Question

what is physiological nursing diagnosis for patient have massive abdominal aortic aneurysm with empending rupture, leaking into retroperitoneal cavity with subsequent hematoma formation

Answer 1

DESCRIPTION:

• An aortic aneurysm is an abnormal dilatation of the arterial wall caused by localized weakness and stretching in the medial layer or wall of an artery.
• The aneurysm can be located any where along the abdominal aorta.
• The goal of treatment is to limit the progression of the disease by modifying risk factors controlling the blood pressure to prevent strain on the aneurysm ,recognize symptoms early and preventing rupture.

ASSESSMENT:

• Prominent pulsating mass in abdomen ,at or above the umbilicus.
• Systolic bruit over the aorta is assess.
• Tenderness on deep palpation.
• Abdominal or lower back pain is assessed.

NURSING DIAGNOSIS:

1. Risk for fluid volume deficit related to hemorrhage.
2. Acute pain related to surgical tissue trauma .
3. Decreased cardiac output related to changes in intra vascular volume, increased systemic vascular resistance,third space fluid shift.
4. Deficient knowledge related to newly identified need for aortic surgery.
5. Ineffective breathing pattern related to effects of general anesthesia, endotracheal incubation, presence of an abdominal incision.