Page 1724 - Saunders Comprehensive Review For NCLEX-RN

extremities, or a persistent elevation of
BP occurs, to notify the PHCP
immediately.

Instruct the client with an aortic aneurysm

to report immediately the occurrence of chest or
back pain, shortness of breath, difficulty swallowing,
or hoarseness.
D. Pharmacological interventions
1. Administer antihypertensives to maintain the BP
within normal limits and to prevent strain on the
aneurysm.
2. Instruct the client about the purpose of the
medications.
3. Instruct the client about the side effects and schedule
of the medication.

E. Abdominal aortic aneurysm resection

1. Description: Surgical resection or excision of the
aneurysm; the excised section is replaced with a graft
that is sewn end to end (Fig. 52-13).
2. Preoperative interventions
a. Assess all peripheral pulses as a
baseline for postoperative comparison.
b. Instruct the client in coughing and
deep-breathing exercises.
3. Postoperative interventions
a. Monitor vital signs.
b. Monitor peripheral pulses distal to the
graft site.
c. Monitor for signs of graft occlusion,
including changes in pulses, cool to
cold extremities below the graft, white
or blue extremities or flanks, severe
pain, or abdominal distention.
d. Limit elevation of the head of the bed to
45 degrees to prevent flexion of the
graft.
e. Monitor for hypovolemia and kidney
failure resulting from significant blood
loss during surgery.
f. Monitor urine output hourly, and notify
the PHCP if it is lower than 30 to 50
mL/hr.
g. Monitor serum creatinine and blood
urea nitrogen levels daily.
h. Monitor respiratory status and

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