Medical-surgical Nursing Demystified

(Michael S) #1

CHAPTER 1 Cardiovascular System^5



  • Diminished femoral pulses

  • Anxiety

  • Restlessness

  • Decreased pulse pressure

  • Increased thready pulse


INTERPRETING TEST RESULTS



  • An aneurysm will be displayed in a chest x-ray, abdominal ultrasound, CT
    scan, or MRI.

  • Swishing sound over the abdominal aorta or iliac or femoral arteries because
    the natural flow of blood is disturbed (bruit).


TREATMENT



  • Surgery to resect the aortic aneurysm by removing the section containing the
    aneurysm and replacing it with a graft.

  • Administer antihypertensives, reducing the force of the pressure within the
    aorta to decrease the likelihood of rupture.

  • Administer analgestics to treat patients who may be having pain from pres-
    sure on nearby structures (nerves, etc.) or tearing of the vessel.

  • Administer oxycodone, morphine sulfate as needed to decrease oxygen
    demand.


NURSING DIAGNOSES



  • Ineffective peripheral tissue perfusion

  • Risk for deficient fluid volume

  • Acute pain

  • Anxiety


NURSING INTERVENTION



  • Monitor vital signs—look for changes in blood pressure or elevated pulse
    and respiratory rates. During aortic dissection the blood pressure (BP) may
    initially increase due to severity of pain. It may then become difficult to

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