62

Cardiovascular system

NURSING DIAGNOSES
Decreased cardiac output
Ineffective breathing pattern
Acute pain

TREATMENT
Surgery: resection of aneurysm with a
Dacron or Teflon graft replacement, possible
replacement of aortic valve

Drug therapy
Analgesic: morphine
Antihypertensives: nitroprusside (Nitropress), labetalol (Trandate)
Negative inotropic: propranolol (Inderal)

INTERVENTIONS AND RATIONALES

Monitor the clients blood pressure,
PAWP, and CVP to detect fluid volume deficit.
Also evaluate pain, breathing, and carotid,
radial, and femoral pulses to detect early signs
of aneurysm rupture.
Review laboratory test results, which must
include a complete blood count, differential,
electrolytes, typing and crossmatching for
whole blood, ABG studies, and urinalysis, to
note Hb levels and ensure that the client can
tolerate surgery.
Insert an indwelling urinary catheter and
monitor intake and output to evaluate fluid
status.
Carefully monitor nitroprusside I.V. infusion rate; use a separate I.V. line for infusion.
Adjust the dose by slowly increasing the infusion rate. Meanwhile, check blood pressure
every 5 minutes until it stabilizes to note the
effectiveness of treatment and prevent hypotension from large dose nitroprusside.
With suspected bleeding from an aneurysm, prepare to give a blood transfusion to
adequately replace deficient fluid volume.
Explain diagnostic tests. If surgery
is scheduled, explain the procedure and
expected postoperative care (I.V. lines,
endotracheal and drainage tubes, cardiac
monitoring, ventilation) to alleviate the clients
anxiety.

to guide treatment regimen and evaluate its

effectiveness.
Check respiratory function. Carefully
observe and record the type and amount of
chest tube drainage and frequently assess
heart and breath sounds to detect early signs of
compromise.
Monitor I.V. therapy to prevent fluid excess,
which may occur with rapid fluid replacement.
Give medications as appropriate to help
improve the clients condition.
Watch for signs of infection, especially
fever, and excessive wound drainage to initiate treatment promptly and prevent complications such as sepsis.
Assist with range-of-motion exercises of
the legs to prevent thromboembolism due to
venostasis during prolonged bed rest.
After stabilization of vital signs and respiration, encourage and assist the client
in turning, coughing, and deep breathing.
If necessary, provide intermittent positive
pressure breathing to promote lung expansion.
Help the client walk as soon as hes able
to prevent complications of immobility, such as
pneumonia and thromboembolism formation.
Before discharge, ensure adherence to
antihypertensive therapy by explaining the
need for such drugs and the expected adverse
effects. Teach the client how to monitor
his blood pressure to prevent complications
associated with ineffective blood pressure
management such as stroke.
Throughout hospitalization, offer the client
and family psychological support to relieve
anxiety and feelings of helplessness.

Teaching topics
Explanation of the disorder and treatment
plan
Medications and possible adverse effects
Monitoring blood pressure and reducing
hypertension
Modifying risk factors, including smoking
cessation

Thrombophlebitis

After repair of thoracic aneurysm

Evaluate the clients level of consciousness. Monitor vital signs, PAP, PAWP,
CVP, pulse rate, urine output, and pain

313419NCLEX-RN_Chap03.indd 62

Thrombophlebitis is marked by inflammation

of the venous wall and thrombus formation.
It may affect deep veins or superficial veins.

4/8/2010 7:01:52 PM