Nursing diagnoses: Abdominal Aortic Aneurysm

1) Fear related to surgery and its outcome.

Intervention:
• Orient to environment using simple explanations.
• Speak slowly and calmly
• Allow personal space
• Encourage expression of feelings
• Encourage responses that reflect reality. Discuss which aspects can be
changed and which cannot.
• Orient client to critical care unit if appropriate
• Explain the rationale for equipment and tubes that may be present
postoperatively (e.g., cardiac monitor, ventilator, intravenous and intra-
arterial lines, naso-gastric tube, urinary catheter)
• Explain that the B/P may be taken in both arms and thighs in order to better
evaluate circulatory status
• Reinforce physician's explanations and clarify misconceptions client has
about effects of the surgery on sexual functioning (impotence can result from
diminished blood flow in the mesenteric or internal iliac arteries during or
after surgery and/or from nerve damage during surgery).

2) Risk for bleeding related to surgery

Intervention:
• Monitor the fluid status of the patient
• Monitor the surgical site for bleeding
• Monitor for signs and symptoms of shock:
• Increased pulse rate with normal or slight decrease in blood pressure,
narrowing pulse pressure, or decrease in mean arterial pressure (MAP)
• Urine output <5 ml/kg/h
• Restlessness, agitation, decreased mentation
• Increased respiratory rate, thirst
• Diminished peripheral pulses
• Cool, pale, moist or cyanotic skin
• Decreased oxygenation saturation, pulmonary artery pressures
• Decreased hemoglobin and hematocrit levels
• If shock occurs, place the client in the supine position unless
contraindicated (e.g. head injury).
• Collaborate with the physician or the advanced practice nurse to
replace fluid losses at a rate sufficient to maintain urine output >0.5
ml/kg/h (e.g Saline or Ringer’s lactate).
• Restrict the patient’s movement and activity.
• Provide reassurance, simple explanations and emotional support to
help reduce anxiety.
• Administer oxygen as ordered.

3) Risk for infection related to surgery and presence of invasive lines

Interventions:
• Meticulous hand washing
• Aseptic technique
 • Isolation measures
• No unnecessary diagnostic or therapeutic procedures
• Encourage and maintain caloric and protein intake in diet
• Observe for clinical manifestations of infection (e.g. fever, cloudy urine,
purulent drainage)
• Monitor skin and urinary system for signs of fungal, viral, or mycobacterial
pathogens.

4) High risk for ineffective therapeutic regimen management related to

insufficient knowledge of home care, activity restrictions, signs and
symptoms of complications, and follow-up care
Interventions:
• Instruct on proper wound care
• Activity restrictions
• Smoking cessations
• Report any changes in color, temperature or sensation in the legs.
• Report any signs of bleeding
• Manage hypertension

5) Risk for ineffective sexuality pattern (male) related to possible loss of

ejaculate and erections secondary to surgery