115-NCLEX-RN Review Made Incredibly Easy, Fifth Edition (Incredibly Easy...

Polish up on client care 35

After the procedure Apply continuous pressure to the puncture site for at least 5 minutes, then apply a pressure dressing for at least 30 minutes. Periodically check the site for bleeding.

Hear that sound? Its blood flowA Doppler ultrasound transforms echoes from sound waves into audible sounds, allow-ing examination of blood flow in peripheral circulation.

Nursing actions Determine the clients ability to lie still. Explain the procedure.

Visualize the veinsIn a venogram, a dye is injected to allow visualization of the veins. This picture is then used to diagnose deep vein thrombosis or incompetent valves.

Nursing actionsBefore the procedure Withhold food and fluids after midnight. Assess and record the clients baseline vital signs and peripheral pulses. Make sure that written, informed consent has been obtained. Note the clients allergies to seafood, iodine, or radiopaque dyes. Inform the client about possible flushing of the face or throat irritation from the injection of the dye.After the procedure Check the injection site for bleeding, infec-tion, and hematoma. Encourage fluids unless contraindicated.

Oxygen in arterial bloodPulse oximetry uses infrared light to mea-sure arterial oxygen saturation in the blood. This test helps assess a clients pulmonary status.

To distinguish it from oxygen saturation obtained by ABGs, oxygen saturation obtained by pulse oximetry is abbreviated SpO2.

Nursing actions Protect the sensor from bright light. Dont place the sensor on an extremity that has impeded blood flow.

Attach the monitoring sensor to a fin-gertip, ear lobe, bridge of the nose, or toe. If a fingertip is used, remove artificial nails, nail tips, and nail polish because they may interfere with light transmission.

Polish up on client careMajor cardiovascular disorders include abdominal aortic aneurysm, angina, arrhyth-mias, cardiac tamponade, cardiogenic shock, cardiomyopathy, coronary artery disease (CAD), endocarditis, heart failure, hyperten-sion, hypovolemic shock, myocardial infarc-tion (MI), myocarditis, pericarditis, peripheral artery disease, Raynauds disease, rheumatic fever and rheumatic heart disease, thoracic aortic aneurysm, thrombo phle bitis, and val-vular heart disease.

For all these disorders, the goal of nursing management is to decrease cardiac workload and increase myocardial blood supply. These steps increase oxygenation to the tissues and reduce overall damage to the heart.

Abdominal aortic aneurysm

An abdominal aortic aneurysm results from damage to the medial layer of the abdominal portion of the aorta. Aneurysm commonly results from atherosclerosis, which over time causes a weakening in the medial layer of the artery. Continued weakening from the force of blood flow results in outpouching of the artery and formation of the aneurysm. The aneurysm may then cause a rupture, leading to hemor-rhage, hypovolemic shock, and possibly death.

There are four types of abdominal aneu rysms:

dissecting (the vessel wall ruptures, and a blood clot is retained in an outpouching of tissue)

false (pulsating hematoma results from trauma)

fusiform (bilateral outpouching)

saccular (unilateral outpouching).

For all cardiac disorders, the goal of nursing care is

to decrease cardiac workload and

increase myocardial blood supply.

Look for signs of shock when caring

for clients with abdominal aortic

aneurysm.

313419NCLEX-RN_Chap03.indd 35313419NCLEX-RN_Chap03.indd 35 4/8/2010 7:01:38 PM4/8/2010 7:01:38 PM

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