(^6) Medical-Surgical Nursing Demystified
impossible to obtain both the BP and pulse in one or both arms because of
blood flow disruption to the arm(s). The patient may go into shock quickly
if the aneurysm ruptures.
- Monitor cardiovascular system by checking heart sounds, peripheral pulses
(upper and lower extremities), and checking for abdominal bruits, swishing
sounds heard over the blood vessel when flow is disturbed. - Measure intake and output.
- Hypovolemia is suspected if there is a low urine output and high specific
gravity of urine. - Palpate abdomen for distention or pulsatile mass.
- Abdominal distention, which is an enlarged abdomen, may signify imminent
rupture of the aneurysm. - Check for signs of severe decrease in blood or fluid (hypovolemic shock).
The BP decreases as less blood circulates. Pulse rate increases as the heart
tries to pump the blood faster to meet the oxygen demands of the body.
Respiratory rate increases to meet oxygen needs while peripheral pulse sites
are harder to find as BP lowers. The further away the pulse is from the heart,
the more difficult it will be to find; it will be harder to locate the dorsalis
pedis and posterior tibialis pulses earlier than the radial pulses. - Pale, clammy skin will be present as circulation decreases.
- Severe back pain due to rupture or dissection.
- Anxiety due to uncertainty of what is happening.
- Restlessness due to anxiety, discomfort, and decreased oxygenation.
- Decreased pulse pressure due to less circulating volume, increased heart rate,
and less filling time between heartbeats. - Increased thready pulse.
- Limit patient’s activity to a prescribed exercise and rest regimen.
- Be alert for decreased peripheral circulation.
- Numbness.
- Tingling.
- Decrease in temperature of extremities.
- Change in skin color in extremities.
- Absence of peripheral pulses.
- Reduce patient anxiety.
- Maintain a quiet place.
- Have the patient express his or her feelings.