CONTINUING EDUCATION

Treatment of AbdominalAortic Aneurysms: The Roleof Endovascular Repair

PHYLLIS A. GORDON,MSN, APRN, ACNS-BC; BOULOS TOURSARKISSIAN,MD, FACS 3.2

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are available for this activity. Earn the CE contact hours by

reading this article, reviewing the purpose/goal and objectives,

and completing the online Examination and Learner Evalua-

tion at http://www.aorn.org/CE. A score of 70% correct on the

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The CE contact hours for this article expire September 30,

2017. Pricing is subject to change.

Purpose/GoalTo provide the learner with knowledge specific to caring for

the patient with an abdominal aortic aneurysm (AAA) under-

going endovascular aortic repair (EVAR).

Objectives

1. Describe aortic aneurysms.

2. Explain methods for diagnosing AAAs.

3. Discuss risk factors associated with the development of

AAAs.

4. Identify intervention parameters for the patient with an

AAA.

5. Discuss perioperative nursing care of the patient under-

going an EVAR procedure.

6. Identify postoperative complications of the EVAR

procedure.

http://dx.doi.org/10.1016/j.aorn.2014.01.025

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Conflict of Interest DisclosuresPhyllis A. Gordon, MSN, APRN, ACNS-BC, and Boulos

Toursarkissian, MD, FACS, have no declared affiliations that

could be perceived as posing potential conflicts of interest in

the publication of this article.

The behavioral objectives for this program were created

by Rebecca Holm, MSN, RN, CNOR, clinical editor, with

consultation from Susan Bakewell, MS, RN-BC, director,

Perioperative Education. Ms Holm and Ms Bakewell have no

declared affiliations that could be perceived as posing potential

conflicts of interest in the publication of this article.

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in the activity.

September 2014 Vol 100 No 3 � AORN Journal j 241

Treatment of Abdominal

Aortic Aneurysms: The Roleof Endovascular RepairPHYLLIS A. GORDON, MSN, APRN, ACNS-BC; BOULOS TOURSARKISSIAN, MD, FACS 3.2

www.aorn.org/CE

ABSTRACT

Rupture of an abdominal aortic aneurysm (AAA) is a significant cause of mortality

in the United States. Often asymptomatic, AAA is considered a silent killer because

it frequently remains undiagnosed until the time of rupture or the patient’s death.

Major risk factors, such as smoking, age, sex, race, and family history of aortic

aneurysm, affect the formation of AAAs. National screening recommendations and

advancements in treatment modalities during the past 20 years have improved

morbidity and mortality, especially with the introduction of stent grafts for endo-

vascular repair of the aorta. Endovascular aneurysm repair is less invasive than open

surgical repair. This article describes the major risk factors, pathophysiology, and

diagnosis of AAA; patient selection for endovascular repair; common adverse events

and complications; and perioperative implications for the patient undergoing

endovascular repair of an AAA. Knowing the treatment options for patients with

AAA who are at high risk for rupture should allow clinicians to determine the

best course of immediate and long-term care. Patients who undergo endovascular

repair of an AAA should receive lifelong monitoring for complications, especially

endoleaks. AORN J 100 (September 2014) 242-256. � AORN, Inc, 2014.

http://dx.doi.org/10.1016/j.aorn.2014.01.025

Key words: aorta, aortic aneurysm, abdominal aortic aneurysm, rupture, endo-

vascular aneurysm repair, EVAR, endovascular, stent graft, endoleak, open repair.

An aortic aneurysm is a dilation of the wall

of the aorta. Dilation can occur at any

point along the aorta from the ascending

aorta to the bifurcation at the level of or including

the iliac arteries. The location of the aortic aneu-

rysm is an important aspect of determining treat-

ment options. Thus, aortic aneurysms commonly

are described by their location:

242 j AORN Journal � September 2014 Vol 100 No 3

n thoracic aortic aneurysms,

n abdominal aortic aneurysms (AAAs),

n thoracoabdominal aortic aneurysms, or

n aortoiliac aneurysms (ie, aneurysmal involve-

ment that includes the iliac arteries).

An AAA is a localized dilation of the part of the

aorta that is in the abdomen. Such aneurysms are

http://dx.doi.org/10.1016/j.aorn.2014.01.025

� AORN, Inc, 2014

AAA AND EVAR www.aornjournal.org

further classified by their relationship to the renal

arteries, and dilation may occur in the aortic wall in

these locations:

n above the renal arteries (ie, suprarenal),

n at the level of the renal arteries (ie, pararenal),

or

n below the renal arteries (ie, infrarenal).

An AAA is a serious condition because of its

asymptomatic development and because it frequently

is not diagnosed until the aneurysm ruptures. With-

out repair, a large AAA is nearly always fatal, which

is why this condition is considered a silent killer.

According to studies, ruptured AAAs carry a mor-

tality rate of nearly 80%.1,2 National screening

recommendations and advancements in treatment

modalities during the past 20 years have improved

morbidity and mortality, especially with the intro-

duction of stent grafts for endovascular aortic

repair.3 Endovascular repair of AAAs is a less in-

vasive alternative to open surgical repair because it

involves insertion of a stent graft into the aorta

without making a large incision into the aorta. The

stent graft acts as an artificial lumen and minimizes

the risk of rupture. Advancements in imaging studies

have contributed to an increase in endovascular repair

as a treatment option.

This article presents considerations and factors

associated with providing care to patients with an

AAA. Understanding the features of an AAA should

allow surgical team members to distinguish it from

other aortic aneurysms and determine treatment.

PATHOPHYSIOLOGY AND ETIOLOGY OFAAAS

By definition, an aneurysm is a dilation of the ves-

sel diameter of more than 150% of the diameter just

proximal to it.4 Normal infrarenal aortic diameter is

approximately 2 cm but may be smaller in women.

In general, the diagnosis of AAA is usually made if

the infrarenal aortic diameter is 3 cm or greater.4

Aneurysms are further described as being saccular

(ie, ballooning of a focal area of the aorta) or

fusiform (ie, circumferential dilation of the aorta).5

The etiology of AAAs may be secondary to

atherosclerotic changes, inflammatory conditions

(eg, large vessel vasculitis), infectious diseases (ie,

bacterial infection of the arterial wall resulting in

a mycotic aneurysm), trauma, or genetic collagen

disorders (eg, Marfan syndrome, Ehlers-Danlos

syndrome). Most aneurysms are considered de-

generative in nature; although frequently seen in

the setting of atherosclerosis, aneurysms are not

necessarily atherosclerotic in etiology and may

be independent of each other.6 The role of athero-

sclerosis in aneurysmal development is not well

understood but may be related to the inflammatory

response of atherosclerosis and degradation of the

extracellular matrix at the vessel wall. The degen-

eration of the arterial wall is the result of proteol-

ysis and cytokine-induced breakdown in elastin,

which can affect the metabolism of collagen, an

essential component of the extracellular matrix.

Degeneration leads to weakening of the aortic

wall, which results in aortic dilation and aneurysm

formation.6-8

RISK FACTORS

Rupture of an AAA is a significant cause of mor-

tality that accounts for approximately 9,000 deaths

in the United States annually,9 a figure that prob-

ably underestimates the mortality rate given the

lack of routine autopsies for unexpected deaths.

Abdominal aortic aneurysms primarily affect peo-

ple 65 years of age or older and is more common in

white people, especially those of Northern Euro-

pean descent.10,11 Table 1 lists the risk factors

associated with development of AAAs. The most

important risk factor for formation of AAAs is

smoking (ie, the relative risk in smokers is five

times higher than in nonsmokers), and smoking

also may increase the rate of aneurysmal expansion

and risk of rupture.12-14 Men are 5.6 times more

likely to experience an AAA than women.12-14

Although AAAs present less frequently in women,

the prognosis is more serious and the risk of rupture

is higher.15,16 White people of Northern European

AORN Journal j 243

TABLE 1. Risk Factors Associated With Development of Abdominal Aortic Aneurysms1-5

Major risk factors

n History of smoking (ie, at least 100 cigarettes in a lifetime)n Men 65 years of age and oldern Women older than 55 yearsn Sex (men > women)n Atherosclerosisn Hypertensionn White race, especially those of Northern European descentn Family history of abdominal aortic aneurysm (ie, first-degree relative with an abdominal aortic aneurysm)n Genetic conditions (eg, Marfan syndrome, Ehlers-Danlos syndrome)

Negative risk factors

n Diabetes mellitus

1. Lederle FA, Johnson GR, Wilson SE, et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detectionand Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med. 1997;126(6):441-449.

2. Lederle FA, Wilson SE, Johnson GR, et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med.2002;346(19):1437-1444.

3. Forsdahl SH, Singh K, Solberg S, Jacobsen BK. Risk factors for abdominal aortic aneurysms: a 7-year prospective study: the Tromsø Study, 1994-2001.Circulation. 2009;119(16):2202-2208.

4. US Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med. 2005;142(3):198-202.5. Aortic aneurysm fact sheet. Centers for Disease Control and Prevention Division for Heart Disease and Stroke Prevention. http://www.cdc.gov/dhdsp/

data_statistics/fact_sheets/fs_aortic_aneurysm.htm. Accessed March 31, 2014.

September 2014 Vol 100 No 3 GORDONdTOURSARKISSIAN

descent are twice as likely to experience a ruptured

AAA compared with multiracial people. Other

risk factors include advanced age and family his-

tory of a first-degree relative who had an AAA.12-14

According to Torsney et al,15 diabetes mellitus is

negatively correlated with development of AAAs.

Stackelberg et al17 investigated the risk of AAA

and excess abdominal adipose tissue (ie, visceral

fat). Results from their study of 63,655 men and

women ages 46 to 84 years demonstrated that the

risk of AAA increased by 15% for each 5-cm

increment in waist circumference; however, re-

searchers found no association between body mass

index and increased risk of AAA.17

SCREENING AND DIAGNOSTICCONSIDERATIONS

Results from multiple randomized controlled trials

have shown that screening for AAA is effective in

reducing AAA-related mortality.12,14,18 Screening,

however, should be suggested for people with a

high risk of developing an AAA. The US Preven-

tive Services Task Force (USPSTF)19 recommends

244 j AORN Journal

screening for men aged 65 to 74 years who have

smoked at least 100 cigarettes at any time in their

life. All major risk factors (ie, advanced age, sex,

race or ethnicity, family history of AAA) also

should be considered when health care providers

determine which patients ought to be screened.

With the advancements in imaging studies, na-

tional screening recommendations, and treatment

options, the age-adjusted mortality rate of all aortic

aneurysms has now declined from a steady rate

of seven per 100,000 in 1990 to four per 100,000

in 2010.10,11 Screening for aortic aneurysms has

demonstrated an average of 42% reduction in aortic

aneurysmerelated mortality.18,20

Physical examination has a poor ability to detect

AAAs, especially in patients with protuberant ab-

domens. Plain radiographic films are notoriously

unreliable for sizing AAAs because they show the

dimension in only one plane. The most appropriate

screening study, therefore, is abdominal ultrasound,

which has a sensitivity of 95% and specificity

near 100% when performed in a quality setting.19

Ultrasound is limited, however, in its ability to

AAA AND EVAR www.aornjournal.org

identify suprarenal or iliac components. If the ul-

trasound findings are uncertain, a computed tomo-

graphy (CT) scan may be indicated. An IV contrast

CT scan should be performed with no more than

3-mm slice thickness to accurately size aneurysms,

a step that is vital in determining whether the patient

is a candidate for endovascular aneurysm repair

(EVAR). If a patient is a candidate for EVAR,

the IV contrast CT scan also should be used for

determining the correct size of the stent graft for

the patient.5

The Centers for Medicare & Medicaid Services21

has instituted a provision for a single ultrasound

screening for AAA, provided that the ultrasound is

performed within the patient’s first year of enroll-

ment in Medicare. Subsequent testing cannot be

performed for screening purposes only but should

be performed based on clinical data (eg, abnormal

pulsation, aortic bruit, pain).21

PRESENTING SYMPTOMS

Most patients with AAAs are asymptomatic, which

is why AAAs often are found incidentally when

an imaging study is obtained for unrelated reasons.

When symptoms are present, they are usually re-

lated to the anatomic location of the aneurysm and

to a mass effect of the expanding aneurysm related

to pressure on surrounding organs (eg, early satiety;

abdominal pain; pressure in the groin, back, or

flank). The most frequently presenting symptom is

pain in the back, flank, or abdomen, although it

may be referred to various areas. The patient may

describe a pulse in his or her abdomen and may

actually feel a pulsatile mass. Many AAAs also can

present with thromboembolic symptoms because

aneurysms are lined by laminated thrombus (ie,

thrombus formed gradually by clotting of the blood

in successive layers22). Embolization is rarely spon-

taneous but may occur when an aneurysm is ma-

nipulated or crossed by a catheter or guide wire

during unrelated procedures, such as cardiac cath-

eterization.23 Sudden, severe pain; symptoms of

dizziness, nausea, or vomiting; cold, clammy skin;

and a rapid heart rate when standing up should raise

concerns about the possibility of a rapidly expanding

aneurysm and impending rupture. These symp-

toms can indicate the urgent need for evaluation.

INTERVENTION PARAMETERS

The most concerning outcome of an aneurysm

is rupture, and the risk of rupture increases with

the size of the aneurysm.24 Thus, after a patient

has been diagnosed as having an AAA, the primary

care provider or a vascular specialist should mon-

itor the patient on a regular basis for increases in

the aneurysm diameter. The annual risk of rupture

is low in patients who have an AAA that is less

than 5.5 cm in diameter and size and has been

stable (ie, minimal changes between imaging pe-

riods); thus, intervention is not recommended.25

However, patients who have an AAA that is greater

than 5.5 cm in diameter or has an annual expansion

rate of 1 cm or greater in a year (or 0.5 cm in

6 months) are at high risk for rupture26,27 and are

candidates for aneurysm repair.14,28,29 Progressive

expansion of an AAA from the patient’s diagnosed

baseline diameter is most strongly associated with

patients who continue to smoke.19 An AAA that is

less than 4 cm can be monitored safely every one

to two years25; however, because of the increased

risk of rupture,14,30 an AAA that is greater than

4 cm in diameter should be monitored every six to

12 months.25,31 National guidelines from the So-

ciety for Vascular Surgery and the International

Society for Cardiovascular Surgery recommend

intervening in a patient with an AAA if one or more

of the following criteria are present:

n clinicians suspect or have documentation of a

rupture;

n the patient is experiencing symptoms of an AAA;

n the AAA is rapidly expanding in diameter (ie,

> 1.0 cm per year or 0.5 cm per 6 months);

n the AAA is 5.5 cm in diameter or larger;

n clinicians suspect a complicated aneurysm (eg,

embolism, thrombosis); or

n clinicians suspect an atypical AAA (ie, dissec-

ting, mycotic, saccular shape).28

AORN Journal j 245

September 2014 Vol 100 No 3 GORDONdTOURSARKISSIAN

TREATMENT OPTIONS FOR ELECTIVEREPAIR

Treatment of AAAs to prevent aneurysm rupture

can be achieved through elective repair. Repair

options are an open surgical repair or an EVAR

procedure. These procedures vary in terms of risks

and optimal outcomes.

Open surgical repair is performed in the OR and

requires general anesthesia, longer surgical time

(ie, four to five hours longer or more), and a large

surgical incision to expose the abdominal aorta.

The vascular surgeon clamps the aorta above and

below the aneurysm, opens the aneurysmal aorta,

removes the thrombus, and attaches a synthetic

tube graft made of polyethylene terephthalate or

polytetrafluoroethylene in place of the aneurysmal

section of the aorta. Open repair requires a longer

recovery, including several days in the intensive

care unit (ICU), and has an increased risk of com-

plications, such as

n pulmonary insufficiency requiring mechanical

ventilation, especially if chronic obstructive

pulmonary disease is present;

n myocardiac dysfunction, arrhythmias, and in-

farction, especially if heart failure or coronary

artery disease was present preoperatively;

n the occurrence of significant fluid shifts as a

result of the larger area of surgical intervention,

which can lead to inflammation and increased

vascular permeability;

n prolonged ileus and return of gastrointestinal

function;

n microthromboembolism to multiple organs and

extremities;

n stroke;

n spinal cord ischemia, which can result in paralysis;

n renal ischemia, insufficiency, and failure; and

n infection and bleeding.

Some surgeons are performing minimally in-

vasive (ie, laparoscopic) surgical aortic repair in

which surgery is accomplished through a smaller

abdominal incision, thus decreasing some of the

complications related to open repair. For an open

246 j AORN Journal

repair, Beck et al32 report a 30-day mortality rate

of 2.3% and a one-year mortality rate of 5.8%.

Repairing an abdominal aneurysm via EVAR

has become increasingly popular because of the

higher perioperative morbidity and mortality linked

to open repair. The EVAR procedure is considered

minimally invasive and can be performed in a

surgical suite with fluoroscopic capabilities, a car-

diovascular catheter laboratory, or an interventional

radiology room. It can be performed under general,

regional (ie, epidural, spinal), or local anesthesia.

Hospital length of stay is reduced significantly to

one to two days. Although the perioperative 30-day

mortality rate for EVAR is 0.5%,32 which is sig-

nificantly lower than the rate for open repair, the

one-year mortality rate is similar at 5.7%. Health

care providers and patients need to consider the

potential complications of the EVAR approach.

These complications include

n vessel injury, resulting in groin pseudoaneur-

ysm and hematoma;

n groin infection;

n spinal cord ischemia;

n limb ischemia, secondary to thromboembolism;

n renal ischemia and insufficiency; and

n endoleaks from the stent graft.

INCLUSION AND EXCLUSION CRITERIAFOR EVAR

The type of EVAR stent graft used is dependent on

a number of factors, such as the patient’s anatomy,

location of the AAA (ie, suprarenal, pararenal, in-

frarenal), and whether the aneurysm involves the

iliac arteries. Currently, a variety of endovascular

graft systems are available. For further detail on

aortic stent grafts, more information is available in

the article by Buckley and Buckley33 in this issue

of the AORN Journal.

Currently, not all patients with AAA who are

candidates for elective repair are candidates for

EVAR. Patients may be excluded for a number of

reasons, including aortic neck anatomy and size of

access vessels to allow safe delivery of the stent

AAA AND EVAR www.aornjournal.org

graft. The aortic neck (ie, the section of the aorta

above the aneurysm and below the renal arteries)

is the area in which the stent graft is placed during

Preoperatively, clinicians should endeavor tooptimize any patient conditions that affect thepulmonary, cardiac, vascular, or renal systems.

EVAR. To meet in-

clusion criteria and so

the stent graft can be

anchored to the aorta,

the aortic neck must

have adequate length

and diameter, be free

of circumferential thrombus or calcifications, and

not have acute angulation relative to the suprarenal

aorta. What constitutes an adequate neck varies

by the brand of stent graft. Most stent graft in-

structions for use require a neck length of 15 mm

and a neck diameter of less than 32 mm, although

some stent graft manufactures can accommodate

neck lengths of 10 mm and 5 mm. Another brand

on the market allows for a 5-mm neck and has

scallops to accommodate flow in the renal arteries.

Most stent graft manufacturers also require neck

angulation of less than 60 degrees, although a brand

released in 2013 has US Food and Drug Adminis-

tration approval for treatment of patients with neck

angulation up to 90 degrees.5

In the past, the size of the iliac vessels has been

an anatomic exclusion factor for EVAR, requiring

treatment using an open method. Earlier EVAR

devices were characterized by large-diameter de-

livery systems ranging from 18 Fr to 24 Fr. Current

EVAR technology, however, has reduced the dia-

meter of some delivery systems to as small as 12

Fr, depending on the manufacturer. Thus, advances

in EVAR device technology have widened the

availability of EVAR to include most small iliac

vessels. Nevertheless, because each stent graft

has a unique combination of features, advances in

EVAR technology should not suggest that all pa-

tients can be accommodated. The treating physician

must have experience using a variety of stent graft

devices and skill at working with small delivery

systems to treat a range of patient anatomies.

There are currently no branched endografts on

the market in the United States, unlike in Europe

and Australia. They are available under research

protocols in a limited number of academic centers

in the United States. These grafts have branches for

the renal and mesen-

teric arteries, thereby

allowing treatment of

suprarenal and thor-

acoabdominal aneu-

rysms. They will

likely be released in

the United States in a few years.5

PREOPERATIVE CONSIDERATIONS FOREVAR

Most patients with an AAA who are preparing to

undergo EVAR have multiple comorbid condi-

tions that need to be optimized before the pro-

cedure. Preoperatively, clinicians should endeavor

to optimize any patient conditions that affect the

pulmonary, cardiac, vascular, or renal systems.

Patients with pulmonary problems, especially

those who have a history of smoking and chronic

obstructive pulmonary disease, are at increased

risk for rupture at any AAA diameter size.20 To be

beneficial, preoperative smoking cessation needs to

occur two months before the planned date

of surgery.34

Significant cardiac comorbidities are present in

a large number of patients with an AAA regardless

of symptoms.35,36 It remains a matter of debate

regarding how extensive a cardiac workup is re-

quired before elective AAA repair. That discussion

is beyond the scope of this article; however, cardiac

disease is very prevalent in patients with an AAA

and can be asymptomatic.35,36 The cardiac stress of

undergoing AAA surgery is much less with EVAR

compared with open repair, however.35,36

Many patients with an AAA have associated

aneurysms in other vessels, such as the femoral

and popliteal arteries.37,38 Frequently, diagnostic

screening for popliteal aneurysms also is accom-

plished with ultrasound. If the peripheral pulses are

abnormal, the surgeon may order a lower-extremity

arterial Doppler ultrasound scan. A carotid artery

AORN Journal j 247

TABLE 2. Nursing Care Plan for a Patient Undergoing Endovascular Aortic AneurysmRepair

Diagnosis Nursing interventions

Decreased cardiac output n Identifies baseline cardiac status.n Identifies physiological status.n Identifies baseline tissue perfusion.n Reports the presence of implantable cardiac devices.n Assesses factors related to risk of ineffective tissue perfusion.n Reports deviation in diagnostic study results.n Monitors physiological parameters.n Monitors changes in cardiac status.n Uses monitoring equipment to assess cardiac status.n Performs ongoing evaluation of cardiac status.n Evaluates tissue perfusion.n Evaluates progress of wound healing.

Acute pain n Assesses pain control.n Identifies cultural and value components related to pain.n Implements pain guidelines.n Implements alternative methods of pain control.n Collaborates in initiating patient-controlled analgesia.n Evaluates response to pain management interventions.

Risk of infection n Assesses susceptibility for infection.n Classifies surgical wound.n Implements aseptic technique.n Protects from cross-contamination.n Initiates traffic control.n Administers prescribed prophylactic treatments.n Administers prescribed medications.n Administers prescribed antibiotic therapy as ordered.n Performs skin preparations.n Monitors for signs and symptoms of infection.n Minimizes the length of the invasive procedure by planning care.n Maintains continuous surveillance.n Administers care to wound sites.n Administers care to invasive device sites.n Encourages deep breathing and coughing exercises.n Evaluates factors associated with increased risk of postoperative

infection at the completion of the procedure.n Evaluates progress of wound healing.n Evaluates for signs and symptoms of infection through the 30 days

following the operative or invasive procedure.

September 2014 Vol 100 No 3 GORDONdTOURSARKISSIAN

duplex scan should be performed as well if the

patient has cervical bruits or a history of transient

ischemic events or strokes.

Given the use of contrast for angiographic imaging

during EVAR procedures, it is critical that the clini-

cian assess each patient for impaired renal function.

In the past, the criterion for renal impairment was a

248 j AORN Journal

serum creatinine level of 1.5 mg/dL or greater;

however, this is now considered to be an insensi-

tive measure, missing 40% of patients at risk for

contrast-induced nephropathy (CIN).39 Current

recommendations to determine renal insufficiency

include using a creatinine clearance or glomerular

filtration rate (GFR). Results from one study

Interim outcome statement Outcome statement

n The patient’s vital signs are stable at the time of dischargefrom the OR and PACU.

n The patient’s hemodynamic status is within the expectedrange at transfer to the postoperative unit.

n The patient’s peripheral pulses are palpable bilaterally andof good quality.

n The patient’s skin is warm, dry, and free from edema.n The capillary refill and SaO2 show adequate tissue

perfusion.

n The patient’s cardiovascular status is maintained at orimproved from baseline levels.

n The patient verbalizes control of pain.n The patient’s vital signs at discharge from the OR are

equal to or improved from preoperative values.

n The patient demonstrates and/or reports adequate paincontrol.

n The patient’s wound is free from signs or symptoms ofinfection and pain, redness, swelling, drainage, or delayedhealing at the time of discharge.

n The patient is free from signs and symptoms of infection.

TABLE 2. (continued) Nursing Care Plan for a Patient Undergoing Endovascular Aortic AneurysmRepair

AAA AND EVAR www.aornjournal.org

demonstrated that patients with a GFR of less

than 60 mL/min/1.73 m2 have a 30% to 40%

increased risk of CIN.40 Oral hydration one

to two days before the procedure may be ade-

quate for these patients. However, according

to Goldfarb et al,41 if the GFR is less than

40 mL/min/1.73 m2, IV hydration with normal

saline solution is recommended for several

hours (and possibly up to 12 hours) before and

after the procedure. Other recommendations to

minimize nephrotoxicity may include use of

N-acetylcysteine 600 mg orally two times a day

starting the day before and on the day of the pro-

cedure for four total doses. Patients with diabetes

AORN Journal j 249

September 2014 Vol 100 No 3 GORDONdTOURSARKISSIAN

who have been taking metformin or a metformin

product should not take the medication for 24 hours

before and 48 hours after the procedure.41,42

Preoperative Assessment

During the preoperative assessment, the clinician

should identify the patient’s allergies and, in par-

ticular, should ascertain whether the patient is

allergic or hypersensitive to contrast dye, iodine, or

shellfish. If present, a protocol of prednisone and

diphenhydramine should be started 12 to 13 hours

before the procedure, another dose at 6 to 7 hours

before, and the last dose administered one hour

before surgery.

The preoperative assessment also should include

an assessment of the patient’s bleeding or clotting

history. The patient can continue platelet inhibitors,

such as aspirin, perioperatively. Clopidogrel is likely

acceptable as well, although some surgeons would

rather avoid it because of a slightly increased risk of

bleeding. The clinician should instruct the patient to

discontinue other more potent agents such as pra-

sugrel and ticagrelor as well as anticoagulants (eg,

warfarin, dabigatran etexilate, rivaroxaban, apix-

aban) for a period of time depending on the specific

agent. The clinician should have any discontinued

medications restarted very soon postoperatively. In

general, warfarin should be held for several days

before the procedure, and the clinician should

prescribe a bridge of a rapid-acting anticoagulant,

with the latter held the day of the procedure.

A bowel prep is not mandatory preoperatively.

However, EVAR is radiation intensive and bowel

gases make visualization of the abdomen more

difficult. Therefore, clinicians may consider imple-

menting measures to reduce flatulence, such as use of

simethicone for a day before the EVAR procedure.

Preoperative instructions should include routine

teaching about postoperative activities to prevent

complications. The clinician should explain respi-

ratory exercises and use of incentive spirometry.

The clinician also should explain how to perform

calf muscle exercises for prevention of venous

stasis and deep vein thrombosis.

250 j AORN Journal

Intraoperative Considerations for EVARGraft Placement

Most EVAR procedures are performed in an OR

setting with a high-quality fluoroscopy unit (C-arm)

or in a special hybrid suite with combined cathe-

terization laboratory and OR capabilities in a sterile

environment. After interviewing the patient in

the preoperative area, the RN circulator should

develop a care plan specific to the patient (Table 2).

Based on the care plan, the RN circulator may need

to obtain standard equipment, such as items need-

ed for protection from C-arm radiation (eg, lead

aprons, thyroid shields, mobile shields, glasses).

The RN circulator also may need to ensure the

availability of a number of specific pieces of

interventional equipment, such as equipment for

rapid injection of the radiopaque dye, if the pro-

cedure is not being performed in a combined

catheterization laboratory and OR. An equipped

OR or hybrid suite would need to have appropriate

surgical equipment and supplies in preparation

for the possibility of the procedure suddenly re-

quiring conversion into an open repair. Although

the RN circulator should be prepared to insert

an indwelling urinary catheter, if ordered, surgical

wound drains are rarely required or used.

The RN circulator may need to ensure the avail-

ability of prophylactic antibiotics to be administered

preoperatively and postoperatively to cover skin

flora and to ensure that antimicrobial levels in the

tissue are adequate and maintained for the duration

of the procedure. According to the National Surgical

Infection Prevention Project, “infusion of the first

antimicrobial dose should begin within 60 minutes

before the initial surgical incision and . . . prophy-

lactic antimicrobials should be discontinued within

24 hours after the end of surgery.”43(p1706)

For the procedure, the perioperative team should

place the patient in a supine position on the OR

bed. The RN circulator extends one of the patient’s

arms outward in case brachial access is needed;

however, it is important not to impede C-arm

movement. Typically, the anesthesia professional

inserts an arterial line, usually via radial artery

PATIENT EDUCATION

Endovascular Repair of Abdominal Aortic AneurysmsOverview

An abdominal aortic aneurysm (an-ur-iz-um; also called an

AAA) is dilation in the wall of the part of the large artery

called the aorta that goes through the abdomen (belly).

What are signs and symptoms of an AAA?

Abdominal aortic aneurysm is considered a silent killer

because typically the person does not feel any symptoms and

frequently it is not diagnosed until it ruptures or the patient

dies. You may experience pain in your back, side, or ab-

domen, or the pain may be referred to other body areas.

How is AAA diagnosed?

It is very difficult to diagnose AAA. Your caregiver may order

an abdominal ultrasound or a computed tomography (CT) scan.

What are your treatment options?

Your caregiver may recommend regular monitoring to watch

for any changes in its size. If the aneurysm is too large or

starts to change, your caregiver may recommend surgery to

replace or repair the aorta.

What will the preoperative care include?

n Smoking is a very serious risk for AAA. Your caregiver

may recommend that you stop smoking before surgery, and

it is best if you stop smoking two months before surgery.

n You caregiver will give you instructions about when to

stop eating and drinking before surgery.

n Ask your doctor whether you should take your current

medications the morning of surgery.

n Before surgery, a nurse will measure your vital signs and

ask questions about your health history. Tell the nurse

about any allergies, previous surgeries, current medica-

tions, and other injuries (cuts, skin abrasions).

n An anesthesia professional will talk to you about the

anesthesia that will keep you pain-free during surgerydgeneral anesthesia (medicine that keeps you asleep) or

spinal anesthesia (a shot in your back that numbs only

the lower part of your body).

What happens during surgery?

Your doctor may make an incision into the femoral artery or

may just put a large needle into the artery so no incision will

be needed. Then your doctor will insert a stent (a metal coil)

or a manmade (synthetic) graft.

What will postoperative care include?

n After surgery, you will be admitted to the recovery area

andmonitored closely. Youmay not need to stay overnight.

n Breathe deeply or use an incentive spirometer to prevent

pneumonia.

n You may feel tired or uncomfortable; your nurse will

work with you to evaluate and treat pain and nausea.

n Before you go home, a nurse will teach you and your

designated support person.

n how to control pain and swelling with medicine, rest,

and ice and

n how to care for the incisions.

What are possible complications of surgery?

n You may get an infection in your leg, get pneumonia, get

a blood clot in one of your legs, or bleed too much.

n Other complications include knee stiffness or graft impinge-

ment, preventing your knee from straightening completely.

These may be fixed by physical therapy or another surgery.

What happens after I go home?

n Eat healthy, stay active, and plan rest into your schedule.

n Keep the incisions dry for the first 7 to 10 days. Then

wash your incisions daily with mild, perfume-free soap

and gently pat dry; do not put any lotion or powder

directly on incisions until they are completely healed.

n Use your pain medicine as instructed to control pain.

Call your doctor immediately if you experience anyof the following postoperative complications:

n shortness of breath or sudden dizziness or weakness;

n increased redness, swelling, or drainage at your incision sites;

n fever greater than 101� F (38.3� C) or chills;

n nausea or vomiting that is not relieved with medication; or

n pain that is not controlled with pain medication.

Resources

Abdominal aortic aneurysm repair. Johns Hopkins Medicine.

http://www.hopkinsmedicine.org/healthlibrary/test_

procedures/cardiovascular/abdominal_aortic_aneurysm_

repair_92,P08291. Accessed May 15, 2014.

Aortic aneurysm repairdEVAR. MedlinePlus. http://

www.nlm.nih.gov/medlineplus/ency/article/007391.htm.

Accessed May 15, 2014.

AORN Journal j 251

AAA AND EVAR www.aornjournal.org

September 2014 Vol 100 No 3 GORDONdTOURSARKISSIAN

access. The anesthesia professional also may place

a central line, although this is not mandatory.

Choice of anesthesia (eg, general, regional, local)

is dependent on the surgeon’s and anesthesia pro-

fessional’s preference, as well as the patient’s

physiology and ability to cooperate.

Many surgeons perform a groin cutdown on the

femoral artery, although a percutaneous approach is

increasingly popular, especially with the availabil-

ity of lower profile devices. When that is the case,

the surgeon may use a vascular device to control

the opening in the femoral artery, which requires

the postanesthesia care unit (PACU) nurse to

closely monitor the patient postprocedure for

bleeding or thrombosis.

The surgeon may use a large sheath for access,

which he or she removes in the procedure room

immediately after stent graft delivery. The surgeon

may use contrast material to help visualize the

anatomy, although the amount can be decreased

quite a bit by the judicious use of IV ultrasound.

The surgeon determines the location of the plan-

ned placement area with fluoroscopy and intravas-

cular ultrasound. The surgeon achieves endovascular

access via small, bilateral femoral incisions. The

surgeon exposes the femoral artery and inserts the

catheters and stent graft in the aneurysmal section of

the aorta. The duration of the EVAR procedure can

vary. It can be as short as 90 minutes for a routine,

uncomplicated procedure and up to several hours for

a more complicated procedure, such as one requiring

adjunctive stenting of renal arteries.

Postoperative Considerations andComplications

In the immediate postoperative period, the PACU

nurse monitors the patient for signs of hemody-

namic insufficiency. The PACU nurse assesses

the patient’s hemodynamic status by measuring

vital signs (eg, blood pressure, heart rate, pulse

oximetry, respiratory rate, pain), urine output, level

of consciousness, and general skin appearance.

The nurse also should monitor the patient’s groin

for hematoma formation, especially if the surgeon

252 j AORN Journal

delivered the stent via percutaneous access.42

Rupture immediately after stent graft insertion is

rare but has been reported.31 Rupture of one of the

iliac vessels used for access also may be a source

of hemorrhage and hemodynamic instability. Fluid

shifting may occur postoperatively and can lead to

hypovolemia; however, fluid shifting is less sub-

stantial in EVAR than in open repair.

Monitoring for thromboembolic events.

Thrombotic complications are possible, either in the

femoral vessel or in one of the limbs of the graft.42

Graft limb thrombosis may be caused by either a kink

or unrecognized dissection just distal to the graft.38

Therefore, the PACU nurse should palpate the pa-

tient’s pulses frequently. Performing a Doppler ultra-

sound should be part of the postoperative routine.42

Postoperatively, the nurse should closely observe for

evidence of a thromboembolic event as indicated by

n distal petechiae in the lower extremities;

n focal areas of cyanosis, especially to one of the

toes; or

n a cold, pale, pulseless extremity.42

Monitoring for ischemic bowel. Complications

related to bowel ischemia may result from thrombus

or atheroembolization, especially if unrecognized

mesenteric arterial occlusive disease is present or the

aneurysm extends suprarenal where the celiac and

superior mesenteric arteries arise from the aorta;

thus, thrombus can be dislodged during stent graft

placement. Often, the origin of the inferior mesen-

teric artery arises from the aneurysmal area of the

infrarenal aorta; therefore, placement of the stent

graft inadvertently can occlude the artery, resulting

in ischemic bowel. Indications of postoperative

ischemic bowel includes abdominal pain, distention,

nausea or vomiting, or prolonged ileus.42

Monitoring renal function. Renal failure can

develop from

n CIN,41

n the stent graft inadvertently covering the renal

artery orifice,

AAA AND EVAR www.aornjournal.org

n failure of a branched graft in cases of branched

endograft placement, or possibly

n severe atheroembolization during wire manip-

ulation of the aorta during stent graft placement.

The PACU nurse should monitor the patient’s serum

chemistries, especially the serum creatinine and blood

urea nitrogen levels, for elevations.28,29 The nurse

also should monitor the patient’s urine output for

the amount and presence of overt hematuria.42

Monitoring for spinal cord ischemia. Spinal

cord ischemia may occur if the spinal arteries are

occludedby the stentgraft orbymicrothromboemboli.44

The ICU or step-down unit nurse should focus onmonitoring thepatient’s vital signs andperipheralpulses frequently, assessing the patient forbleeding, and maintaining the patient’s bloodpressure at a normotensive level.

This complication is

more likely to occur if

the stent graft place-

ment is suprarenal,

including the area

where the visceral

and some of the lum-

bar arteries exit the

aorta.44 The PACU

nurse should assess for neuromotor deficits by

evaluating the patient’s extremity strength and

movement together with the patient’s quality of

bladder control.42

After the immediate postoperative recovery

period in the PACU, most patients recover for the

first 24 hours in a monitored bed setting, either an

ICU or a step-down unit. The ICU or step-down

unit nurse should focus on

n monitoring the patient’s vital signs and periph-

eral pulses frequently,

n assessing the patient for bleeding, and

n maintaining the patient’s blood pressure at a

normotensive level (ie, preventing hypotension

or hypertension) to decrease the risk of rupture

or other complications.

In general, additional postoperative management

considerations for the ICU or step-down unit nurse

include fluid administration, diet, line removal,

and activities of daily living. Patients who have

undergone an EVAR procedure do not usually

require the large amounts of IV fluids seen with

patients who have undergone open AAA proce-

dures. However, fluids usually are administered to

offset the contrast load often used in endovascular

procedures, which can lead to diuresis. Fluids also

are administered to decrease the risk of CIN.

Typically, the nurse resumes the patient’s diet on

the evening after surgery for a routine EVAR

procedure performed that morning. Often, the

nurse can remove invasive lines and monitors on

the first postoperative day. The patient may sit up

in bed as early as a couple of hours after the

procedure if he or she underwent a vascular

cutdown for cannula

passage. Supine bed

rest likely will be

longer, however, if the

patient underwent the

percutaneous approach

to the EVAR proce-

dure to decrease the

risk of bleeding at the

stent graft access site. The patient can be ambu-

lated on postoperative day one, and many are dis-

charged on postoperative day two.

On discharge, the nurse should instruct the patient

to avoid strenuous physical activities for at least

one week. The actual duration of restrictions

depends on the approach (ie, open versus percu-

taneous) andwhether any postoperative complica-

tions developed. The nurse should instruct the

patient not todrive until he or she is free of pain

and not taking pain medications. The nurse provides

the patient with routine oral and written discharge in-

structions for incision care. The nurse also instructs

the patient on signs of infection and bleeding or healing

problems that should be reported to the surgeon.

LONG-TERM FOLLOW-UP CARE

Complications unique to EVAR are related to endo-

leaks (ie, blood flow outside the stent graft yet inside

the aneurysm sac),24 which are classified as types

1 through 4 (Table 3). The most common endoleak

AORN Journal j 253

TABLE 3. Endoleak Complications After Stent Graft Insertion1-3

Types ofendoleaks Description

Risk of abdominalaortic rupture

Treatmentrecommendations

Type 1 Blood flow around the site of thestent graft device caused bypoor graft attachment eitherproximally or distally

Very high Should be corrected if possible

Type 2 Blood flow back into the aneu-rysmal sac from either the infe-rior mesenteric artery orthe lumbar arteries

Low risk, unless sac growthaccompanies this complication

May require more frequent sur-veillance for continued increasein size because of the associ-ated increased risk of rupture

Type 3 Blood flows directly into theaneurysmal sac because ofstructural failure of the stentgraft in which there is a sepa-ration of stent graft devicecomponents

High Requires surgical repair as soonas possible

Type 4 Transient graft porosity phenom-enon (ie, blood flows throughthe graft itself as a result ofabnormally high graft porosity)is seen for a few days afterimplantation with some graftbrandsa

Low Usually resolves without interven-tion; observing the endoleakand aortic size with CT scans isacceptable

a Usually a transient phenomenon but may be of relevance in stent brand selection if the stent graft implantation is for an acute abdominal aortic aneurysmrupture.

1. Eliason JL, Rasmussen T. Complications after endovascular ruptured abdominal aortic aneurysm repair. In: Upchurch GR Jr, Criado E, eds. Contem-porary Cardiology Aortic Aneurysms Pathogenesis and Treatment. New York, NY: Humana Press, Springer ScienceþBusiness Media: 2009:207-216.

2. Toursarkissian B. Abdominal aortic aneurysm. In: Cohn SM, Brower ST, eds. Surgery: Evidence-based Practice. Shelton, CT: People’s Medical Pub-lishing House-USA; 2012:661-666.

3. White SB, Stayropoulos SW. Management of endoleaks following endovascular aneurysm repair. Semin Intervent Radiol. 2009;26(1):33-38.

September 2014 Vol 100 No 3 GORDONdTOURSARKISSIAN

is a type 2, which 40% of patients may experience

after undergoing an EVAR procedure.24,45

Endoleaks are one of the reasons why stent

grafts for AAAs require lifelong imaging surveil-

lance.24 In addition to identifying endoleaks, ul-

trasound or CT scanning is used to detect other

postoperative complications, such as graft migra-

tion, kinking, or aortic neck enlargement. Ultra-

sound requires an experienced observer for

endoleak detection. A CT scan ideally is performed

with and without contrast and with delayed imaging

to detect type 2 endoleaks.46,47 If the initial scan

is free of anomalies, the patient usually is asked

to return in one year for another scan unless there

are reasons for earlier surveillance. Other potential

long-term complications are limb occlusion, graft

254 j AORN Journal

infection, and development of aneurysms in other

locations, such as the iliac and popliteal arteries.46

CONCLUSION

Often clinicians diagnose AAAs incidentally be-

cause they are asymptomatic until a rupture occurs.

The seriousness of the diagnosis is related to the

fact that rupture carries a very high mortality rate.

This rate has decreased with the initiation of

screening programs based on known AAA risk

factors, especially for men 65 to 74 years of age

with any previous smoking history. An elective

repair should be considered for AAAs that are

5.5 cm in diameter or larger or have an increase

in size of 1 cm in the previous year.14,26-29 In an

elective repair, preoperative evaluation for cardiac

AAA AND EVAR www.aornjournal.org

and pulmonary risks should be considered along

with the patient’s candidacy for an endovascular

versus open repair. For the patient who undergoes

EVAR, ongoing monitoring for complications,

especially endoleaks, is an essential part of the

patient’s care.

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Phyllis A. Gordon, MSN, APRN, ACNS-BC,

is a clinical nurse specialist in the Vascular

Surgery Division of the Department of Sur-

gery, School of Medicine, and a clinical as-

sistant professor in the School of Nursing at

the University of Texas Health Science Center

at San Antonio. Ms Gordon has no declared

affiliation that could be perceived as posing a

potential conflict of interest in the publication

of this article.

Boulos Toursarkissian, MD, FACS, is a pro-

fessor and the chief of the Vascular Surgery

Division of the Department of Surgery, School

of Medicine, at the University of Texas Health

Science Center at San Antonio. Dr Toursarkissian

has no declared affiliation that could be per-

ceived as posing a potential conflict of interest

in the publication of this article.

EXAMINATION

CONTINUING EDUCATION

3.2

www.aorn.org/CETreatment of Abdominal Aortic

Aneurysms: The Role of EndovascularRepair

PURPOSE/GOAL

�

To provide the learner with knowledge specific to caring for the patient with an

abdominal aortic aneurysm (AAA) undergoing endovascular aneurysm repair

(EVAR).

OBJECTIVES

1. Describe aortic aneurysms.

2. Explain methods for diagnosing AAAs.

3. Discuss risk factors associated with the development of AAAs.

4. Identify intervention parameters for the patient with an AAA.

5. Discuss perioperative nursing care of the patient undergoing an EVAR procedure.

6. Identify postoperative complications of the EVAR procedure.

The Examination and Learner Evaluation are printed here for your conve-

nience. To receive continuing education credit, you must complete the online

Examination and Learner Evaluation at http://www.aorn.org/CE.

QUESTIONS

1. Aortic aneurysms commonly are described by

their location, which includes

1. abdominal.

2. aortoiliac.

3. thoracic.

4. thoracoabdominal.

a. 1 and 2 b. 2 and 3

AORN, Inc, 2014

c. 1, 2, and 3 d. 1, 2, 3, and 4

2. Diagnosis of an AAA is usually made if the

infrarenal aortic diameter is 3 cm or greater.

a. true b. false

3. Risk factors for formation of an AAA are

1. body mass index.

2. diabetes mellitus.

3. excess visceral fat.

4. sex.

5. race or ethnicity.

6. smoking.

a. 1, 2, and 3 b. 3, 4, 5, and 6

September 2014 Vol

c. 1, 2, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6

4. The most appropriate screening study of AAAs,

with a sensitivity of 95% and specificity near

100% when performed in a quality setting, is

a. abdominal ultrasound.

100 No 3 � AORN Journal j 257

September 2014 Vol 100 No 3 CE EXAMINATION

b. computed tomography.

c. physical examination.

d. plain radiographic films.

5. National guidelines from the Society for Vascular

Surgery and the International Society for Car-

diovascular Surgery recommend intervening in a

patient with an AAA if

1. it is 5.5 cm in diameter or larger.

2. it is suspected to be an atypical AAA.

3. it is suspected to be a complicated aneurysm.

4. it is rapidly expanding in diameter.

5. clinicians suspect or have documentation of a

rupture.

6. the patient is experiencing symptomsof anAAA.

a. 1, 3, and 5 b. 2, 4, and 6

258 j AORN Journal

c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

6. For preoperative smoking cessation to be

beneficial, the patient must quit smoking

____________ before the planned date of

surgery.

a. two weeks b. four weeks

c. two months d. six months

7. A preoperative bowel preparation is mandatory

because EVAR is radiation intensive and bowel

gases make visualization more difficult.

a. true b. false

8. For an EVAR procedure, the RN circulator may

need to obtain equipment and supplies including

1. an indwelling urinary catheter.

2. appropriate surgical equipment and supplies

to manage an open repair.

3. equipment for rapid injection of the

radiopaque dye.

4. lead aprons, thyroid shields, mobile shields,

and lead glasses.

5. prophylactic antibiotics for preoperative and

postoperative administration.

6. surgical wound drains in a variety of sizes.

a. 1, 3, and 5 b. 2, 4, and 6

c. 1, 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6

9. The nurse should closely observe the patient

for evidence of a postoperative thromboembolic

event as indicated by

1. distal petechiae in the lower extremities.

2. focal areas of cyanosis, especially to one of

the toes.

3. heat and warmth over the calf.

4. a cold, pale, pulseless extremity.

a. 1 and 3 b. 2 and 4

c. 1, 2, and 4 d. 1, 2, 3, and 4

10. Potential postoperative complications after an

EVAR procedure include

1. aneurysmal development in other locations.

2. endoleaks.

3. graft infection.

4. graft kinking or migration.

5. aortic neck enlargement.

6. limb occlusion.

a. 1, 3, and 5 b. 2, 4, and 6

c. 2, 3, 5, and 6 d. 1, 2, 3, 4, 5, and 6

LEARNER EVALUATION

CONTINUING EDUCATION PROGRAM

3.2

www.aorn.org/CETreatment of Abdominal Aortic

Aneurysms: The Role of EndovascularRepair

This evaluation is used to determine the extent to

which this continuing education program met

your learning needs. The evaluation is printed

here for your convenience. To receive continuing

education credit, you must complete the online

Examination and Learner Evaluation at http://www.aorn.org/CE. Rate the items as described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Describe aortic aneurysms.

Low 1. 2. 3. 4. 5. High

2. Explain methods for diagnosing AAAs.

Low 1. 2. 3. 4. 5. High

3. Discuss risk factors associated with the development

of AAAs. Low 1. 2. 3. 4. 5. High

4. Identify intervention parameters for the patient with

an AAA. Low 1. 2. 3. 4. 5. High

5. Discuss perioperative nursing care of the patient

undergoing an EVAR procedure.

Low 1. 2. 3. 4. 5. High

6. Identify postoperative complications of the endo-

vascular aneurysm repair (EVAR) procedure.

Low 1. 2. 3. 4. 5. High

CONTENT

7. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

8. To what extent were your individual objectives met?

Low 1. 2. 3. 4. 5. High

� AORN, Inc, 2014

9. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

10. Will you change your practice as a result of

reading this article? (If yes, answer question

#10A. If no, answer question #10B.)

10A. How will you change your practice? (Select all

that apply)

1. I will provide education to my team

regarding why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other: ______________________________

10B. If you will not change your practice as a result of

reading this article, why? (Select all that apply)

1. The content of the article is not relevant to

my practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make a

change.

4. Other: ______________________________

11. Our accrediting body requires that we verify

the time you needed to complete the 3.2 con-

tinuing education contact hour (192-minute)

program:________________________________

September 2014 Vol 100 No 3 � AORN Journal j 259