The Patient With an Intracranial Aneurysm
- Perform a complete neurologic assessment: level of patient's consciousness, pupillary reaction (sluggishness), motor and sensory function, cranial nerve deficits (extraocular eye movements, facial droop, ptosis), speech difficulties, visual disturbance, headache, nuchal rigidity, or other neurologic deficits.
- Document and report neurologic assessment findings, and reassess and report any changes in patient's condition; report changes immediately.
- Detect subtle changes, especially altered levels of consciousness (earliest signs of deterioration include mild drowsiness and slight slurring of speech).
Nursing Diagnoses
- Ineffective tissue perfusion (cerebral) related to bleeding or vasospasm
- Disturbed sensory perception due to the restrictions of aneurysm precautions
- Anxiety due to illness and/or medically imposed restrictions (aneurysm precautions)
Collaborative Problems/Potential Complications
- Vasospasm
- Seizures
- Hydrocephalus
- Rebleeding
- Hyponatremia
Patient goals include improved cerebral tissue perfusion, relief of anxiety, and absence of complications. Cerebral aneurysm precautions are implemented for the patient with a diagnosis of aneurysm to provide a nonstimulating environment, prevent increases in ICP, and prevent further bleeding.
Improving Cerebral Tissue Perfusion
- Monitor closely for neurologic deterioration, and maintain a neurologic flow record.
- Check blood pressure, pulse, level of consciousness, pupillary responses, and motor function hourly; monitor respiratory status and report changes immediately.
- Implement aneurysm precautions (immediate and absolute bed rest in a quiet, nonstressful setting; restrict visitors except for family).
- Elevate the head of the bed 15 to 30 degrees or as prescribed.
- Avoid any activity that suddenly increases blood pressure or obstructs venous return (e.g., Valsalva maneuver, straining), instruct patient to exhale during voiding or defecation to decrease strain, eliminate caffeine, administer all personal care, and minimize external stimuli.
- Apply antiembolism stockings or sequential compression devices. Observe patient's legs for signs and symptoms of deep vein thrombosis tenderness, redness, swelling, warmth, and edema.
Relieving Sensory Deprivation
- Keep sensory stimulation to a minimum; no television or reading.
- Dim lighting is helpful as photophobia is common.
- Explain restrictions to help reduce patient's sense of isolation.
Relieving Anxiety
- Inform patient of plan of care.
- Provide support and appropriate reassurance to patient and family.
Monitoring and Managing Potential Complications
- Assess for and immediately report signs of possible vasospasm, which may occur several days after surgery or on the initiation of treatment (intensified headaches, decreased level of responsiveness, or evidence of aphasia or partial paralysis). Also administer calcium channel blockers or fluid-volume expanders as prescribed.
- Maintain seizure precautions. Also maintain airway and prevent injury if a seizure occurs. Administer anticonvulsant medications as prescribed (phenytoin [Dilantin] is medication of choice).
- Monitor for onset of symptoms of hydrocephalus, which may be acute (first 24 hours after hemorrhage), subacute (days later), or delayed (several weeks later). Report symptoms immediately: Acute hydrocephalus is characterized by sudden stupor or coma; subacute or delayed is characterized by gradual onset of drowsiness, behavioral changes, and ataxic gait.
- Monitor for and report symptoms of aneurysm rebleeding (occurs most often in the first 2 weeks). Symptoms include sudden severe headache, nausea, vomiting, decreased level of consciousness, and neurologic deficit. Administer medications as prescribed.
- Hyponatremia: Monitor laboratory data often because hyponatremia (serum sodium level less than 135 mEq/L) affects up to 50% of patients. Report low levels persisting for 24 hours, as syndrome of inappropriate antidiuretic hormone or cerebral salt-wasting syndrome (kidneys cannot conserve sodium) may develop.
Educating Patients About Self-Care
- Provide patient and family with information to promote cooperation with the care and required activity restrictions and prepare them for patient's return home.
- Identify the causes of intracranial hemorrhage, its possible consequences, and the medical or surgical treatments that are implemented.
- Discuss the importance of interventions taken to prevent and detect complications (e.g., aneurysm precautions, close monitoring of patient).
- Education should include the use of assistive devices or home environmental changes to assist the patient with a disability at home.
- As indicated, facilitate patient's transfer to a rehabilitation unit or center.
Continuing and Transitional Care
- Urge patient and family to follow recommendations to prevent further complications and to schedule and keep follow-up appointments.
- Refer patient for home care if warranted, and encourage health promotion and screening practices.
Expected Patient Outcomes
- Demonstrates stable neurologic status, vital signs, and respiratory patterns
- Demonstrates functional sensory perceptions
- Exhibits reduced anxiety level
- Is free of complications
For more information, see Chapter 67 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.