Activity intolerance, risk for adaptation, impaired airway clearance, ineffective allergy response, latex allergy response, risk for latex anxiety [specify level]. Breastfeeding, effective breastfeeding, ineffective breastfeeding, interrupted breathing pattern, ineffective cardiac output, reduced caregiver role stress Caregiver role stress, risk to communication, impaired verbal communication, readiness for heightened conflict, decision making (specify). Lifestyle, sedentary Loneliness, risk to memory, impaired mobility, impaired bed mobility, impaired physical mobility, impaired wheelchair Nausea.
Sexual dysfunction Sexuality pattern, ineffective skin integrity, impaired skin integrity, risk for impaired sleep, readiness for improved sleep deprivation.
CAUSES
An abdominal aortic aneurysm (AAA) is a localized bulging or dilatation of the arterial wall in the posterior part of the descending segment of the aorta. AAAs are the most common type of arterial aneurysm, occurring in 3% to 10% of people over age 50 in the United States. Leakage of the aortic wall occurs when the muscle-elastic middle layer or media of the artery weakens (often due to plaque and cholesterol deposits) and degenerative changes occur.
The inner and outer layers of the arterial wall are stretched, and as the pulsating force of blood passes through the aorta, the vessel wall becomes increasingly weak and the aneurysm enlarges.
GENETIC CONSIDERATIONS
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
ASSESSMENT
PRIMARY NURSING DIAGNOSIS
PLANNING AND IMPLEMENTATION Collaborative
Educate the patient about the disease process, breathing and leg exercises, the surgical procedure and postoperative routines. If the patient is admitted in shock, support airway, breathing and circulation, and speed up the surgical procedure. To ensure adequate respiratory function and to prevent complications, assist the patient with coughing and deep breathing after extubation.
Turn the patient from side to side every 2 hours to ensure good ventilation and prevent skin damage.
DOCUMENTATION GUIDELINES
Note that the surgical procedure may be performed on an emergency basis, limiting the time available for preoperative instruction. Splint the incision with pillows, provide adequate pain relief before coughing sessions, and position the patient with the head of the bed elevated to facilitate coughing. Remember that emergency surgery is a time of extreme anxiety for both the patient and the significant other.
If the patient or family is unable to cope effectively, you may need to refer them for counseling.
DISCHARGE AND HOME HEALTHCARE GUIDELINES
Ask the patient to describe the onset of bleeding (circumstances, amount and presence of pain). Assess the patient's abdominal circumference every hour by placing a tape measure at the level of the umbilicus. The patient experiences fear of loss of sex life, contamination of others, rejection and stigma.
During the more acute stages of the disease, focus on maximizing the patient's health and promoting comfort.
CAUSE
In the middle stage of ARDS, the patient may have basilar cracks or even gross cracks. Expect the patient to be extremely frightened and the family to be anxious or even angry. Make sure the patient and family are aware of the next follow-up visit with the healthcare provider.
The early withdrawal stage usually occurs within 48 hours of the patient's last drink, generally with mild symptoms.
GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATION
The patient may notice that he or she feels “shaking” or nervous “inside” (internal vibrations). The patient should feel safe that you are there to protect him or her. If a pattern of heavy drinking is identified, the patient is often placed on prophylactic benzodiazepines.
Monitor the patient constantly for signs of dehydration, such as poor skin turgor, dry mucous membranes, weight loss, concentrated urine, and hypotension. If the patient's blood pressure falls below 90 mm Hg, significant fluid volume loss has occurred; notify the doctor immediately. However, if symptoms do occur, remain at the bedside during episodes of extreme agitation to reassure the patient.
Encourage the patient to seek help from Alcoholics Anonymous (AA) or to see a counselor or join a support group. After an alcohol withdrawal experience, the patient may be able to accept that he or she has an alcohol abuse problem. Hypertension often complicates the course, and if the bleeding is large, the patient may develop a fluid volume deficit.
The patient may experience a disturbance in body image due to the disfigurement caused by the rash and swelling. Determine the patient's response to her or his appearance and identify whether the changes interfere with the implementation of various roles such as parenting or work.
DIAGNOSTIC HIGHLIGHTS
Assist the patient with colloid baths and daily activities if joint pain and lesions give the patient limited activity tolerance. Teach the patient to protect the lesions from additional trauma by wearing long-sleeved blouses or shirts. Provide the patient with information about medications, including dosage, route, action, and side effects.
Initial patient management begins with educating family and caregivers about the disease, prognosis, and lifestyle changes needed as the disease progresses. Anticipate and assess the patient's needs primarily through nonverbal communication because the patient cannot communicate meaningfully through speech. Often, emotional outbursts or changes in behavior are a sign of a patient's toileting needs, discomfort, hunger, or infection.
Encourage the patient to remember, as short-term memory loss causes anxiety in the patient. Maintain physical patient safety by providing loose carpeting, supervising electrical equipment, and closing doors and windows. Make sure the patient carries proper identification in case he or she gets lost.
Make sure the patient carries identification so they can be returned safely if they get lost. Commercially manufactured products are available that sound an alarm if the patient strays from the safe area.
GENDER AND LIFE SPAN CONSIDERATIONS
If the patient is hospitalized, instruct the patient to sit on the edge of the bed before getting up. Instruct the patient to avoid enemas and rectal thermometers because of the risk of rectal perforation.
GENDER, ETHNIC/RACIAL AND LIFE SPAN CONSIDERATIONS
Of all cases, approximately 60% are associated with hyperplasia of the submucosal lymphoid follicles and 35% with faecal stasis or fecalith. Familial appendicitis may be due to a hereditary predisposition to obstructions in the lumen of the appendix.
PRIMARY PREOPERATIVE NURSING DIAGNOSIS
PRIMARY POSTOPERATIVE NURSING DIAGNOSIS
Encourage the patient to assume a semi-Fowler position while in bed to promote lung expansion. Make sure the patient understands any pain medication being prescribed, including dosages, route, action and side effects. In addition, there is calcification of the media and a loss of elasticity that predisposes the patient to dilatation or thrombus formation.
Teach the patient to observe the wound and report to the physician any increased swelling, redness, drainage, odor, or separation of the wound edges. Elicit a history of previous illnesses or surgeries that were vascular in nature; Ask if the patient has a history of arterial occlusive disease. Determine whether the patient has had transient ischemic attacks (TIAs) due to reduced cerebral circulation.
Ask if the patient has had signs of vertebrobasilar artery involvement, such as binocular visual disturbances, vertigo, dysarthria, or episodes of falling. Determine if the patient has a limp on the right arm (claudication), which is a sign of possible involvement of the innominate artery. Determine whether the patient's mesenteric artery is involved by asking if he has had acute abdominal pain, nausea, vomiting, or diarrhea.
Determine if the patient has experienced sporadic claudication of the lower back, buttocks, and thighs or impotence in male patients, all of which are indicators of iliac artery occlusion. Discover a history of sporadic claudication of the patient's calves after exercise; ask whether the patient has experienced pain in the feet - these are signs of involvement of the femoral and popliteal arteries.
PRIMARY NURSING DIAGNOSES
Assess the ability of the patient and significant others to cope with this potential change. Provides supportive care for the patient and significant others, and makes referrals for sexual counseling as appropriate. Teaching performed, the patient's understanding of the content, the patient's ability to perform procedures demonstrated.
Remain with the patient for the first 15 minutes of the transfusion to monitor for signs of a hemolytic reaction. Keep airway management equipment (endotracheal tube, laryngoscope, nasal and oral airways) within easy reach of the patient. Provide careful and ongoing assessment of the patient's feelings (anger, depression, anxiety, fear) and body image concerns.
A decrease in the patient's weight leads to a decrease in the mass of the diaphragm, which contributes to poor respiratory muscle function. Elevate the head of the bed to allow the patient to assume an easier position for breathing.
DOCUMENTATION GUIDELINES Emergent-Resuscitative Phase
Monitor the patient for signs of infection such as fever, chills, and increased white blood cell count. Assess the level of pain and the patient's ability to cope. Strain the patient's urine to detect passing stones for analysis.
Teach the patient to take analgesics as ordered and to use other appropriate comfort measures. If the patient is given antibiotics, encourage him to fill the entire prescription. The patient may complain of a burning sensation or pain in the mouth or difficulty swallowing.
Inspect the patient's vagina for vulval rash; erythema; inflammation; cheesy exudate; or lesions of the labia, vaginal walls or the cervix. Intravenous fluids or total parenteral nutrition therapy may be necessary if the patient's fluid and nutritional intake is compromised. Teach the patient to keep his or her skin clean and dry, especially in skin folds.
Assess the patient's degree of anxiety about the traumatic event, injuries sustained and the potential consequences of the injuries. Perform serial monitoring of vital signs to determine if the patient's cardiac function is changing.
