Nursing 211

N211: Health Differences Across the Lifespan I Three types of AAA: Ascending (most common and deadly), Descending or Transverse. Nursing Assessment: signs and symptoms are severe ripping, boring pain of the shoulder, neck, lower back or abdomen. Bradycardia, pericardial friction rub, pulse intensity disparity. A bruit, swooshing sound heard over a constricted artery, when auscultated is heard over the abdominal aorta, pulsation in the upper abdomen. Abdominal radiograph (aortogram, angiogram, abdominal ultrasound) is used to confirm diagnosis if aneurysm is calcified. Symptoms of rupture include hypovolemic or cardiogenic shock with sudden, severe abdominal pain. Nursing Diagnosis • Altered tissue perfusion related to enlargement and weakening of the aorta • Pain related to pressure of nerves and tissues created by enlarged vessel and tissue trauma Nursing Interventions and Plans Assess all peripheral pulses and vital signs regularly. Peripheral pulses are radial, femoral, popliteal, posterior tibial and dorsalis pedis. Observe for signs of occlusion after graft; change in pulses, severe pain, cool to cold extremities below graft and white to blue extremities. Observe renal functioning for signs of kidney damage (artery is clamped during surgery may result in kidney damage). Urine output of less than 30ml/hr, amber urine and elevated BUN and creatinine (early signs of renal failure). Observe for post-operative ileus by checking bowel sounds every shift and maintaining nasogastric tube to low continuous suction for 1 to 2 days post operatively. During abdominal aneurysm repair the large arteries are clamped for a period of time, and kidney damage can result. Normal BUN is 10-20 mg/dl and normal creatinine is 0.6-1.2mg/dl. The ratio of BUN and creatinine is 20:1. If the ratio of BUN and creatinine increases or decreases, suspect renal problems. The procedure involves the surgical removal of a portion of weakened arterial wall with an end-to-end anastomosis to a prosthetic graft. Gangrene is a lack of oxygen supply that leads to thrombosis and tissue necrosis and localized edema. The signs and symptoms are severe localized pain, discoloration and swelling that usually occurs within 72 hours of surgery or trauma. Tachycardia, tachypnea and hypotension related to toxemia and hypovolemia is also seen. 1.7 Arteriosclerotic Heart Disease


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