Page 171 - Critical Care Nursing Demystified

156 CRITICAL CARE NURSING DeMYSTIFIED

Nursing Interventions

Assess and continuously monitor VS, especially BP. HTN can increase the
size of or rupture an AAA.

Assess and continuously monitor pain. Unrelieved pain can indicate an en-
larging AAA or imminent rupture.

Assess for presence of thrill/bruit in lower abdominal area. This indicates a
possible AAA.

Teach patient the possible surgical options, to help the patient make an in-
formed choice.

Teach patient about keeping control of BP, cessation of smoking, and lower-
ing cholesterol to prevent the AAA from enlarging.

Teach patient about the signs/symptoms of impending rupture/bleeding and
seeking medical attention early.

Teach patient about keeping follow-up appointments. Lifelong monitoring
is important.

CASE STUDY Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.

7 M.J., a 50-year-old African American, arrives at the hospital with complaints
of frequent nocturia, a persistent cough, a 20-lb weight gain within 1 week, extreme
fatigue, and shortness of breath while climbing his stairs at home and going
outside to check his mail. He has a history of hypertension and sleeps with several
pillows and his feet propped up since his “feet and ankles have become very
swollen within the past week.” As a nurse, you begin to suspect the onset of HF
in M.J.

QUESTIONS
1. Identify probable causes of heart failure.

2. List assessment findings in M.J. that confirm the likelihood of HF.
3. Identify the diagnostic tools that might be used to support evidence of HF.
4. What side of M.J.’s heart is primarily affected in this scenario?
5. Develop several actual nursing diagnoses for this patient.
6. Describe nursing interventions that would promote the relief of some of M.J.’s
persistent symptoms.