Cerebral Aneurysm

  1. General information
    1. Dilation of the walls of a cerebral artery, resulting in a sac-like outpouching of vessel
    2. Caused by congenital weakness in the vessel, trauma, arteriosclerosis, hypertension
    3. Pathophysiology
      1. Aneurysm compresses nearby cranial nerves or brain substance, producing dysfunction
      2. Aneurysm may rupture, causing subarachnoid hemorrhage or intracerebral hemorrhage
      3. Initially a clot forms at the site of rupture, but fibrinolysis (dissolution of the clot) tends to occur within 7-10 days and may cause rebleeding.
  2. Assessment findings
    1. Severe headache and pain in the eyes
    2. Diplopia, tinnitus, dizziness
    3. Nuchal rigidity, ptosis, decreasing LOC, hemiparesis, seizures
  3. Nursing interventions
    1. Maintain a patent airway and adequate ventilation.
      1. Instruct client to take deep breaths but to avoid coughing.
      2. Suction only with a specific order.
    2. Monitor vital signs and neuro checks and observe for signs of vasospasm, increased ICP, hypertension, seizures, and hyperthermia.
    3. Enforce strict bed rest and provide complete care.
    4. Keep head of bed flat or elevated to 20°-30° as ordered.
    5. Maintain a quiet, darkened environment.
    6. Avoid taking temperature rectally and instruct client to avoid sneezing, coughing, and straining at stool.
    7. Enforce fluid restriction as ordered; maintain accurate I&O.
    8. Administer medications as ordered.
      1. Antihypertensive agents to maintain normotensive levels
      2. Corticosteroids to prevent increased ICP
      3. Anticonvulsants to prevent seizures
      4. Stool softeners to prevent straining
      5. Aminocaproic acid (Amicar) to decrease fibrinolysis of the clot (administered IV).
    9. Prevent complications of immobility.
    10. Institute seizure precautions.
    11. Provide nursing care for the unconscious client if needed.
    12. Prepare the client for surgery if indicated (see Craniotomy).

Tuesday, May 20, 2008 | Labels: |

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