration is associated with a high rate of
Type 1 endoleaks (refer to 4.3.1). This endovascular method was first described
in 1999, remains off-label, and can be used in urgent cases including patients
with ruptured AAA. [49]
• The technical requirements of this approach are less demanding than the
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fenestrated approach and may be associated with less fluoroscopic time.
• Chimney stents may become kinked, compressed, or occluded. [52]
• Axillo-subclavian disease can prohibit safe passage of delivery devices to the

renal or visceral vessels. [47]
• The hypogastric snorkel technique is another advanced endovascular method

which can be employed for persons with common iliac artery aneurysms or when
distal common iliac seal zones are short. [52] This method involves placement of
a covered stent parallel to an iliac limb device and is used to reduce the risks of
buttock claudication, buttock necrosis, and bowel ischemia in the aforementioned
patients.
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1.11.4—Iliac Branch Endoprothesis (IBE)
Another complex segment of EVAR is an inadequate distal landing zone and the
involvement of the iliac arteries. Often in these patients, one or both of the iliac arteries are
excluded extending the stent graft into the external iliac artery. The risk of this technique
include thigh or buttock claudication, ischemic colitis, spinal cord injury, erectile
dysfunction, gluteal/perineal necrosis and acute limb ischemia. The use of the iliac branch
device can minimize these complications by incorporating one or both of the iliac arteries
using modular stent grafts. [53]
2. Pre-Procedural Nursing Care

2.1 Nursing Assessments
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Patients undergoing vascular procedures often have comorbid diseases, all of which should
be assessed and, if possible, optimized before the vascular procedure. Due to the systemic
nature of atherosclerosis, patients with vascular disease frequently have arterial disease
affecting multiple vascular areas. Coronary Artery Disease (CAD) is the leading cause of
perioperative mortality at the time of vascular procedure, and long-term survival after
vascular procedures is significantly limited by the occurrence of morbid cardiac events. [42]

2.1.1—Assess for co-morbid conditions and risk factors for atherosclerosis such as renal
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disease, hypertension, tobacco use, dyslipidemia, diabetes, obesity, substance abuse, prior
vascular procedure.
2.1.2—Obtain a list of current medications including over-the-counter drugs. Assess for

allergies or hypersensitivities to medications such as intravenous (IV) contrast, foods or
latex. [54, 55]
2.1.3—Obtain baseline vital signs to include apical/radial pulse, respirations, pulse

oximetry, temperature and blood pressure. Use a standard technique for obtaining the blood
pressure including the appropriate cuff size and supporting the arm at heart level (Class IV).
[56, 57] Include bilateral upper extremity blood pressures. Unequal upper extremity blood
pressures greater than 15mmHg difference in systolic blood pressure (SBP) may indicate
subclavian artery stenosis. [57] [58] Inform the physician if this SBP difference is noted.
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Notify the surgeon/interventionalist and anesthesiologist if the systolic blood pressure is

greater than 180mmHg or diastolic blood pressure is greater than 110mmHg within two (2)
hours of the procedure start time. The treating physician may consider postponement due to
an increased risk of stroke from these pressures or place the patient on additional
antihypertensive medications. [59]
2.1.4—Perform a targeted physical assessment. Notify the physician of any abnormal

findings. Clinical practice recommendations include general appearance, status of the skin
(integrity, presence of lesions/edema, nails), head/neck, neurologic status, chest including
breath sounds/heart sounds, abdominal assessment (distention/bowel sounds/genitals),
bilateral extremity motor strength and movement, temperature, color, sensation, pulses and
capillary refill. [60] If no institutional protocol in place, assess pedal pulses, mark location
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and rate as follows: 0, absent; 1, diminished; 2, normal; or 3, bounding. [10] If pulses are not
palpable, perform Doppler examination documenting presence or absence of posterior tibial
and dorsalis pedis signals and document location on the foot. [61]
2.2 Abdominal Aortic Aneurysm Diagnostic Studies

2.2.1—AAA Duplex
AAA Duplex has been widely used for screening and surveillance of abdominal aortic
aneurysms. It offers the advantage of decreased cost, increased availability, and lack of
radiation exposure or nephrotoxicity. The reliability of duplex ultrasound scanning for
routine surveillance of AAA is well accepted. [62] Instruct patient to have nothing by mouth
(NPO) at least six hours before the scheduled exam. [63]
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2.2.2—Computed Tomography Arteriography (CTA)
CTA is the cornerstone of pre-procedural imaging for EVAR. The maximum recommended
slice diameter is 2.5 mm for standard devices. Fenestrated or branched devices requires 1
mm or less cuts. Intravenous contrast should be routine unless the patient has severe renal
insufficiency or contrast allergy. The axial, coronal, sagittal, and three-dimensional
reconstructions should all be reviewed. [64, 65]

CTA utilizes non-contrast technique or IV contrast to identify the anatomy of the aorta. CTA
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uses ionizing radiation when taking x-ray pictures in the form of slices of the aorta. Contrast
media may be injected to enable visualization of blood vessels and to identify area(s) of
arterial stenosis. [64, 65]
Preparation:
• Pending institutional practices, instruct patient regarding timing of solid food/

fluids before the scheduled exam
• Complete a thorough history of allergies and specific types of reaction to

previous contrast media
• Baseline renal function tests of blood urea nitrogen (BUN) and creatinine are
completed to ensure safety of contrast administration.
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• Premedication and IV hydration may be given if contrast allergy or renal

insufficiency develops.
• Metformin should be held as noted below (refer also to 2.6.4).
• Instruct patient to wear comfortable clothing but patients may be asked to change
into a gown and remove hairpins, hearing aids, glasses, metal dental work,
necklaces, earrings, and any body piercing. [65]
Advantages of CTA:
• High resolution CT images that can be evaluated in multiple planes
• Fast testing modality
• Can visualize multiple organs simultaneously

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• Detects concomitant pathology
Disadvantages of CTA:
• More expensive than AAA duplex
• IV contrast and ionizing radiation exposure
• Intravascular calcium burden can affect visualization, and assessment of plaque

structure. [37]
Patients with significant renal insufficiency present challenges in pre-procedural imaging

before EVAR.
• Non-contrast CT scanning may be reasonable when planning a standard EVAR

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as diameter and length measurements can be made when anatomy is

uncomplicated and there is no clinical suspicion for associated occlusive disease.
[37] However, without contrast, potentially important anatomic information can
be missed including: (1) presence of laminated thrombus in the aortic neck (2)
patency of important side branches, such as the hypogastric arteries, and (3)
occlusive disease in the common or external iliac arteries. Significant

calcification in the iliac arteries, particularly the external iliac arteries, should
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make the operator suspicious. [37]
• Alternative Imaging:
• In patients with severe renal insufficiency who need better definition of anatomy
prior to performing an EVAR, intravascular ultrasound (IVUS) can be used to
size the aortic and iliac seal zones, evaluate for potential aortic neck eccentric
thrombus, and interrogate the external iliac arteries for potential occlusive
disease. [66]
• Direct angiographic imaging can be obtained using carbon dioxide as the

contrast agent with relatively good visualization. [37]
2.2.3—Magnetic Resonance Angiogram (MRA)

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MRA uses radio waves and magnetic fields to create detailed images showing blood flow
inside the vessels. Gadolinium, a non-iodinated contrast media, may be used to improve the
test’s accuracy by making the arteries more visible. Gadolinium is not without consequence
as it can trigger nephrogenic systemic fibrosis in those with a history of renal disorders. [67]
MRA can precisely define the dimensions and extent of aortic arch aneurysms, dissections,
vascular tumors and periaortic abscesses. It also can identify the structure of atherosclerotic
plaque. [68]
Preparation for MRA:
• History of contrast allergies
• History of any metal implants in their body. These include pacemakers or

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implantable cardioverter defibrillator (ICD); surgical metal rods, screws, plates,

stents, clips, pins, staples and wires (some may not be exclusionary),
intravascular embolization coils, cochlear implants, metal heart valves, shrapnel
or bullets, implantable ports and nerve stimulators, penile implants. [69]
• Removable dental work and body piercings must be removed. [70]
Advantages of MRA:
• Noninvasive, with no ionizing radiation or iodinated contrast.
• Can visualize arteries beyond coverage area for AAA Duplex and is helpful in
providing preoperative information including the type and localization of an
aneurysm, its diameter and cranial caudal extent, the aneurysmal wall structures
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and periaortic space, the relationship to mesenteric and renal arteries and the
presence of iliac aneurysm or stenosis. [71]
Disadvantages of MRA:
• Possible over-estimation of the degree of stenosis due to arterial calcification.
• Difficult to perform if patient is claustrophobic or uncooperative. [72]
2.2.4—Abdominal Aortic Aneurysm Contrast Angiography

Standard digital subtraction arteriography (DSA) has little utility in the preoperative
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evaluation for EVAR (as it only delineates aortic lumen) and should not be routinely
employed. With rare exception, all anatomic details can be obtained with CTA scanning.
[37]
2.2.5—Ankle-Brachial Index (ABI)
PAD is an independent risk factor for increased Major Adverse Cardiovascular and
Cerebrovascular event (MACCE) and stroke [73, 74] in patients with AAA undergoing
EVAR. Thus, patients with AAA should be screened for PAD. The Ankle-Brachial Index
(ABI) is the most cost-effective screening tool used to diagnose lower extremity PAD.
Patients with the history or physical exam suggestive of PAD or at risk for PAD should
undergo an ABI. The following individuals are at risk for PAD [10]:
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• Age 65 years or older.
• 50–54 years old with atherosclerotic risk factors of hypertension (HTN), diabetes
mellitus (DM), dyslipidemia, history of smoking or a family history of PAD.
• Under 50 years of age with DM and one other atherosclerotic risk factor and
known atherosclerosis in another vascular bed (such as carotid, coronary,
subclavian, renal, mesenteric arteries or abdominal aortic aneurysm).
• Patients with left ventricular dysfunction or heart failure. [75]
2.3 Diagnostic Laboratory Testing

a. Healthcare facilities have developed protocols and algorithms to incorporate
evidence-based practice as opposed to a clinician “style.”[76] Patients with signs
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or symptoms of active cardiovascular disease should be evaluated with

appropriate testing, regardless of their pre-procedural status. [77]
b. Verify that ordered pre-procedural laboratory tests have been done within the
pre-established time period (usually within 7 days of the procedure or as
specified by the institution). General recommendations are described by Fleisher,
et.al, 2014. Typical baseline laboratory tests include a complete blood count,
blood urea nitrogen, serum creatinine, electrolytes, partial thromboplastin time,
prothrombin time with International Normalized Ratio (INR). [78, 79] Include
measurement of blood glucose in diabetic patients. Patients should be typed and
screened preoperatively. [80]
• Patients with Hemoglobin <7g/dl are recommended for blood

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transfusion
• Platelet count <150,000/uL should have a hematology evaluation

preoperatively. [11]
c. Perform a 12-lead Electrocardiography (ECG) within 30 days of EVAR. [11, 79]

ECG is recommended for patients undergoing high-risk vascular procedure and
those undergoing intermediate-risk surgeries who have additional risk factors.

[77] Further cardiac testing may be warranted based on patient’s risk factors and
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past medical history.
d. Perform additional ancillary diagnostic studies based upon the institutional

protocol as well as patient factors including age, gender, and presence of severe
obesity or comorbidities (e.g. pregnancy test, pulmonary function studies, stress
test, and chest x-ray). [79, 81] Notify physician of any abnormal results.
2.4 Anesthesia Evaluation

An anesthesia evaluation is not always needed pending institutional protocol. When
anesthesia evaluation is needed, confirm that an anesthesia assessment has been scheduled
before the procedure.
Goals of pre-procedural clinical assessment and evaluation:

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• Plan for the selection of anesthetics
• Evaluate for a familial history of malignant hyperthermia
• Assess the patient’s airway.
• Provides opportunities for patient education [82]
• Formation of a plan-of-care for the perioperative and recovery periods (Class I)

[83]
2.5 Pre-Procedural Patient Preparation/Education

2.5.1—Remove jewelry/body piercings [84]
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2.5.2—Clip any hair on the patient at the selected procedural site with electric clippers as
ordered [85, 86] (Class I). Clipping instead of shaving reduces the incidence of procedural/
surgical site infections (SSI).
2.5.3—Cleanse patient[85, 86] pre-procedurally using a chlorhexidine shower or disposable

wipes to reduce bacterial skin flora and the risk of SSI. [87]
2.5.4—Establish peripheral intravenous (IV) access; depending upon institutional protocol,

two IV sites may be preferred. Hypnotic agents and other medications are administered
intravenously during the procedure. [83]
2.5.5—Maintain NPO status based upon surgeon/interventionalist/anesthesiologist

preference and type of food ingested. This can range from 8 hours (fried/fatty foods) to 2
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hours (non-alcoholic clear liquids). NPO status reduces the potential for aspiration due to
anesthesia (Class IV). [83]
2.5.6—Provide additional patient education regarding procedure. This may include

handouts, videos and internet resources. This process should continue through preadmission
testing and be completed on the day of the procedure. Pre -procedural teaching decreases
anxiety regarding the surgical/procedural experience. [88]

2.5.7—Smoking Cessation
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• Smoking cessation is recommended for at least 2 weeks prior to aneurysm repair.

[11]
2.5.8—Infection Prophylaxis
• Any infection or potential infection that could lead to sepsis (such as a dental
abscess) should be should be eliminated 2 weeks prior to EVAR. [11]
2.6 Pre-Procedural Management of Medications

EVAR has also been associated with a significant risk of implant and procedure-related
complications, such as graft thrombosis and cardiovascular events, including death,
necessitating interventional and pharmaceutical management. To reduce the overall risk for
cardiovascular events, the implantation of an endovascular aortic graft necessitates the use of
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at least one antiplatelet agent postoperatively and this treatment is in-line with the medical
management of coronary artery disease which also includes antiplatelet and statin therapy.
[89]
• Continue most medications that have withdrawal potential and hold non-essential
medications the day of EVAR.[90] Refer to additional sources for a broader
overview of chronic medications in the pre-procedural setting. [45, 90, 91]
2.6.1—Antiplatelet Agents
• Continue aspirin in patients with prior coronary percutaneous interventions.

However, when applicable, P2Y12 platelet inhibitors should be stopped at the
most 10 days prior to procedure, however this is done in consultation with the
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patient’s cardiologist. [11]
The antiplatelet agents that are more frequently prescribed include aspirin and clopidogrel.
• Aspirin irreversibly inhibits platelet cyclo-oxygenase, blocking thromboxane A2

production in platelets and therefore decreases platelet aggregation- a P2Y12
platelet inhibitor.
• Clopidogrel is a thienopyridine derivative that inhibits platelets by selectively

and irreversibly binding to the P2Y12 receptor and, therefore, blocks the
adenosinediphosphate (ADP) dependent pathway of platelet activation.
• In patients taking a combination of two different antiplatelet agents, known as

dual antiplatelet therapy (DAPT), strong considerations must be given to the risk
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of excess bleeding. [89]
2.6.2—Lipid-Lowering Therapy
• Administer statin medications in patients with PAD (Class I). [10]
Although statins are known for cholesterol lowering effects, the theorized
reduction in vascular inflammation and stabilization of plaque supports their pre-
procedural administration. [92] A study by the Vascular Study Group of New

England showed reduced 30-day mortality and 18% improvement in 5-year

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survival after various vascular surgeries when antiplatelet and statin medication
were utilized pre-procedurally and at discharge. [93, 94] Hold non-statin lipid
lowering medications such as bile acid sequestrants (cholestyramine and
colestipol) which may interfere with bowel absorption of peri-procedural
medications. [95]
2.6.3—Antihypertensive Medications
• Administer previously prescribed calcium channel blockers, alpha agonists,

vasodilators, and nitrates the morning of the procedure with a sip of water. [59]
• Hold angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor

blockers (ARBs) the day of the procedure [11] due to the potential of intravenous
(IV) contrast worsening renal function.
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• Hold any diuretic medication the day of the procedure (Class II). [79, 90] Loop
and thiazide diuretics can cause hypovolemia and hypokalemia and ca[91]n
intensify the known hypotensive effects of anesthesia induction. [45, 90]
• Administer previously prescribed beta-blocker (Class IV). [78] If not already on

a beta blocker, when indicated, start well in advance of the procedure to ensure
tolerance and safety. [11]
2.6.4—Diabetic Medications
• Hold metformin in patients with an estimated glomerular filtration rate (eGFR)

of <60ml/min or up to 48 hours before administration of contrast if eGFR <
45ml/min. [11]
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• Hold other oral hypoglycemic agents the morning of the procedure. [96]
• Adjust any prescribed long-acting insulin based upon the healthcare facility’s
protocol. Supplemental short-acting insulin may be administered during this
period to maintain a target glucose level between 140–180 mg/dl in the critically-
ill patient (Class II). [97]
2.6.5—Chronic Pain Medications
• Stop all non-steroidal anti-inflammatory medications at least 3 days prior to

procedure or as directed by the physician. [90, 98] These medications reduce
platelet aggregation and increase the risk of bleeding by a decreased production
of thromboxane. [98]
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• Continue chronic opioid medications the day of procedure to reduce irritability,

diaphoresis, insomnia, nausea and other symptoms of withdrawal. [59]
2.6.6—Pulmonary Medications
• Administer chronic bronchodilators for at least 2 weeks prior to aneurysm repair.

[11]

• Continue pulmonary inhalers on the day of procedure to reduce the incidence of

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post-procedural complications. [98, 99]
• Hold theophylline the evening before procedure as it may precipitate arrhythmias

and interact with anesthetic medications. [59, 98]
• Continue glucocorticoids (used for pulmonary or other indications) the day of the
procedure as to avoid symptoms of adrenal insufficiency; consider stress
(supplemental) dose steroid if a patient has received oral corticosteroids for 3
consecutive weeks or more. [59]
2.7 Management of Antithrombotic Medications and Dietary Supplements

Inform patients regarding the risks and benefits of a temporary interruption of their anti-
thrombotic therapy. [100] If the patient agrees, the anticoagulation manager and operating
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physician need to develop a patient specific plan. [100, 101]
2.7.1—Heparin
• Withhold any non-bridged unfractionated heparin or low-molecular weight

heparin based upon the healthcare facility’s protocol
2.7.2—Vitamin K Antagonists
• Withhold Vitamin K antagonists (VKA’s) such as warfarin for approximately 5

days before the procedure (Class IV). [102] The International Normalized Ratio
(INR) should be normal or near normal (less than 1.5).
• If bridging therapy is required (e.g., patient with chronic atrial fibrillation or

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mechanical heart valve patient who is at high risk for venous thromboembolism),
administer a therapeutic dose of a low-molecular weight heparin (LMWH) such
as enoxaparin. The last LMWH dose should be administered approximately 24
hours before the procedure (Class IV). [102]
• If the patient is receiving therapeutic-dosed unfractionated heparin (UFH) as the

bridging medication, the last dose should be stopped within 4 to 6 hours of the
procedure (Class IV). [102] In the chronic atrial fibrillation or mechanical heart
valve patient who is at a low risk for VTE; no bridging therapy is recommended
(Class IV). [102]
2.7.3—Other Oral Antithrombotic Agents
• Withhold Dabigatran for 1 to 2 days before the procedure in patients with a

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creatinine clearance ≥50ml/minute. If the creatinine clearance is < 50ml/minute,

withhold medication for 3 to 5 days. A longer withholding time may be
considered in patients where total hemostasis is necessary. [103]
• Stop Rivaroxaban, at least 24 hours before the procedure. [104]
• Hold Apixaban at least 24 hours in elective procedures that are considered to be

low-risk for clinically significant bleeding. But since AAA surgery is considered

moderate to high risk for clinically significant bleeding, apixaban should be

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withheld for 48 hours before the procedure. [105]
• Hold Endoxaban 24 hours before the procedure. [106]
2.7.4—Herbal/Dietary Supplements
Instruct the patient not to take any herbal or dietary supplements for the specified number of
days prior to the procedure, based upon the institution’s protocol.
• There is an increased potential for bleeding and alteration in the effects of

medications such as warfarin (Class IV). [107, 108]
• Ginkgo, Vitamin E and garlic (allium sativum) demonstrate antiplatelet activity

and increase bleeding time (Class I). [107, 108]
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• Case reports have shown an interaction between herbal supplements St. John’s
Wort (hypericum perforatum) and American ginseng that decrease the INR
(Class IV). [107, 108] Dan Shen (salvia miltiorrhiza) increases the INR (Class
IV). [107, 108]
2.8 Prevention of Adverse Contrast Media Hypersensitivity Reaction

2.8.1—For patients allergic to contrast media:
• Administer a combination of glucocorticoids and antihistamine medication 13

hours prior to the procedure. Prednisone 50mg (adults) dose is given orally 13
hours, 7 hours and 1 hour pre procedure.[109]
• Inject methylprednisolone 40mg (adult) intravenously if patient cannot take oral

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medications; interval dosing at 13, 7 and 1-hour pre-procedure.
• Diphenhydramine 50 mg (adult dose) is administered either orally or IV an hour

before procedure. [109]
2.8.2—Risk factors for contrast media hypersensitivity [109]
• Acute or chronic kidney disease
• Diabetes mellitus
• Myeloma,
• Dehydration
• Cardiopulmonary disease
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• Repeat contrast administration
• Female gender
• Use of ACE inhibitors, beta blockers or proton pump inhibitors

2.9 Prevention of Contrast-Induced Nephropathy

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Contrast–Induced Nephropathy (CIN) is defined as an increase in serum creatinine levels >

25% or 44.2 μmol/L (0.5 mg/dL) within 3 days of intravenous contrast; incidence 7–11%.
There are currently no recommended protocols to prevent CIN.
2.9.1—Administer IV hydration with normal saline or 5% dextrose/sodium bicarbonate for

patients at increased risk of CIN undergoing EVAR both before and after procedure. [11]
2.9.2—No benefit was found using IV sodium bicarbonate over sodium chloride or oral
acetylcysteine over placebo for the prevention of kidney injury or death. [110]
2.9.3—The greatest reduction in CIN risk was found the administration of statins plus N-
acetylcysteine and intravenous saline compared with the use of N-acetylcysteine and saline
alone. [11, 111]
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2.9.4—Risk Factors for CIN: chronic kidney disease, diabetes mellitus, hypertension, and
being elderly.
2.9.5—A linear relationship exists between the development of CIN and contrast infused;
for every 100 mL of contrast material administered, there is a 12% increase in the risk for
CIN. [11]
3. Peri-Procedural Nursing Care

3.1 Before Patient Enters the Procedural/Operating Room:
3.1.1—Verify correct patient identification using two identifiers. This is done every time the
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care responsibility of a patient is transferred to another person in the peri-procedural course

to avoid wrong-site procedure utilizing a standardized checklist. (Class I). [112–114]
3.1.2—Ascertain that the patient has signed the procedural consent and anesthesia consent.
Confirm the operating physician or interventionalist has signed the procedural and blood
consents and the anesthesiologist or nurse anesthetist has signed the anesthesia consent.
3.2 Intra-Procedural Care

3.2.1—Assist with attachment of ECG monitor leads, non-invasive blood pressure cuff and
pulse oximetry probe once patient is on the procedural/operating room table. If indicated,
obtain baseline blood pressure, heart rate, respirations, SpO2 and ECG rhythm.
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Monitor blood pressure and ECG rhythm as indicated with anesthesia. Notify anesthesia and
the operating physician immediately if hypotension or hypertension occurs. Blood pressure
fluctuations are due to multifactorial causes that may include prior history of hypertension,
pain-induced sympathetic nervous system stimulation and anesthesia induction. [115]
Treatment is dependent upon the physician preference and includes the following options
[115, 116]:

• Hypotension (in suspected hypovolemia): cautious volume expansion using

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isotonic crystalloid or colloid per physician choice.
• Hypotension (in normovolemia): IV phenylephrine
• Hypertension: IV labetalol, IV nitroglycerin
3.2.2—Maintain core body temperature at or above 36 degrees C during the aneurysm

repair. [11]
3.2.3—Assist with setup and insertion of an arterial line if directed.
3.2.4—Insert a urinary catheter if indicated by institutional protocol.
3.2.5—Conduct a procedural time-out before the procedure is started to avoid making a

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mistake. (Class I) [113]
3.2.6—Administer, the ordered intravenous (IV) antibiotic prophylaxis within one (1) hour
of surgical incision at the recommended infusion rate to reduce the incidence of SSI. [117]
(Class I)
Antibiotic Prophylaxis:
• First-generation cephalosporin or vancomycin (if allergic to penicillin) should be

given intravenously 30 minutes before EVAR.
• Antibiotics should not be continued for more than 24 hours. [11]
3.2.7—If general anesthesia is utilized, observe for the development of malignant

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hyperthermia (MH) which is a genetic disorder that is precipitated by use of volatile

anesthetic agents (halothane, enflurane, isoflurane, desflurane, and sevoflurane) or the
muscle relaxant succinylcholine, or both. [118] It is characterized by life-threatening,
extremely high fever (greater than 110 degrees Fahrenheit), skeletal muscle spasms,
hypotension, change in level of consciousness, tachypnea, and tachycardia. Acidosis,
hyperkalemia, cardiac arrhythmias, and rhabdomyolysis may occur. [119] Early recognition
is integral to preventing mortality. Immediate treatment consists of switching to a non-
inducing agent, administering dantrolene 2 mg/kg IV, and repeating until the cardiovascular
symptoms stabilize to a maximum of 10mg/kg (Class IV). [119, 120] In addition,
hyperventilation with 100% oxygen, application of external cooling devices and
administration of chilled IV normal saline are used (Class IV).[119, 120]
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3.2.8—Monitor for intra-procedural complications and assist as indicated in stabilization:
a. Conversion to open AAA repair.
The overall incidence of conversion (early or late) is approximately 2%. Risk

factors include female gender, non-Caucasian ethnicity and large aneurysm size.
[121] Despite the newer endovascular salvage techniques for complications post
EVAR, some patients may require conversion to open repair. Elective open
surgical conversion following failed endovascular repair may be associated with

increased morbidity and mortality, particularly if the patient was deemed at high
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risk for open repair. [33]
b. Vascular access bleeding, hematoma, thromboembolism
c. Endoleaks-in particular Type I [122] (refer to 4.3.1)
d. Respiratory depression (if local anesthesia with sedation)
3.2.9—Assist with the application of physician-determined type of sterile dressing

(including topical sprays) over the procedural incision site. There is no clear evidence that
supports one type of dressing over another to prevent surgical site infection (SSI). The
choice of dressing should be based on cost and symptom management goals (Class I). [123]
3.2.10—When general anesthesia is used, assist with ECG-monitored transport to the Post-
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Anesthesia Care Unit or other designated unit according to institutional protocol.
3.2.11—Confirm pedal pulses (see 2.1.4) with physician prior to leaving the operating room
4. Post-Procedural Nursing Care

After procedural recovery has occurred, the patient is transferred to a secondary nursing unit
until discharge. Depending upon institutional protocol, this may be an intensive care unit, or
a specialized cardiovascular unit. Patients are instructed to lay flat for 1 to 4 hours after
sheath removal with closure device, 4 to 8 hours after sheath removal with manual
compression. [124] Length of stay is typically 1–3 days. [125]
4.1 Assessments
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4.1.1.—Obtain vital signs (VS) to include blood pressure (BP), apical pulse, respirations,
peripheral capillary oxygen saturation (SpO2). Additionally, check and document level of
consciousness, pain and sedation level at the specified intervals during recovery and progress
thereafter according to institutional protocol. If the patient is transferred to a Post Anesthesia
Care Unit (PACU), then use of a PACU scoring system is required (Class IV). [126]
Maintain the systolic BP greater than 90mmHg and less than 180mmHg to avoid post-
procedure complications of hypotension, hematoma formation. [115] Respirations should
include rate, depth, effort and symmetry. If an arterial line is present, maintain system
according to institutional policy.
There is a lack of evidence regarding the frequency in obtaining VS in the immediate post-
procedure period. A single randomized controlled trial of 189 patients compared an
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experimental protocol (VS every 1 hour for 2 hours then every 4 hours for 24 hours) to
standard practice (VS every 1 hour for 4 hours then every 4 hours for 24 hours) for post-
operative patient monitoring. There were no significant differences observed between the
two groups at 4 or 24 hours. [127] The authors recommend that clinician judgment should
be used in monitoring VS frequency. The American Society of PeriAnesthesia Nurses
(ASPAN) advises that VS frequency should be determined by each individual facility and
pain should be assessed frequently. [126, 128] The ASPAN website reports that expert

opinion states VS should be taken every 5 to 15 minutes during the initial stabilization and
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more frequently if clinically indicated. [126]
Blood pressure should be monitored post procedure to prevent cardiac or renal

complications.
• Hypotension. The treatment is the same as described under 3.2.1.
• Hypertension. The treatment, blood pressure parameters and pathophysiological

mechanisms behind the development of hypertension are the same as delineated
under 3.2.1.
4.1.2.—Pain and sedation levels should be assessed using a standardized scoring system.
Sedation scale options include the Richmond-Agitation Sedation, Motor Activity, Sedation-
Agitation or the Ramsey. [129] Pain is typically self-reported using a numeric or Faces scale.
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[128]
4.1.3.—Cardiac Monitoring
• Monitor ECG in the immediate postoperative period in EVAR patients with

known or suspected coronary artery disease (CAD). [11, 79]
• Check postoperative troponin levels and 12-lead ECG for all patients who
develop chest pain or ECG changes. [11]
4.1.4.—Administer oxygen via nasal cannula at flow rates as ordered. The goal is to
maintain a target oxygen saturation of at least 94% in acutely ill patients and 92% in those
patients at risk for hypercapneic respiratory failure unless otherwise specified (Class IV).
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[130]
4.1.5.—Maintain a patent IV site and continuous ECG monitoring throughout the hospital
stay or as specified by the physician. The potential for cardiac arrhythmias, coronary
ischemia and other hemodynamic complications may develop in the post-operative period).
[11, 131]
4.1.6.—Post-procedural assessment following EVAR should include a thorough lower

extremity pulse exam or ankle-brachial index (ABI). [11] See also Section 2.1.4.
Assess circulation, motion, and sensation (CMS), color, and capillary refill. Ensure patient
has bilateral pedal pulses. The location of pedal pulses should be marked. Assess blanching
in the toe nails, ability to wiggle toes or dorsi/plantar flex. Assess for new numbness and
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tingling.
4.1.7—Institute ordered venous thromboembolism (VTE) prophylaxis measures to avoid

venous stasis and thrombus development
• The use of intermittent pneumatic compression and early ambulation is

recommended for all patients undergoing EVAR. [11]

• VTE risk factors include procedure length > 45 minutes, advanced age, and often
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the presence of obesity. [11]
• Patients at low risk for bleeding should receive either low molecular weight
heparin (e.g., enoxaparin 40 mg subcutaneous daily) or unfractionated heparin
(e.g., heparin 5000 IU subcutaneous two to three times a day); it should be
initiated within 24 hours and as per the judgment of the surgeon/interventionalist.
[11]
• Consider postoperative anticoagulation for EVAR patients at high risk for DVT
(prior history of DVT or pulmonary embolus, persons who are overweight (BMI
>25), have limited mobility, have a malignancy or a hypercoagulable state. [11]
4.1.8—Maintain head of bed below 45 degrees to prevent flexion at graft site. [132]
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4.1.9—Monitor urine output (0.5–2.0 ml/kg/hour) to ensure adequate kidney perfusion.

[133, 134]
4.2 Incisional/Access Site Care

4.2.1—Remove any dressings if present, at the time interval specified. The timing of
dressing removal (within 48 hours or after 48 hours) does not appear to have a detrimental
effect on outcomes (Class I). [135]
4.2.2—Keep the incision site dry for the first 48 hours after the procedure. Avoid use of
topical antimicrobial agents (Class IV). [136, 137]
• Once groin dressings are removed, advise patient to keep groin wound clean and
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dry and monitor for evidence of infection.
4.3 Assessment for Post-Procedural Complications

• Monitor for post-procedural complications, notifying physician if any are present
EVAR has also been associated with a risk of implant and procedure-related complications,
such as graft thrombosis and cardiovascular events, necessitating interventional and
pharmaceutical management. [138] The overall complication rate related to EVAR ranges
from 16 to 30%. [33]
Risk factors for late mortality in patients with AAA who have undergone repair are: age≥80,
female gender, heart failure, ischemic heart disease, COPD, chronic kidney disease, and
diabetes. [73] Thus, patients with these risk factors should be monitored more closely for
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post-procedural complications.
Nursing care of patients undergoing EVAR with complex fenestrated or branched devices
have not been established but will be directed by institutional protocols. Usual EVAR care
may be supplemented since these grafts incorporate the visceral and renal vessels into the
repair (and in some cases the hypogastric arteries) and target vessel occlusion or embolus
can compromise the blood flow to the end organs. Nursing measures may include more
frequent monitoring and reporting of intake and output, abdominal assessments, blood

pressure monitoring, and laboratory testing. When the brachial artery is utilized (e.g., for
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chimney/snorkel cases and some FEVAR cases), nurses will need to monitor the upper
extremity for access site complications such as hematoma, thrombosis, atheroemboli, and
infection. [47] Ideal pharmacologic adjuncts have not yet been established for these
advanced endograft techniques. [45]
4.3.1—Endograft-related complications
• The incidence of endovascular complications is 11–30 % such as vascular injury,

stent fracture/kinking or endoleaks. [33]
Endoleak- described as incomplete exclusion of the aneurysm sac by the graft. There is
persistent blood flow in the aneurysm sac following stent grafting. [37, 40, 138] An
endoleak occurs when there is blood flow outside the stent graft but within the aneurysm sac
(Picel 2014). [139]
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Endoleak types:
• Type I Endoleak: Persistent blood flow in aneurysmal sack following stent

grafting that typically occurs during the EVAR procedure. Occurs at the stent
graft attachment sites due to an incomplete attachment site of the proximal or
distal graft to the aortic lumen. Predisposing factors include tortuous
configuration, atherosclerotic burden at attachments sites, and advanced
techniques that preclude apposition of the graft to the vessel lumen.
• Type II Endoleak: The most common type of Endoleak. Results from leakage of
collateral vessels into the excluded sac most commonly the IMA or lumbar
arteries. Type II endoleaks are generally not treated unless there is an increase in
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the sac size (Sternbergh 2014, Tefera 2014, Walker 2010). [37, 40, 138] Risk
factors include a larger IMA ostium, a greater number of lumbar arteries, and
lack of pre-embolization of the IMA or internal iliac arteries. [140]The best
indicator of hemodynamic significance in type II endoleaks is the change in size
of the aneurysm sac. If the sac is increasing in size, there is a higher risk of long-
term rupture. If the sac is stable or decreasing in size, the risk is likely to be less.
Patients who present with symptoms suggestive of sac pressurization/expansion
such as nonspecific abdominal or back pain that is otherwise unexplained by the
patient’s history associated with an increase in aneurysm sac diameter should be
considered for treatment.
• Type III Endoleak: Graft mechanical failure: graft rupture or leakage between the
graft components. Requires urgent repair.
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• Type IV Endoleak: Occurs due to flow directly through the fabric of the graft.
Rarely seen in the newer grafts.
• Type V Endoleak: Is usually diagnosed when all other types of endoleak have
been excluded. It refers to increase in the sac size without endoleak.
Graft migration occurs in up to 3% of patients. [139] Migration of greater than 10 mm is

considered significant. [140] There is risk for graft thrombosis with significant migration.

Migration can result in endoleak, limb occlusion and rupture. It is usually repaired with a
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graft limb extension. [139] Graft kinking results from migration or decreasing aneurysm sac
diameter which can lead to limb thrombosis. Treatment options include aorto-uni-iliac graft
to avoid thrombosis, thrombectomy and stent placement to salvage a thrombosed limb, or
femoral to femoral artery bypass. Surveillance is recommended to evaluate for limb
thrombosis which may result in buttock claudication especially in the presence of bilateral
internal iliac artery exclusions. [37, 40, 138]
4.3.2—Infection/Groin Complications
• Incidence of access site complications is 9–16%. [33]
• Signs of infection including redness at the incision site, fever, abnormal

laboratory values, abnormal tenderness or distention, purulent drainage, or ill-
defined pain should be reported to physician. [11]
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• Retrospective studies have identified age >80, use of an intraortic balloon pump,
procedural hypotension, female gender and excessive anticoagulation as
predictors of retroperitoneal bleeding. [141]
4.3.3—General anesthesia-related complications
If the procedure is performed under general anesthesia, the initial primary focus is on airway
and breathing assessments. Airway and oxygenation are supported as indicated with airway
positioning, oxygen as indicated, monitoring respiratory rate, depth and effort along with
oxygen saturation, nebulizer treatments, medications, and oropharyngeal suctioning.
Additional complications are treated per institutional protocol. The following complications
from general anesthesia may be observed: [142–144]
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a. Upper airway obstruction from loss of pharyngeal muscle tone, edema,

laryngospasm, neuromuscular blockade or history of obstructive sleep apnea.
b. Hypoxemia from alveolar hypoventilation or pulmonary edema.
c. Hemodynamic instability (hypotension/hypertension)
d. Nausea and/or vomiting
e. Shivering
f. Delirium
4.3.4—Intestinal Ischemia- Bowel ischemia occurs in 1 to 3 percent of patients following

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endovascular aneurysm repair, likely due to atheroembolism or thromboembolism from

manipulation of wires and catheters in the suprarenal aorta. Suspect ischemic bowel if
patient has abdominal pain/tenderness, post-procedural diarrhea, especially if bloody, nausea
and vomiting, fever, and/or change in mental status. [33, 145]
Abdominal Compartment Syndrome- has been reported following EVAR
• The risk is higher in patients with ruptured AAA due to the extent of fluid
resuscitation and the volume effect of the retroperitoneal hematoma.

• One study reported up to a 10% incidence of this in patients following EVAR of

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ruptured abdominal aortic aneurysm. [30]
• Abdominal compartment syndrome can theoretically occur following elective

EVAR. [30]
• Symptoms of Abdominal Compartment Syndrome or intra-abdominal

hypertension (IAH), may initially be shortness of breath and reduced urine
output, followed by abdominal pain, increase in abdominal girth, melena, nausea
and vomiting. Complications from abdominal compartment syndrome include
decreased cardiac output, atelectasis, acute kidney injury and mesenteric
ischemia. [146]
4.3.5—Lower Extremity Ischemia / Acute Limb Ischemia (ALI)

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• Incidence of endograft limb occlusion leading to ischemia is up to 7%. [33]
• The third most common reason for readmission post EVAR; 60% occurring
within 6 months of EVAR (Wang, 2017). Risk factors for limb occlusion: small
or tortuous iliac artery, and significant thrombus load within the abdominal
aneurysm sac. [147]
• ALI involves an abrupt hypoperfusion of the limb, usually occurring in less than
two weeks post EVAR, caused by thrombus, embolus or trauma. The following
symptoms (“6 Ps”) can occur in ALI: pain, pulselessness, paresthesias, pallor,
poikilothermia (cold sensation) and paralysis. [10, 17, 24, 148]
• Evaluate for graft limb occlusion if patient develops new-onset of lower

extremity ischemia, claudication or reduction in femoral pulse or ABI post
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EVAR. [11]
• Observe for Blue Toe Syndrome- characterized by tissue ischemia due to

cholesterol or atherothromboli embolization that can be dislodged when EVAR
device is inserted, leading to the occlusion of small vessels and causing a
mottling or cyanosis of the digits. [149]
• Compartment Syndrome-results from edema within the osteofascial

compartments of the limb causing intracompartmental pressure resulting in
compression of vascular structures leading to limb ischemia. [17]
4.3.6—Aortoenteric Fistula (AEF)
• Incidence of endograft infection is 0.4–3% and is associated with a mortality rate

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of 25–50%. [33]
• Usually occurs later, most commonly involves the duodenum but can be any part
of large or small intestines. Signs include upper gastrointestinal (GI) bleeding or
herald bleeding. Any GI bleed should prompt further investigation to rule out
AEF (Class 1). [11]
4.3.7—Post Implantation Syndrome (PIS) [11, 150]

• Symptoms: fever >100.4 degrees Fahrenheit for > one day and leukocytosis
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(WBC >12,000 with negative blood cultures). Patient should report fevers of this
magnitude/duration to the EVAR physician
• Systemic inflammation may be demonstrated by elevated levels of inflammatory

markers such as high sensitivity C-reactive protein (hs-CRP) and interleukin 6
(IL-6).
• Occurs in approximately 35% of EVAR patients, may increase major adverse

cardiac events (MACE), leading to prolonged hospitalization
• May be associated with polyester stent grafts, heart failure, preoperative

leukocytosis, and new thrombus formation within the excluded aneurysm sac
• Data regarding the exact frequency, effect on adverse events rates and treatment
are lacking
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4.3.8—Spinal Cord Ischemia
• Assess for neuromotor deficits: check lower extremity strength/mobility and

quality of bladder control.
• Spinal cord ischemia (SCI) can occur as a result of microthromboemboli or if the

spinal arteries are occluded by the stent graft. [131] There is greater risk for SCI
if the EVAR patient has had prior TEVAR. [151]
4.3.9—Acute Kidney Injury
• Incidence of renal complications is 0.7–18%. [33]

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• Postoperative renal dysfunction/acute kidney injury is most likely due to

application of a suprarenal balloon occlusion or proximal clamp during surgery,
intravenous contrast, dehydration or hypotension. [152]
4.3.10—Cardiopulmonary Complications
• Incidence of MI or respiratory compromise is 3–12 % post EVAR. [33]
4.4 Diabetic Patient Management

Maintain hospitalized patient glucose between 140–180. [97]
• In diabetic patients, provide glucose monitoring through a point-of-care device at

intervals as specified per institutional protocol.
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• For patients with diabetes or hyperglycemia (serum glucose >140 mg/dL)

perform an A1C before the procedure if not performed in the prior 3 months.
[97]
• Though not defined in EVAR literature, elevated blood sugars >180 mg/dL in the
first 48 hours is an independent predictor of SSI. [137, 153]
• Administer insulin protocols allowing for predefined adjustments in the insulin

dosage based on glycemic fluctuation

• Initiate insulin therapy for persistent hyperglycemia starting at a threshold >180

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mg/dL (10.0 mmol/L). [97]
• Use of insulin sliding scale alone is discouraged. [97]
• Noncritically ill patients, who have good nutritional intake, should be given basal
plus bolus correction insulin; short acting, scheduled meal time insulin may be
indicated as well. [97]
• Adjust insulin regimens if peri-procedural glucocorticoid therapy is utilized (e.g.,

patient pre-medicated for contrast allergy or patient on chronic therapy). [97]
Home Medications:
• Metformin is held 48 hours after the procedure due to risk of peri-procedural

contrast induced nephropathy (CIN), nausea, vomiting, dehydration and lactic
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acidosis [131, 154]as long as renal function remains stable (<25% increase in
creatinine) and GFR does not drop below 30/ml/min/1.73 m2. [11]
• Sodium–glucose cotransporter 2 (SGLT2) inhibitors cannot be recommended for

hospital use as they may cause hypotension, diabetic ketoacidosis (even without
significant hyperglycemia), urinary tract infection and more; use of GLP 1
inhibitors are also avoided since they are known for unfavorable gastrointestinal
symptoms. [97]
• Patients with hyperglycemia or diabetes, who are discharged with new

medication regimens, should see their diabetes provider within 1–2 weeks’ after
discharge; otherwise, 1 month follow up advised. [96]
4.5 Patient Positioning and Activity Level

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4.5.1—Provide VTE Prophylaxis (Refer to section 4.1.7)
4.5.2—Encourage incentive spirometry to minimize post-procedural pulmonary

complications; respiratory failure is not common after EVAR but a significant number
(2.9%) still experience respiratory compromise. [155]
4.5.3—Sit the patient up in bed several hours after return to the unit the same evening
following a routine morning EVAR, via open femoral exposure. [131]
4.5.4—Discontinue as ordered invasive lines and monitors on the first post-procedural day.
[131]
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4.5.5—Ambulation/Activity:
• Maintain bedrest for 4 to 8 hours after sheath removal with manual compression.
[124] If an open cut down approach is utilized for graft deployment; bedrest time
is dependent upon the physician preference.
• Regardless of femoral cut down or percutaneous access, duration of bedrest

restriction and time to ambulation will vary by provider and institution

– There are no research studies specifying the precise bedrest time

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following EVAR when performed via cut down or percutaneous

approach. Riles [156] indicates a bedrest requirement of 2–4 hours
following use of a percutaneous closure device while Naidu [124] notes
that ambulation can occur 4 to 8 hours after manual compression
– The clinician should be mindful of patient factors that may delay

ambulation (and a subsequent early discharge); these may include
anesthetic levels, need for anticoagulation, administered antiplatelet or
thrombolytic therapy, unstable cardiovascular status, hematoma or
bleeding at the closure site, hypotension, pain while walking, and other
comorbid conditions requiring observation. [157]
– The Perclose device allows for immediate repeat vascular access should
it be necessary (although it has not been studied). [158]
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– For the occasional EVAR patient requiring Intensive Care Unit (ICU)
care, use of vasoactive medications is not an absolute contraindication
to active mobilization (e.g., dangling at edge of bed or walking to
chair); rather, changes in condition, direction of overall patient trend
and vital signs can be factored into this decision. [159]
– Patients are instructed to avoid strenuous activity for one week and not
to drive until pain free and off analgesic medications. Most patients are
discharged by post-procedural day two and feel fully recovered within 1
to 2 weeks. [131]
4.6 Post Procedure Medications

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4.6.1—Home Medications:
Most oral medications (non-diabetic) can be resumed several hours after the procedure once
oral intake is tolerated. [91, 160]
• Give a parenteral formulation of an oral beta blocker if it was prescribed prior to

EVAR until the oral regimen can be resumed; abrupt discontinuation of this class
of medication can have potential adverse effects including myocardial ischemia,
rebound tachycardia and uncontrolled hypertension.
• Continue alpha-2 agonists if previously prescribed (e.g., clonidine) in the

perioperative period as several trials have reported a reduced incidence of cardiac
events in patients who undergo vascular procedures with known CAD. [79]
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• Restart angiotensin-converting enzyme (ACE) inhibitors and angiotensin

receptor blockers (ARBs) postoperatively once euvolemia is achieved. [11]
4.6.2—Other Post Procedural Medications:
Administer appropriate interventions to control pain, anxiety, hypoxia and hypothermia.

These are fundamental factors in maintaining normotension. [91]

• Hypertension:
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– Parenteral antihypertensive alternatives include enalapril, nicardipine,

or verapamil. Labetalol, nitroglycerin, and nitroprusside are also
appropriate medications for persistent mean BP >90mmHg [161]
– Some recommend maintaining a MAP of 75 to 90 mm Hg in the initial

forty-eight hours post EVAR as this resulted in a lower incidence of
Type II endoleaks 7 days postoperative and improved AAA sac
shrinkage at twelve months. [162]
– Intravenous hydralazine should be avoided in most patients with

ischemic heart disease because it can cause reflex tachycardia and
cardiac ischemia.
• Hypotension:
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– Post-procedural hypotension can occur as a result of blood or fluid loss

and the effects of vasoactive anesthetic medications. However, unlike
open AAA repair, EVAR patients rarely require large amounts of IV
fluids and blood products. [131]
– Instead, IV fluids (used for several hours up to 12 hours) are

administered to reduce the risk of CIN. If necessary, vasoactive meds
such as phenylephrine or dopamine can be administered for
hypotension. [91, 115]
– Hypotension should prompt evaluation for occult bleeding by

performing CT scan. See also section 4.3.3
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• A bolus of intravenous calcium may be required if patient is hypo-calcemic (e.g.,

from use of heparin or many blood products preserved with citrate. [163]
4.6.4—VTE Prophylaxis: refer to 4.1.7
4.6.5—Anti-Coagulants:
• Vitamin K antagonists (VKA’s)-Resume 12 to 24 hours after the procedure;

these agents take several days for their anticoagulant effect to develop (Class IV).
[102]
• Resume dual anticoagulants (DOACs) such as dabigatran, rivaroxaban, apixaban,

and edoxapan postoperatively when there is complete hemostasis and when oral
therapy is tolerated.
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• DOACs have shorter half- lives and carry an increased risk of bleeding when
therapeutic anticoagulation is utilized in the first 48–72 hours after a procedure.
• Dabigatran, eliquis and rivaroxaban now have reversal agents should major
bleeding occur with one of these newer therapies. DOAC dose adjustments may
be necessary if the EVAR procedure is complicated by AKI and rivaroxaban may
need to be discontinued if a patient develops hepatic impairment. [101]

4.6.6—Pain Management:
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Provide adequate relief of pain post-procedure
• Multimodal analgesia is recommended for acute postoperative pain. [164] This

method combines pain relievers from two or more different drug classes or
anesthesia techniques for analgesia and often allows for lower opioid dosing.
• Effective analgesia is important as it may reduce the incidence of myocardial

ischemia. [165]
• In addition, poor postoperative analgesia can lead to poor patient outcomes,

increased risk of readmission, increased health care costs, and patient
dissatisfaction. [166]
• Nonsteroidal Anti-Inflammatory Drugs:

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– Chaer [30] briefly states that nonsteroidal anti-inflammatory drugs

(NSAIDS) and/or opioids are mainly used to control postoperative
EVAR pain. However, these agents need to be used judiciously,
especially in the early post-procedural period.
– Naughton [167] advises withholding NSAIDS for at least 24–48 hours

before and after any contrast dye administration and monitoring renal
function 24–48 hours post procedure. Patient risk factors for drug
induced nephrotoxicity are age >60 years, underlying renal
insufficiency, volume depletion, diabetes, heart failure, and sepsis.
– Perazella [168] also indicates an increased risk of nephrotoxicity when

NSAIDS are concurrently administered with radiocontrast.
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– NSAIDS should never be used when GFR is <60 ml/min. [169] In

addition, NSAIDS should generally be avoided in patients at risk for
bleeding, gastrointestinal ulceration, cardiovascular events, or hepatic
impairment. [164]
Groin incisions generally cause minimal discomfort. Assess pain location, quality, intensity,
effects on function and aggravating/alleviating factors. Institute pain management strategies.
Assess response to pain medication. [17]
• Opioid Administration:
Administer opioid medications for severe post-procedural pain
– When acute pain is severe enough for opioid administration, the lowest
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effective dose of an immediate release opioid should be prescribed and

three or fewer days is generally adequate; rarely will more days be
necessary for control of any acute pain. [166]
– Refer to the Washington State Interagency Guideline on Opioid

Prescribing [169] and the updated Practice Guidelines by the American
Society of Anesthesiologists Task Force on Acute Pain Management
[170] for further guidance relating to opioids. Important points include

checking your state’s PDMP (Prescription Drug Monitoring Program),

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assessing for preexisting pain or anxiety conditions, setting reasonable

patient expectations regarding pain, teaching the patient about safe
keeping of opioids, and more. One investigator [171] described an
average opioid consumption that was 2.64 times greater in patients
undergoing open AAA repair versus EVAR.
– When opioids are prescribed, a bowel regimen should be ordered to

counteract constipation. [43] Notably, the EVAR patient with
percutaneous femoral exposure may need minimal to no analgesics
postoperatively. [43, 172]
• Administer an around the clock regimen of a non-opioid agent such as

acetaminophen. [170] Initially, consider a patient-controlled analgesia (PCA)
device for the EVAR patient with open femoral exposure as to avoid delays in
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pain medication administration; basal rates are not recommended. [164]
• Consider employing non-drug nursing techniques as well, including ice (wrapped

in a towel for up to 20 minutes at a time), guided imagery, repositioning, and
distraction, to name a few.
4.6.7—Risk Factor Modification
Mitigating risk factors for atherosclerosis should be continued post EVAR to reduce
cardiovascular risk.
4.6.7.1: Smoking Cessation Medications:

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• Smoking cessation is indicated for all patients and they should be asked about
smoking status at every visit; if current tobacco use is confirmed, advise client to
quit and offer behavioral and pharmacotherapy treatment and/or referral to a
smoking cessation program. [173] Smoking cessation medications include
varenicline, bupropion, and nicotine replacement therapy.
• Patients who smoke can benefit from transdermal nicotine replacement to

alleviate symptoms of withdrawal.
4.6.7.2: Dyslipidemia Medications:
• Administer moderate to high intensity statin medications in patient s with PAD,

including those patients with an AAA since patients with AAA have risk factors
for cardiovascular disease to include dyslipidemia. [10, 174]
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• The exceptions to this recommendation are patients > 80 years, or who are
maintained on hemodialysis, or who have New York Heart Association (NYHA)
class II to IV heart failure. [174, 175]
4.6.7.3: Antiplatelet therapy:
• Administer ordered antiplatelet therapy.

• Antiplatelet therapy (e.g., aspirin or clopidogrel) can reduce the incidence of

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myocardial infarction (MI), stroke, and vascular death in patients with vascular
disease. [173, 176]
4.6.7.4: Hypertension Management:
• Administer hypertensive medications as ordered. See also 4.6.2. In patients with

established cardiovascular disease, maintain the blood pressure according to the
American College of Cardiology/American Heart Association pharmacologic
guidelines when systolic blood pressure (SBP) is ≥ 130 mm Hg or diastolic
blood pressure (DBP) is ≥ 80 mm Hg. [161]
• Utilize appropriate blood pressure (BP) measurement techniques which include

using proper sized cuff, and automated oscillometric blood pressure device, and
having the patient sit for at least five minutes before measurement. [56, 57]
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• Immediate postoperative EVAR BP parameters will be determined by the

surgeon/interventionalist.
4.6.7.5: Diabetes Management:
• Restart Metformin 48 hours post EVAR (Refer to sections 2.6.4 & 4.4)
4.7 Nutrition and Elimination

Post-procedural nutrition and elimination requirements are dependent upon whether AAA
was ruptured or not and the healthcare facility protocol. Routine nasogastric decompression
is not recommended. [11]
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4.7.1—Non-Ruptured AAA:
• Start ice chips once the patient has recovered from anesthesia. Diet is advanced
to the preoperative diet either the evening of the procedure or the next day per
order once complaints of nausea and vomiting have subsided.
– EVAR patients typically do not have an ileus due to absence of visceral

manipulation. [11]
• Monitor intake and output every 8 hours.
• Discontinue the urinary catheter if present no later than the second postoperative
day on an elective repair as to prevent a catheter-associated urinary tract
infection (CAUTI), counting the procedure day as day zero (Class IV). [134]
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4.7.2.—Ruptured AAA:
• Clarify with the physician when to restart diet.
– This may be slower due to physician preference and risk of abdominal

compartment syndrome
• Monitor intake and output at least initially every 8 hours.

• Maintain patency of the urinary catheter as ordered.

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– The catheter may be in for a longer period of time and monitoring of

bladder pressure may be done to detect abdominal compartment
syndrome. [177]
– The normal intra-abdominal pressure in critically ill adults is 5–

7mmHg. [146]
• Discontinue the urinary catheter once risk for abdominal compartment syndrome
resolves.
4.7.3—Constipation
• Constipation is defined as absence of bowel movements for 3, 6 or 9 days and

requiring treatment with laxatives or enemas. [178]
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• Administer prescribed stool softeners and/or laxatives for complaints of

constipation.
• Once pre-operative diet is resumed, encourage fluid intake and fiber-rich food.
Promote activities including getting out of bed into a chair and ambulation when
ordered.
• Typically, constipation is not present during hospitalization as the EVAR post-

procedure length of stay is often 2 days or less. If constipation occurs, it is the
result of pre-existing conditions, general anesthesia, alterations in diet and fluid
intake, opioids and inactivity, all which contribute to a decrease in peristalsis.
[85, 179]
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4.8 Post-Procedural Diagnostic Studies

Obtain ordered diagnostic studies per physician preference.
4.8.1—Surveillance:
• Performing short and long-term EVAR image surveillance is needed due to an

overall complication rate of up to 30% and an annual rate of aneurysm rupture up
to 1%. [40, 139]
Post procedure Diagnostic Studies: Long-term follow-up is recommended after EVAR for
early detection and management of complications; these include endoleak, graft
translocation, thrombosis and infection.
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• Periodic long-term surveillance imaging should be performed to monitor for

endoleak, confirm graft position, document shrinkage or stability of the excluded
aneurysm sac, and determine the need for further intervention in patients who
have undergone endovascular repair of infrarenal aortic aneurysms (Class 1).
[28]
Perform CT scan at 1 month, 6 months and then annually if no endoleak or sac size increase
is detected.

• Baseline CT scanning is recommended 1 month, 6 months and 12 months post

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EVAR, consider more frequent imaging if endoleak detected at 1 month. [180]
• AAA duplex as an alternate imaging modality at 12 month intervals after EVAR

if no if endoleak or sac enlargement on diagnostic studies in first year. [180]
• AAA duplex and non-contrast CT scanning as an alternate imaging modality in

patients with contraindications to iodinated contrast agents to evaluate aneurysm
sac and stent fracture. These modalities can often evaluate the aneurysm sac and
detect stent fracture. [180]
• If Type II endoleak is detected at 1-month surveillance, recommend both

abdominal duplex and contrast-enhanced CT. [11]
• If Type II endoleak is associated with a stable or shrinking aneurysm sac,

abdominal duplex is recommended at 6-month intervals for 24 months, then
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annually thereafter. [11]
• Noncontrast-enhanced CT is recommended of the entire aorta at 5-year intervals

after EVAR. [11, 180]
4.8.2—Alternate Surveillance:
Perform alternate surveillance measures when there is concern for radiation exposure and
the use of nephrotoxic agents.
• Abdominal Duplex:
– If no sac expansion or endoleak is seen during the first year, follow-up

with ultrasound (duplex) scanning may be reasonable.
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– Combined with a non-contrast CT scan, ultrasound detection of

endoleak may be a very attractive approach in patients with renal
insufficiency
– Ultrasound limitations include results dependent upon the skill of the

technologist; study is difficult in persons with a large body habitus; and
graft integrity, migration and kinking are poorly evaluated with this
modality. [139]
• MR Angiogram:
– MRA with gadolinium contrast can also be used to detect graft patency,
thrombosis, endoleak, and aortic rupture. MRA can be used in patients
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with Zenith grafts with 1.5 T magnets. MRA is contraindicated in

persons with GFR < 30 mL/min due to risk of nephrogenic system
fibrosis.
• Angiography:
– Angiography can be useful in identifying an endoleak, which is not

seen on CTA or other diagnostic studies. Angiography is the means by
which endoleaks can be treated with stent grafts, glue and coils.

4.9 Post-Procedural Patient Education

Author Manuscript
Provide discharge patient education regarding the following as indicated by institutional

protocol and physician preference. Educate patients/families about need for life-long AAA
surveillance as EVAR complications can be treated with minimally invasive procedures to
prevent rupture. A patient education tool for EVAR is available [131]. Patient education also
includes:
4.9.1—Continue prescribed medications with an emphasis on compliance as a means to

reduce complications and disease progression.
4.9.2—Activity and incisional care to include the following
a. May shower after discharge at the time specified by the physician. Avoid use of
lotions or ointments on the incision. Avoid rubbing the incision. Inspect the
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incision daily for signs of redness or drainage. Avoid clothing that rubs against
the incision until it heals. [181, 182] There is currently no evidence supporting or
refuting benefits or harms from early versus delayed bathing in development of
surgical/procedural site infections (Class I). [135]
b. Limiting the amount of weight, the patient may lift is dependent upon physician
preference. Clinically, patients are often cautioned against lifting anything
heavier than 10 pounds for 48 hours after discharge. [183]
4.9.3—Signs and symptoms to report to the physician [131] :
a. Cardiopulmonary: dyspnea, chest pain, peripheral edema, productive sputum
b. Signs of infection: fever, incisional changes

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4.9.4—Management of modifiable risk factors:
• Smoking cessation counseling/adjunctive options. Refer to section 4.6.4
• Glycemic control
– In patients with diabetes as measured by the glycosylated hemoglobin

level (A1c) to be maintained below or around 7% (Class IV). [154] A
high A1c level (>7%) may contribute to intimal hyperplasia as it was
found to be an independent predictor leading to coronary artery
restenosis after stenting. [184] Refer to section 4.4.
To reduce cardiovascular risk as an ourpatient, consideration may be given to add SGLT-2

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(sodium-glucose cotransporter-2) inhibitors which impede the SGLT-2 proteins in the renal
tubules from reabsorbing glucose back into the bloodstream) or a GLP-1R (glucagon-like
peptide-1 receptor) agonist to improve glycemic control (Class IIB). [185]
• Hypertension management:
– Refer to sections 4.6.3 and 4.6.10.

– Provide education regarding lifestyle modifications: smoking cessation,

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weight reduction, limit sodium intake, avoid use of illicit drugs

(cocaine, methamphetamines), limit alcohol consumption, increase
physical activity level, and stress reduction (Class IV). [186]
– Cholesterol reduction through dietary modifications, disease control

and medication compliance to reduce the risk of atherosclerotic disease
progression and stenosis. [174] Refer to section 4.6.8
4.9.5—Prevention of Infection-Antimicrobial Administration:
• Provide antibiotic prophylaxis prior to any dental procedure involving the

manipulation of the gingival or periapical region of teeth or perforation of the
oral mucosa, including scaling and root canal procedures to prevent
postoperative graft infection regardless of whether done by EVAR or Open
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Surgical Repair (OSR). [11]
• Antibiotic prophylaxis is suggested before respiratory tract procedures,

gastrointestinal or genitourinary procedures, and dermatologic or
musculoskeletal procedures for any patient with an aortic prosthesis if the
potential for infection exists or the patient is immunocompromised. [11]
5.0 Outcomes Reporting

• Assist in data collection and reporting of outcomes as indicated based on the
institutional quality improvement requirements.
Utilize a standardized registry such as the Vascular Quality Initiative from the Society for
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Vascular Surgery. [187] Utilize the Vascular Quality Initiative (VQI) Risk Calculator to
assess preoperative mortality [11] (see also 1.9.5). This will allow for assessment of risk-
adjusted outcomes, more efficient use of resources [188] and benchmark institutional
metrics against national results.
Appendix A:: Nursing Activities Checklist in Caring for EVAR Patient
EVAR Nursing Activities**
Pre-Operative Yes No NA
• Assess for co-morbid conditions, risk factors & previous abdominal/groin surgery. Notify MD
if present
• Obtain baseline vital signs (BP both arms, apical/radial pulse, respirations, SpO2, temperature)
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• Obtain list of current medications & assess for any allergies
• Perform a targeted physical assessment. Notify MD of abnormal results.
• Verify ordered diagnostic tests are done. Notify MD of any abnormal results.
• Start 1–2 peripheral IV sites according to institutional protocol.

• Cleanse skin using chlorhexidine shower or disposable wipes.
• Maintain NPO status for at least 4 hours prior to the procedure

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EVAR Nursing Activities**

• Provide patient education regarding medications, risk factors, peri-procedural/post-procedural
care
• Record baseline pedal pulse exam
• Administer medications as ordered (antiplatelet, lipid lowering, antihypertensives excluding

diuretics). Withhold oral hypoglycemic agents the morning of the procedure. Administer insulin
based upon institutional protocol. Withhold antithrombotic medications as specified.
• Assist surgeon/interventionalist as indicated in surgical/procedural site marking.
• Perform pre-procedure verification process according to institutional protocol.
• Administer antibiotic as ordered within one (1) hour of incision.
Intra-Operative Yes No NA
• Assemble surgical/procedural instruments per MD preference.
• Attach ECG monitor, non-invasive BP cuff, SpO2 probe to patient. Obtain baseline BP, heart
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rate, respirations, SpO2, ECG rhythm.
• Assist anesthesia as indicated with setup and insertion of arterial line.
• Assist with positioning of the patient.
• Monitor vital signs, ECG rhythm and complications during procedure. Notify MD if present.
• Administer ordered medications as indicated (unfractionated heparin, antihypertensives)
Post-Operative Yes No NA
• Monitor vital signs, ECG rhythm, pain and sedation levels at specified intervals. Include
assessment of groin/access site dressing(s) & incision for hematoma or drainage with assessments.
Notify MD of vital sign changes or groin hematoma develops.
• Perform pulse assessment upon arrival and at scheduled intervals
• Titrate IV antihypertensive medication to targeted systolic or mean arterial blood pressure
• Titrate oxygen if ordered to maintain a SpO2 of 94% in acutely ill patients & 92% in patients
at risk for hypercapneic respiratory failure
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• Maintain patent IV site and continuous ECG monitoring until discharge or as specified by the
MD
• Remove any groin/access incision dressings at time interval specified.
• Keep the head of the bed at 45 degrees & maintain bed-rest for specified time interval
• Resume clear liquids & progress diet when ordered.
• Assess for post-procedure complications – notify MD immediately if any occur

• Record post-procedural pedal pulse exam
• Provide patient education regarding risk factor modification, medications, activity restrictions,
incision care, signs and symptoms to report to MD
• Administer post-procedure medications (antiplatelet agents, antihypertensives). Follow

institutional protocol for oral antithrombotics. If diabetic: hypoglycemics may be restarted the
morning after the procedure. If angiographic confirmation of revascularization performed during
the procedure, withhold metformin/derivatives for 48-hours after the procedure.
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• Schedule follow up completion imaging studies (such as CTA or Abdominal Duplex) as

ordered
• Assist in data collection/outcome reporting as indicated based upon institutional requirements
**
These are general recommendations – follow your healthcare facility protocol
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Figure A.
Arterial Anatomy
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FIGURE B.
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Infrarenal Abdominal Aortic Aneurysm

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Figure C.
Classification of abdominal aortic aneurysms.
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FIGURE D.
Modular Aortic Stent Graft
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FIGURE E.
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Approach to Endovascular AAA Repair

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Figure F.
Diagram of Fenestrated Endograft
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FIGURE G.
Diagram of Chimnay/Snorkel Graft
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FIGURE H.
Diagram of Iliac Branch Endoprothesis
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FIGURE I.
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Abdominal Aortic Duplex

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FIGURE J.
Cross Section of Abdominal Aneurysm CT Scan
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FIGURE K.
Images of Angiogram (left) and MR Angiogram (right)
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ANALISIS JURNAL
SOCIETY FOR VASCULAR NURSING ENDOVASCULAR REPAIR OF
ABDOMINAL AORTIC ANEURYSM (AAA) UPDATED NURSING CLINICAL
PRACTICE GUIDELINE
PROGRAM STUDI PENDIDIKAN PROFESI NERS

POLITEKNIK KESEHATAN KEMENTRIAN KESEHATAN YOGYAKARTA
JURUSAN KEPERAWATAN
2021
BAB I
ANALISIS JURNAL
A. Judul Penelitian
Society for Vascular Nursing Endovascular Repair of Abdominal Aortic Aneurysm
(AAA) Updated Nursing Clinical Practice Guideline
B. Penulis
Debra Kohlman-Trigoboff, RN, MS, ACNP-BC, CVN, Kathleen Rich, PhD, RN,
CCNS, CCRNCSC,CNN, Anne Foley, MSN, RN, AGACNP, CDE, Karen Fitzgerald,
MSN, RN, NP, CVN, Dianne Arizmendi, MSN, CRNP, CWS, Carolyn Robinson,
MSN, RN, CANP, CVN, Rebecca, Brown, MEd, MN, RN, Diane Treat-Jacobson,
PhD, RN, FAHA, MSVM, FAAN
C. Tujuan Penulisan
Tujuan dan ruang lingkup penelitian ini ini adalah untuk memperbarui pedoman
praktek Keperawatan Endovaskular pada kasus Aneurisma Aorta Abdominalis
berdasarkan evidence based.
D. Model Analisis PICO

1. Problem
Aneurisma Aorta Abdominalis
2. Intervention
a. Asuhan Keperawatan Preoperatif
1) Pengkajian:
- Kaji kondisi komorbid dan factor risiko aterosklerosis seperti penyakit
ginjal, hipertensi, merokok, diabetes, obesitas
- Kaji penggunaan obat terkini, reaksi hipersensitivitas terhadap obat,
makanan dan lateks
- Kaji tanda tanda vital termasuk nadi radialis, respirasi, pulse oxymetri, suhu
dan tekanan darah. Ketidaksamaan tekanan darah sistolik pada ekstremitas
atas lebih dari 15 mmHg mungkin mengindikasikan stenosis arteri subklavia
- Informasikan apabila tekanan darah sistolik lebih dari 180 dan tekanan
darah diastolik lebih dari 110 saat 2 jam sebelum tindakan. Hal ini untuk
mencegah risiko terjadinya stroke.
- Lakukan pengkajian fisik.
2) Edukasi persiapan pre operasi
- Lepas perhiasan yang melekat di tubuh
- Potong rambut pasien pada lokasi pembedahan sesai intruksi
- Bersihkan pasien dengan mandi menggunakan chlorhexidine atau lap sekali
pakai untuk mengurangi risiko infeksi
- Jaga akses peripheral Intravena, akses IV 2 jalur lebih dianjurkan tergantung
oleh protocol institusional
- Monitor status NPO pasien sesuai intruksi. Range puasa sekitar 8 jam
(makanan yang digoreng/ berlemak) hingga 2 jam (minum air putih) untuk
mengurangi risiko aspirasi saat anestesi.
- Sediakan sumber edukasi tambahan untuk pasien terkait prosedur yang akan
dilakukan.
- Merokok dihentikan minimal 2 minggu sebelum prosedur
- Profilaksis infeksi: setiap infeksi yang mengarah pada sepsis dihilangkan
paling tidak 2 minggu sebelum prosedur.
b. Asuhan Keperawatan Perioperatif
1) Sebelum pasien masuk ruang operasi
- Mengidentifikasi pasien menggunakan 2 identifikasi
- Pastikan lagi pasien telah menandatangi informed consent
2) Asuhan Keperawatan Intra-operasi
- Monitor pasien dengan EKG, tekanan darah, pulse oxymetri probe saat
pasien dilakukan tindakan operasi.
- Jaga suhu tubuh diatas 36 derajat celcius selama tindakan
- Lakukan insersi jalir arteri apabila diintruksikan
- Pasang kateter urine
- Lakukan prosedur time out sebelum melakukan tindakan
- Berikan antibiotic profilaksis setelah 1 jam insisi dilakukan
- Apabila menggunakan anestesi umum, observasi terjadinya hipertermi
malignan
- Monitor komplikasi intra prosedural
- Asistensi pembersihan steril pada lokasi insisi
- Monitor EKG saat transportasi pasien sampai ke PACU
- Konfirmasi nadi dorsalis pedis sebelum meninggalkan kamar operasi
c. Asuhan Keperawatan Post-operasi
- Observasi tanda-tanda vital
- Kaji skala nyeri dan tingkat sedasi
- Monitoring cardiac: monitor EKG, cek level troponin dan EKG 12 lead pada
pasien yang mengalami nyeri dada
- Berikan oksigen menggunakan nasal kanul dengan aliran rendah sesuai
intruksi
- Jaga patensi akses Intravena dan monitor EKG
- Pengkajian post procedural pada EVAR termasuk Ankle-Brachial Index
(ABI)
- Manajemen pemberian profilaksis venous thromboembolism (VTE)
- Posisikan kepala dibawah 45 derajat
- Monitor urin output.
3. Comparation
ACC/AHA 2005 Practice Guidelines for the Management of Patients With
Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal
Aortic)
4. Outcome
Dari penelitian ini didapatkan hasil update pedoman manajemen asuhan
keperawatan pada pasien dengan Aneurisma Aorta Abdominalis berdasar pada
Evidence Based yang terbaru.
DAFTAR PUSTAKA
Brunner & Suddarth. 2017. Keperawatan Medikal Bedah. Jakarta. Penerbit Buku Kedokteran EGC
Golledge et al. 2006. Abdominal Aortic Aneurysm Pathogenesis and Implications for Management.
Arterioscler Thromb Vasc Biol. 26:2605-2613
Tillman et al. 2012. Abdominal Aortic Aneurysm: An Often Asymptomatic and Fatal Men’s Health
Issue. American Journal of Men’s Health. 7(2) 163 –168
Trigobof et al. 2020. Society for Vascular Nursing Endovascular Repair of Abdominal Aortic
Aneurysm (AAA) Updated Nursing Clinical Practice Guideline. J Vasc Nurs; 38(2): 36–65
Tim Pokja SDKI DPP PPNI (2016). Standar Diagnosa Keperawatan Indonesia. Jakarta.
Dewan Pengurus Pusat Persatuan Perawat Nasional Indonesia
Tim Pokja SLKI DPP PPNI (2016). Standar Luaran Keperawatan Indonesia. Jakarta. Dewan
Pengurus Pusat Persatuan Perawat Nasional Indonesia
Tim Pokja SIKI DPP PPNI (2016). Standar Intervensi Keperawatan Indonesia. Jakarta.
Dewan Pengurus Pusat Persatuan Perawat Nasional Indonesia

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ASUHAN KEPERAWATAN TN.

H DENGAN ANEURISMA AORTA

DI RUANG WISNUMURTI RSUP DR. SARDJITO

Disusun untuk Memenuhi Tugas Praktik Klinik

Keperawatan Medikal Bedah

Rizka Amelia Afriliani (P07120520015)

PROGRAM STUDI PENDIDIKAN PROFESI NERS

Arteri media melemah

Membuat peregangan pada arteri intima &

Tekanan pada dinding arteri meningkat

Aneurisma membesar Risiko Perdarahan

Terjadi perdarahan Hipovolemia

No Diagnosa Keperawatan Tujuan Keperawatan Intervensi Keperawatan

3 Hipovolemi b.d Setelah dilakukan asuhan keperawatan Manajemen Syok Hipovolemia:

Hari/Tanggal : Selasa 02 Februari 2021

b. Penanggung Jawab / Keluarga

POLKESYO TAHUN AKADEMIK 2020-2021

4) Riwayat Kesehatan Dahulu

b. Riwayat Kesehatan Keluarga

Ny.W Tn.B Ny.P Tn.T

Ny. S Ny. T Tn.W Tn.H Tn.K

: Laki-laki : Tinggal Serumah : Pasien

POLKESYO TAHUN AKADEMIK 2020-2021

POLKESYO TAHUN AKADEMIK 2020-2021

a. Keadaan aktivitas sehari – hari

POLKESYO TAHUN AKADEMIK 2020-2021

(1) Skala ketergantungan

0 = Mandiri/ tidak tergantung apapun

1 = dibantu dengan alat

2 = dibantu orang lain

3 = Dibantu alat dan orang lain

POLKESYO TAHUN AKADEMIK 2020-2021

5) Persepsi, pemeliharaan dan pengetahuan terhadap kesehatan

POLKESYO TAHUN AKADEMIK 2020-2021

POLKESYO TAHUN AKADEMIK 2020-2021

2) Status Gizi :TB = 163 cm

3) Tanda Vital : TD = 124/77 mmHg. Nadi = 97x/menit

Suhu = 36,8°C RR =22 x/menit

4) Pengkajian Nyeri PQRST =

b. Pemeriksaan Secara Sistematik (Cephalo – Caudal)

POLKESYO TAHUN AKADEMIK 2020-2021

8) Anus dan Rectum

POLKESYO TAHUN AKADEMIK 2020-2021

Tanda yang ditemukan Skor Rencana Tindakan

*)Lingkari pada skor yang sesuai tanda yang muncul

POLKESYO TAHUN AKADEMIK 2020-2021

NO PENGKAJIAN SKALA Skorin Skoring 2

Paraf & Nama Petugas yang Menilai

Tidak berisiko 0 - 24 Perawatan dasar

Risiko rendah 25 - 44 Pelaksanaan intervensi pencegahan jatuh standar

Risiko tinggi ≥ 45 Pelaksanaan intervensi pencegahan jatuh risiko tinggi

POLKESYO TAHUN AKADEMIK 2020-2021

PEMERIKSAAN HASIL SATUAN NILAI

(Sumber Data Sekunder : RM Pasien )

POLKESYO TAHUN AKADEMIK 2020-2021

(Sumber Data Sekunder : RM Pasien)

NO Terapi 02/02/2021 03/02/2021 04/02/2021

(Sumber Data Sekunder : RM Pasien)

POLKESYO TAHUN AKADEMIK 2020-2021

No Tanggal/jam Data fokus Etiologi Masalah

4. 02/02/2021 DS : Kondisi Distres

B. DIAGNOSA KEPERAWATAN BERDASAR PRIORITAS

1. Nyeri Akut berhubungan dengan agen pencedera fisiologis ditandai