Continuation of 38
Notifying the surgeon
Elevating the extremity
Administering pain medication
Placing a warm blanket on the operative limb
Elevated temperature and diaphoresis
Loss of sensation and pallor proximal to surgical site
Swelling, pain, and tension of affected limb
Increased pulse amplitude and warmth below surgical site
Performing passive range-of-motion exercise on the affected limb to increase flexibility
Preparing the client for return to the operative suite for surgical correction
Medicating the client for pain and placing the client in a knee-chest position
Loosening the dressing and elevating the extremity to the level of the heart
Measurement of abdominal girth
Observation of abdominal wall movement
Auscultation of any area of the abdomen
Palpation of the abdominal midline area
The aneurysm has become obstructed.
The aneurysm may be undergoing expansion.
The client is experiencing inflammation of the aneurysm.
The client is experiencing normal sensations associated with this condition.
Measuring abdominal girth
Auscultating the abdomen
Increasing the IV rate
Measuring blood pressure in both arms
Measuring the abdominal girth and check pulses
Raising the head of the bed to 90 degrees
Measuring the cardiac output
Irrigating the Foley catheter
“You may drive your car any time.”
“Avoid sleeping on your left side.”
“Avoid lifting heavy objects for about 3 months.”
“You can expect to have an increase in abdominal girth for about 6 weeks.”
Keeping environmental temperatures comfortably warm
Avoiding injury to the hands or feet
Using a heating pad on the feet
Reddened, with diminished distal pulses
Cold and pale, with proximal bounding pulses
Cyanotic, with hyporeflexive distal deep tendon reflexes
Brownish, with hyperreflexive distal deep tendon reflexes
“Take oral vasoconstrictive agents when you have symptoms.”
“Wear warm clothing when exposed to cool temperatures.”
“Avoid placing lotion on affected extremities.”
“Check the pulses in your arms and legs daily.”
The client’s aPPT is half of the control value.
The client’s aPPT is the same as the control value.
The client’s aPPT is twice the control value.
The client’s aPPT is five times the control value.
Administer the medications as prescribed.
Turn off the heparin drip for 1 hour before administration of the warfarin.
Discontinue the heparin drip completely before warfarin administration.
Hold the dose of warfarin.
“You must have your aPTT checked every 2 weeks.”
“Massage the injection site after the heparin is injected.”
“Notify your health care provider if your stools appear tarry.”
“You will have an IV catheter placed that you can use for intermittent injection of the heparin.”
“Apply antiembolism stockings before getting out of bed in the morning.”
“Clean the ulcer with Betadine before applying a dressing.”
“Take one low-dose aspirin daily to prevent inflammation.”
“Remove and reapply the DuoDerm dressing daily.”
Excess hair growth on the arms and legs
Pitting edema in the feet
Cyanosis of the nail beds
Loss of toe nails
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