Polish up on client care

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.

Attach the monitoring sensor to a fingertip, 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.

Hear that sound? Its blood flow

A Doppler ultrasound transforms echoes
from sound waves into audible sounds, allowing examination of blood flow in peripheral
circulation.

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

Visualize the veins

In 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 actions
Before 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, infection, and hematoma.
Encourage fluids unless contraindicated.

Oxygen in arterial blood

Pulse oximetry uses infrared light to measure 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.

313419NCLEX-RN_Chap03.indd 35

35

For all cardiac

disorders, the goal
of nursing care is
to decrease cardiac
workload and
increase myocardial
blood supply.

Polish up on client care

Major cardiovascular disorders include
abdominal aortic aneurysm, angina, arrhythmias, cardiac tamponade, cardiogenic shock,
cardiomyopathy, coronary artery disease
(CAD), endocarditis, heart failure, hypertension, hypovolemic shock, myocardial infarction (MI), myocarditis, pericarditis, peripheral
artery disease, Raynauds disease, rheumatic
fever and rheumatic heart disease, thoracic
aortic aneurysm, thrombophlebitis, and valvular 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 hemorrhage, hypovolemic shock, and possibly death.
There are four types of abdominal
aneurysms:

Look for signs of

shock when caring
for clients with
abdominal aortic
aneurysm.

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).

4/8/2010 7:01:38 PM