Nurse Care Plan

Cerebral aneurysm is an outpouching of the wall of a cerebral artery that results from weakening of the wall of the vessel. It is difficult to determine the frequency of cerebral aneurysm because of differences in the definitions of the size of aneurysm and the ways that aneurysms are detected. The prevalence is estimated to range from 5% to 10%; unruptured aneurysms account for approximately 50% of all aneurysms.

Cerebral aneurysm have a variety of sizes, shapes, and causes. Most cerebral aneurysm are sacular or berry-like with a stem and a neck. The incidence of cerebral aneurysm has been estimated at 10 per 100,000 per population, with approximately 15% to 25% of patients having multiple aneurysms, often bilateral in the same location on both sides of the head. Clinical concern arises if an aneurysm ruptures or becomes large enough to exert pressure on surrounding structures. When the vessel wall becomes so thin that it can no longer withstand the
surrounding arterial pressure, the cerebral aneurysm ruptures, causing direct hemorrhaging of arterial blood into the subarachnoid space (subarachnoid hemorrhage).
Complications of a ruptured cerebral aneurysm can be fatal if bleeding is excessive. Subarachnoid hemorrhage can lead to cerebral vasospasm, cerebral infarction, and death. Rebleeding often occurs in the first 48 hours after the initial bleed but can occur any time within the first 6 months. Other complications include meningeal irritation and hydrocephalus.

Possible causes are congenital structural defects in the inner muscular or elastic layer of the vessel wall; incomplete involution of embryonic vessels; and secondary factors such as arterial hypertension, atherosclerotic changes, hemodynamic disturbances, and polycystic disease. Cerebral aneurysm also may be caused by shearing forces during traumatic head injuries.

Nursing care plan assessment and physical examination
Prior to rupture, cerebral aneurysm are usually asymptomatic. The patient is usually seen initially after subarachnoid hemorrhage (SAH). Ask about one or more incidences of sudden headache with vomiting in the weeks preceding major SAH. Other relevant symptoms are a stiff neck, back or leg pain, or photophobia, as well as hearing noises or throbbing (bruits) in the head. “Warning leaks” of the aneurysm in which small amounts of blood ooze from the aneurysm into the subarachnoid space can cause such symptoms. These small “warning leaks” are rarely detected because the condition is not severe enough for the patient to seek medical attention.

Identify risk factors such as familial predisposition, hypertension, cigarette smoking, or use of over-the-counter medications (e.g., nasal sprays or antihistamines) that have vasoconstrictive properties. Ask about the patient’s occupation, because if the patient’s job involves strenuous activity, there may be a significant delay in going back to work or the need to change occupations entirely.

In most patients, the neurological examination does not point to the exact site of the aneurysm, but in many instances, it can provide clues to the localization. Signs and symptoms can be divided into two phases: those presenting before rupture or bleeding and those presenting after rupture or bleeding. In the phase before rupture or bleeding, observe for oculomotor nerve (cranial nerve III) palsy—dilated pupil (loss of light reflex), possible drooping eyelids (ptosis), extraocular movement deficits with possible double vision—as well as pain above and behind the eye, localized headache, or extraocular movement deficits of the trochlear (IV) or abducens (VI) cranial nerves. Small, intermittent, aneurysmal leakage of blood may result in generalized headache, neck pain, upper back pain, nausea, and vomiting. Note if the patient appears confused or drowsy.

The patient has to cope not only with an unexpected, sudden illness but also with the fear that the aneurysm may rupture at any time. Assess the patient’s ability to cope with a sudden illness and the change in roles that a sudden illness demands. In addition, assess the patient’s degree of anxiety about the illness and potential complications.

Nursing care plan primary nursing diagnosis: Alteration in tissue perfusion (cerebral) related to interruption in cerebral blood flow or increased ICP.

Nursing care plan intervention and treatment
The first priority is to evaluate and support airway, breathing, and circulation. For patients unable to maintain these functions independently, assist with endotracheal intubation, ventilation, and oxygenation, as prescribed. Monitor neurological status carefully every hour, and immediately notify the physician of any changes in the patient’s condition.

Surgery is indicated to prevent rupture or rebleeding of the cerebral artery. The decision to operate depends on the clinical status of the patient, including the level of consciousness and severity of neurological dysfunction, the accessibility of the aneurysm to surgical intervention, and the presence of vasospasm. Surgical procedures used to treat cerebral aneurysm include direct clipping or ligation of the neck of the aneurysm to enable circulation to bypass the pathology. An inoperable cerebral aneurysm may be reinforced by applying to the aneurysmal sac such materials as acrylic resins or other plastics. Postoperatively, monitor the patient closely for signs and symptoms of increasing ICP or bleeding, such as headache, unequal pupils or pupil enlargement, onset or worsening of sensory or motor deficits, or speech alterations.

The environment should be as quiet as possible, with minimal physiological and psychological stress. Maintain the patient on bedrest. Limit visitors to immediate family and significant others. Apply thigh-high elastic stockings and intermittent external compression boots. Discourage and control any measure that initiates Valsalva’s maneuver, such as coughing, straining at stool, pushing up in bed with the elbows, turning with the mouth closed. Assist with hygienic care as necessary. If the patient has a facial weakness, assist her or him during meals.

Preoperatively, provide teaching and emotional support for the patient and family. Position the patient to maintain a patent airway by elevating the head of the bed 30 to 45 degrees to promote pulmonary drainage and limit upper airway obstruction. Suction the patient’s mouth and, if needed, the nasopharynx and trachea. Before suctioning, oxygenate the patient well, and to minimize ICP increases, limit suctioning to 20 to 30 seconds at a time. If the patient has facial nerve palsy, apply artificial tears to both eyes. Take appropriate measures to prevent skin breakdown from immobility. Postoperatively, promote venous drainage by elevating the head of the bed 20 to 30 degrees. Emotional support of the patient and family is also important. The patient may be dealing with a neurological deficit, such as paralysis on one side of the body or loss of speech. If the patient cannot speak, establish a simple means of communication such as using a slate to write messages or using cards. Encourage the patient to verbalize fears of dependency and of becoming a burden.

Nursing care plan discharge and home health care guidelines
Prepare the patient and family for the possible need for rehabilitation after the acute care phase of hospitalization. Instruct the patient to report any deterioration in neurological status to the physician. Stress the importance of follow-up visits with the physicians. Be sure the patient understands all medications, including dosage, route, action and adverse effects, and the need for routine lab monitoring if anticonvulsants have been prescribed.