Cerebral Aneurysm

A. Background of the study

A cerebral aneurysm (also known as an intracranial or intracerebral aneurysm) is

a weak or thin spot on a blood vessel in the brain that balloons out and fills with
blood. The word aneurysm comes from the Latin word aneurysma, which means
dilatation. Aneurysm is an abnormal local dilatation in the wall of a blood vessel,
usually an artery, due to a defect, disease, or injury. The bulging aneurysm can put
pressure on a nerve or surrounding brain tissue. It may also leak or rupture, spilling
blood into the surrounding tissue (called a hemorrhage).

B. Objectives

General:

To be able to gain knowledge and practice skills.

Specific:

At the end of the study, the SN will be able to:

• Promote wholeness and well-being including safety and comfort on

patient.
• Recognize patient’s needs and prioritize nursing care.
• Know the health information of the patient have a cerebral aneurysm
C. Significance of the study

The importance of the study is to give information about the proper

management and care for patient who developed the disease. .

Nursing Student:

• This will help student nurse to understand the true meaning of

Cerebral Aneurysm, and level of needs of infected patient.
• SN will also be able to practice skills acquired and learned during
lectures.
• SN can also educate patient or family on how they can prevent and
reduce the complication of the disease even they already have the
disease or not.

Clinical instructor:
• Will be able to identify the students weakness and they can able to
focus on what aspects of the disease must be discusses further so that
the skill would be performed better.

D. Scope and Limitations:

 The study will cover from assessments for 2days exposure in the Surgical
Intensive Care Unit (SICU) starting from May 11 to 12, 2010. Information was
gathered through interview, assessing the patient and getting information to his
chart. The scope of this case study involves only the case of Mr. F.C.N. ; this does
not involve any other special cases regarding cerebral aneurysm. The student
nurse focused on the nursing aspect of care, to give a basic knowledge about
cerebral Aneurysm and management of treatment to be applied to the disease.

E. Theoretical Framework

Jean Watson’s Human Caring Theory

Caring is the essence of Nursing and it connotes responsiveness

between the nurse and the person. Watson contends that caring can assist
the person to gain control, become more knowledgeable and thus promote
health changes.

Her Carative factors are viewed as a guide of a nurse in honoring the

human dimensions of nursing’s work and the inner life world especially the
subjective experiences of the people we serve. These Carative factors point
to the aspects of nursing which affect the one caring and the one being cared
for, thereby potentiating the therapeutic healing process.

The nurse assumes many roles such as teacher, leader and stranger.
This theory is effective in dealing with patient with this kind of disorder. The
nurse should gave his wholeness of care to the patient, not just being obliged
to do the responsibility as a nurse, but also giving love and care that may
form a good relationship with the patient and nurse.

II. Nursing Assessment

A. Personal Data
 The patient, Mr. F.C.N. is a 53 yrs Old male from B1 – B14th Avenue Brgy.
Socorro Cubao, Quezon City. Taking of demographic information took place at
University of Sto. Thomas Hospital last May 12, 2010.

B. Chief Complaint

Vomiting, headache and dizziness.

C. Diagnosis

Subarachnoid haemorrhage secondary to Left MCA Aneurysm

D. History of Past Illness

The patient does have complete immunization. Other than his disease, he
already acquired hypertension (paternal) since 2005, and appendicitis last
2006.

E. History of Present Illness

April 10, 2010 4pm, patient experienced vomiting, left sided headache,
and dizziness not associated with loss of consciousness. This was
associated with increase in BP of 210/100. At 6pm he occurred in CT scan
and has a result of Subarachnoid Haemorrhage (SAH). He was continued
at the ICU for 5 days and was advised to undergo surgery but due to
financial constraints, this was not done. He was discharged again medical
advised on April 15, 2010. Then he was noted vomiting every time he
would eat and have headache for which he took tramadol almost every
4hrs. He was compliant for his discharged and was kept on bed rest. He
was kept on bed rest until May 1.

He was admitted at PHC 3pm, for possible ruptured aneurysm. A CT

scan was done which revealed 30cc of blood on his brain. Other Lab
results were called. He was confined at the ICU from May 1 – 5 2010. Then
he was advised to transfer to USTH for Surgery.

f. Family History

The patient’s father has history of hypertension. There were no other histories
of illness that is related to his family history.

g. Patient’s concept of health and illness and hospitalization

Mr. F.C.N.’s concept of health and illness and hospitalization is based on belief of his
family. They didn’t base their health and illness to herb doctors but they base their
health to real physicians.
 H. Psychosocial History

The patient socialize with other person normally

I. Physical Assessment

Area assessed Technique Normal Findings Actual Findings

Used

SKIN

Color and pigmentation Inspection Light to deep brown Pallor

Lesions Inspection No lesions, scars or (+) scar right

lower quadrant
of abdomen
Mobility and turgor Palpation The skin springs back The skin springs
to its previous state back to its
after being pinched previous state
after being
pinched

NAILS

Shape Inspection Convex Convex

Lesions Inspection No inflammation of No inflammation

the skin around the of the skin
nail around the nail
Thickness Palpation Firm Firm

HEAD

Size Inspection Proportion to the body Proportion to the

and the skull is body and the
rounded and smooth skull is rounded
Symmetry Inspection Symmetrical

Symmetrical

HAIR

Color Inspection Black bald

Texture Inspection Curly hair, straight bald

SCALP

Distribution of hair Inspection Evenly distributed bald

Lesions Inspection No inflammation, No inflammation,

lumps or masses lumps or masses

FACE

Texture Inspection Smooth Smooth

Facial movement Inspection Symmetric facial (-) facial

movement movement

EYES

Eyebrows Inspection Evenly distributed, Evenly

Equally aligned distributed,
Eyelashes Inspection Equally aligned
Evenly distributed,
Eyelids Inspection curved outward Evenly
distributed,
Pink conjunctiva curved outward
Conjunctiva Inspection
Pale palpebral
conjunctiva
EARS

Color Inspection Same as facial color Same as facial

color
Symmetry Inspection Symmetrical at the
level of the eyes Symmetrical at
corner the level of the
eyes corner

Shape and size Inspection Symmetric to head

Canal discharge Inspection Symmetric to
No discharges and head
inflammation

No discharges
and inflammation

NOSE

Color Inspection Same with facial color Same with facial

color
Shape Inspection Symmetric
Symmetric
Discharges Inspection No discharges
no discharges

MOUTH & PHARYNX

Lips Inspection Symmetric Symmetric

Symmetry Inspection Pink Pale

Color

Palpation Moist Dry

Moisture

TONGUE

Position Inspection Positioned at the Central position

center can move
freely

Dull red
Color Inspection Smooth Dull red

Texture Inspection Can move freely Smooth

Mobility Inspection No lesions or Cannot move

inflammation freely
Lesions Inspection
No lesions or
inflammation

Gums Inspection No lesion, no signs of No lesion, no

bleeding signs of bleeding

Teeth Inspection No cavities No cavities

Tonsils Inspection No swelling, able to Cannot swallow

swallow foods, (+) OF
feeding

NECK

Position Inspection Head centered Head centered

Symmetry Inspection Symmetrical Symmetrical

Range of movements Inspection Smooth movements (-) movements

without discomfort

THORAX

Chest Inspection Symmetrical chest Symmetrical

expansion chest expansion
Palpation
No tenderness No tenderness
Lungs Auscultation
No adventitious sound No adventitious
sound

HEART

Rate Auscultation normal normal

UPPER AND LOWER

EXTREMITIES
 Size

Symmetry Inspection Equal size Equal size

Skin color Inspection Symmetrical Symmetrical

Lesions Inspection Light to deep brown Light to deep

brown
Inspection No lesions,
deformities or No lesions,
Temperature inflammation deformities or
Palpation inflammation
Normal
Normal (36.7
degree Celsius)

J. Gordon’s Functional Pattern

FUNCTIONAL BEFORE DURING INTERPRETATION

HEALTH HOSPITALIZATION HOSPITALI- WITH ANALYSIS
PATTERN ZATION
Health Mrs. F.C.N doesn’t In the The patient and
perception and believe in any type of hospital, all family shows
health medicines, the willingness to
management hospitalization and prescribed cooperate with the
seeking help to any drugs were medical team and
health professional. taken by the accepted all the
client they medical
also bought requirements that
all the things she needed.
that were
asked by the
Nutritional and doctor
metabolic
The patient’s regular
meals are green leafy
OF feeding
vegetables, fish and
during
rice. The patient is unable
hospitalizatio
to swallow foods so
Elimination n
OF feeding is given
pattern

The patient suffers

from irregular bowel
The patient is
elimination or urine
Patient urine currently in
output
output unconscious state
and unable to
80cc/hr control urination

Activity
exercise patter

No bowel
Sleep-rest
movement
pattern The patient is not
yet.
engaged to any
exercise activities or The patient can’t
sports activities but defecate normally
he is sure living an Can’t walk
 Going to the
active way bathroom.

Although Mrs. F.C.N.

The patient is in
is having difficulty in
unconscious state
Cognitive sleeping no
can sleep normally
perceptual medication was taken The patient but not controllable
pattern to fall asleep. appears to be
Sometimes he always
experience sleepless asleep,
nights. His usual especially if
sleeping time is 10pm certain
and often wakes up at operations
3am and not be able may be
to go back to sleep applied
again.

The patient still has

problems on senses
No problems on because of the
senses, Mr. F.C. N. are illness
Self able to see and hear The patient
perception/self without any has an score
concept pattern difficulties. Everything of 9-10(GCS),
he needs that that is good
requires her senses is for the
attained and she is patient
able to perform it except for his
speaking
response

The relative of the The patient can

patient stated that his sleep comfortably
Role –
fiancée occurred in
relationship
severe headache and
pattern
also vomiting While he was
in the
hospital, he
 can sleep
comfortably,
he said she
fall asleep at
11 pm and
wakes up at 3
or 4 am.

Whenever
she tries to
go back to
sleep she’ll
just drink
some milk,
The patient is not
she believes
much of a believer of
Sexuality that it helps
science but she is
reproductive her fall
surely one of the
Pattern He is in an extended asleep.
common patients
type of family; his
who are still open for
Coping stress sister is living with
these things
pattern them. The patient is
The client is especially when it is
the eldest of the
unconscious for free and
house and also he is
beneficial.
working as a business
man to be able to
contribute in the
family income, though
the patient is working
he still manage to
watch over his
children he is doing
his work at home, her
salary is not that high
but still helpful for the
Values and family. He is only
belief pattern earning around 5
thousand a month.

The patient admitted

that he is not sexually
active s. n/a
 The patient
The patient describes accepts
his everyday life as everything
stressful, but despite that the
of that he doesn’t doctor or the
take any medications nurse is
to relieve stress, he giving him, he
only take some rest believes that
every time he feels they know
like he needs doing so better than
and every time that him.
he is needing a warm
This type of family is
conversation, he can
not included in the
rely on his sister to be
higher class nor in
able to overcome
the middle class. But
stress
still they are the
ones who are
persevering to live a
While she is better life. They both
The religion is very in the
important to his life work to be able to
hospital, her support their
because he believes sister is the
that through this, a finances.
one who is
person can survive in taking
all types of challenges responsible
In life. He also for all her
mentioned that faith needs.
in God is the one of
the best way to
survive everyday
living. She and her
family is actively
engaged in the
church. She is
spiritually healthy
which is very helpful
to maintain a healthy
body.
K. Laboratory Results

Blood Chemistry

Urea
9.023.0mg/dl
Sodium 137 –
147mEq/L

Potassium 151.69 148.25 147 141

3.8 – 5.0
meq/L

Chloride 46.13 3.64 3.45 3.99

Bicarbonate

Glucose 70.9 0.96

– 110.0 mg/dl

Creatinine 1.19 1.19

Ionized Ca 1.19

Blood Chemistry May 10, 2010

Test Result Male reference Result

range

Creatini 0.96 Mg/dL 0.5-1.2 84.9 Umol/L (44.20-

ne 106.08)

SGOT- 108.63 high U/L 0-38 108.9 U/L (0000-

AST 38.00)

SG PT – 155.30 high U/L 0-41 158.3 U/L (0.00-

ALT 41.00)

Sodium 141.00 Mmol/L 137- 141 Mmol/L (137.00

147 -
147.00)

potassi 3.99 Mmol/L 3.8-5 4.0 Mmol/L (3.80-

um 5.00)
Blood Chemistry May 09, 2010

Test Result Male reference Result

range

Sodium 142.00 Mmol/L 137- 147 Mmol/L (137.00

14.7 -
147.00)

Potassi 3.45 Low Mmol/L 3.8-5 3.5 Mmol/L (3.80-

um 5.00)

Ionized 1.19 Mmol/L 1.12- 1.2 Mmol/L (1.12-

Ca 1.32 1.32)

Complete Blood Count

Result Limit Ref. Range

HGB 98 g/L 120-170

RBC 3.65 X10^12/L 4.0-6.0

HCT 0.30 U^3 0.37-0.54

MCP 81.40 g 87+.5

MCH 26.90 g/L 29+-2

MCHC 33.10 8L 34+-2

RDW 16.20 X10^9/L 11.6-14.6

MPV 8.80 X10^9/L 7.4-10.4

Platelet 223 150-450

WBC 11.60 4.5-10.0

Differential
Count

Neutrophils 0.83 0.50-0.70

Metamyelocytes -

Bands - 0.00-0.70

Segmented 83 0.50-0.70

Lymphocytes 0.14 0.20-0.40

monocytes 0.01 0.00-0.07

Eosinphils 0.02 0.00-0.-5

Basophils - 0.00-0.001

Gastat -601 Result 10/05/08

pH 7.421

pCO2 20.8mmHg L

pO2 142.8mmHg H

Temp 37.5degree C

F102 40.0%

BP 757.5mmHg

HCO3 13.5mmHg

O2SAT 98.8%

BE 8.6mmol/L

TCO2 14.2mmol/L

O2CT 13.5VoL%
3B 37.1mmol/L

SBE -9.2mmol/L

A9bo2 117.4mmHg

q/A 0.55

RI 0.8

Electrocardiogrphic Report 05/06/10

Rythm sinus

Atrial rate 107/min

Ventricular rate 107/min

RR 0.14sec

QRS 0.08sec

QTC 0.36sec

Mean frontal axis

QR Axis + 280

III. Anatomy and Physiology

 The cerebral hemispheres make up the largest portion of the human

brain.

 The cerebral hemispheres appear as highly convoluted masses of

gray matter that are organized into a folded structure.

 The crests of the cortical folds (gyri) are separated by furrows (sulci)
or deeper fissures.

 The folding of the cortex into gyri and sulci permits the cranial vault
to contain a large area of cortex (nearly 2 1/2 square feet), more
than 50% of which is hidden within the sulci and fissures.
Main Sulci & Fissures

 The surfaces of the cerebral hemispheres contain many fissures and

sulci that separate the frontal, parietal, occipital, and temporal
lobes from each other and the insula.

 The lateral cerebral fissure (Sylvian fissure) separates the temporal

lobe from the frontal and parietal lobes.

 The insula, a portion of cortex that did not grow much during
development, lies deep within the fissure The circular sulcus
surrounds the insula and separates it from the adjacent frontal,
parietal, and temporal lobes.

 The hemispheres are separated by a deep median fissure, the

longitudinal cerebral fissure.

 The central sulcus (the fissure of Rolando) arises about the middle of
the hemisphere, and separates the frontal lobe from the parietal
lobe.

 The parieto-occipital fissure separates the parietal lobe from the

occipital lobe.
Corpus Callosum

 The corpus callosum connects the two hemispheres

 It is a large bundle of myelinated and nonmyelinated fibers, that

crosses the longitudinal cerebral fissure and interconnects the
hemispheres.

 The corpus callosum serves to integrate the activity of the two

hemispheres and permits them to communicate with each other.

 Most parts of the cerebral cortex are connected with their

counterparts in the opposite hemisphere by axons that run in the
corpus callosum.
White Matter

 The white matter of the adult cerebral hemisphere contains

myelinated nerve fibers of many sizes as well as neuroglia.

 Transverse (commissural) fibres

interconnect the two cerebral hemispheres (mainly the corpus
callosum)

Projection fibres connect the cerebral cortex with lower portions of the
brain or the spinal cord.

 Association fibres connect the various portions of a cerebral

hemisphere and permit the cortex to function as a coordinated
whole.

Areas of the cerebrum

 Brodmann numbers to identify functions- down to individual sulci

 Question localisation now that we know more about connectionism

and we have amore dynamic view of the brain works
Primary Motor Cortex

 The primary motor projection cortex is located on the anterior wall

of the central sulcus.

These cells control voluntary movements of skeletal muscle on the

opposite side of the body.

Homunculus

 Map of motor control

  Reflects the body

 Sizes indicate the amount of ‘brain’ needed for various functions

 Note vast area for the face- why?

Primary Visual Cortex

 The primary visual receptive cortex is located in the occipital lobe.

 In primates, an extensive posterior portion of the occipital pole is

concerned primarily with high-resolution macular vision;

 the more anterior parts are concerned with peripheral vision.

 The visual cortex in the right occipital lobe receives impulses from
the right half of each retina,

 The left visual cortex receives impulses from the left half of each
retina. The upper portion of area 17 represents the upper half of
each retina, and the lower portion represents the lower half.

Primary auditory cortex

 The primary auditory receptive area is located in the superior

temporal gyrus toward the lateral cerebral fissure.

 The auditory cortex on each side receives the auditory radiation

from the cochlea of both ears, and there is point-to-point projection
of the cochlea on the acoustic area.

 Wernicke's area (in the posterior third of the superior temporal

gyrus in the dominant (usually left) hemisphere, is involved in high-
order auditory discrimination and speech comprehension.

Basal ganglia
  The term basal ganglia are masses of gray matter deep within the
cerebral hemispheres.

 The term is debatable because these masses are nuclei rather than
ganglia

 Anatomically, the basal ganglia include the caudate nucleus, the

putamen, and the globus pallidus.
Together they are called the corpus straitum

Functionally, the basal ganglia and their interconnections and

neurotransmitters form the extrapyramidal system.

Extrapyramidal system

 Influences motor instructions sent to the periphery

 Has a role in stabilising the large and complicated systems that

control movement

 Helps to direct action and interpret sensory information

• Observation
• Craniotomy and clipping
•
Craniotomy and clipping of aneurysm. Skin incision and proposed
craniotomy bone removal are indicated (A). Clip application to the
neck of the aneurysm, permanently preventing blood flow into the
aneurysm, is also shown (BEndovascular coiling

Endovascular coiling of cerebral aneurysm. Transfemoral approach

to gain access to the aneurysm via a small microcatheter (A) and
final occlusion of the aneurysm with coils
Pathophysiology

Precipitating Factors Predisposing Factors

• Females
• Smoking • Over 40 y/o
• Head trauma • Older age
• Hypertensive vascular disease
• Atherosclerosis
• Congenital defect of vessel wall
 Artery enlarges

Aneurysm ruptures
Causing
SAH

Brain
Normal brain metabolism
being
disrupted
exposed to
blood

Increased Intracranial
Due to
pressure ICP blood
occupyin
g space

Ischemia from reduced

10-20cc
perfusion and vasospasm
bleed or
50cc
Massive
bleed
Drug Study

Acetylcysteine (N-acetylcysteine)

Brand Name: Action: Contraindication: Adverse effects:

Acetadote
Splits links to Contraindicated Nausea,
Generic Name: the with stomatitis,
Acetylcysteine mucoproteins hypersensitivity urticaria, rash,
contained in the to acetylcysteine rhinorrhea
Dosage: respiratory
mucus secretios, Nursing
600mg/tab BID decreasing the Considerations:
viscosity of the
mucus Intervention

Indication: -Dilute the 20%

acetylcysteine
Mucolytic solution with
adjuvant therapy either normal
for abnormal, saline or sterile
viscid or water for
inspissated injection
mucus secretions
in tracheostomy Teaching points
care.
-Report difficulty
of breathing or
nausea

Losartan potassium

Brand Name: Action: Contraindication: Adverse effects:

cozaar
Selectively Contraindicated Headache,
Generic Name: blocks the with dizziness,
Losartan binding of hypersensitivity syncope,
Potassium angiotensin II to to losartan insomnia,
specific tissue hypotension,
Dosage: receptors found rash
50mg/tab OD in the vascular
smooth muscles Nursing
and adrenal Considerations:
gland
Intervention
Indication:
-Monitor the
Treatment of patient in any
hypertension, situation that
alone or in may lead to a
combination with decrease in BP
other secondary
antihypertensive reduction in fluid
s volume

Teaching points

-Take drug
without regard
to meals. Do not
stop taking this
drug without
consulting your
health care
provider.

Mannitol

Brand Name: Action: Contraindication: Adverse effects:

Osmitrol Elevates the Contraindicated Dizziness,

osmolarity of with anuria due headache,
Generic Name: glomerular to severe renal blurred vision,
filtrate, thereby disease seizures
mannitol hinderingthe
reabsorption of Nursing
Dosage: Considerations:
water and
100ml/IV every leading to a loss
of water, sodium Intervention
8hrs
chloride.
-do not expose
solutions to low
 Indication: temperatures

Reduction of -Make sure the

intracranial infusion set
pressure and contains filter if
treatment of giving
cerebral edema concentrated
mannitol

-Monitor Serum
electrolytes
periodically with
prolonged
theraphy

Teaching points

-Report difficulty
of breathing,
pain at IV site
and chest pain

Phenytoin

Brand Name: Action: Contraindication: Adverse effects:

Phenytek Has an anti Contraindicated Nystagmus,

epileptic activity with ataxia,
Generic Name: without causing hypersensitivity dysarthria,
general CNS to hydantoins, slurred speech,
Diphenylhydanto depression; sinus mental
in, phenytoin stabilizes bradycardia, etc confusion,
sodium neuronal dizziness,
membranes and drowsiness,
Dosage:
prevents insomnia,
100mg/cap every hyperexcitability transient
8hrs caused by nervousness
excessive
stimulation Nursing
Considerations:
Indication:
Intervention
Prevention and
treatment of -Monitor
seizures injection sites
occurring during carefully
or following
neurosurgery -Recommend
 that phenytoin
prescription be
filled with the
same brand each
time

Teaching points

-Take this drug

exactly as
prescribed, with
food to reduce GI
upset

-Do not
discontinue this
drug abruptly or
change dosage,
except on the
advice of your
health care
provider

Tramadol hcl

Brand Name: Action: Contraindication: Adverse effects:

Ultram Binds to mu – Contraindicated Sedation,

opioid receptors with allergy to dizziness,
Generic Name: and inhibits the tramnadol or vertigo,
reuptake of opioids or acute confusion,
Tramadol hcl norephinephrine intoxication with dreaming,
and serotonin alcohol, opioids sweating,
Dosage:
or psychoactive anxiety
Indication: drugs.
100mg every 6hr
Nursing
Relief of to Considerations:
severe chronic
pain on adults Intervention
who need
around-the-clock -Control
treatment for environment if
extended periods sweating or CNS
effect occur

Teaching points
 You may
experience this
side effects:
dizziness,
sedation,
drowsiness

Discharge Plan

Medication:

Advised the patient to continue the medication prescribed by the doctor

such as:

• Losartan potassium

50mg/tab OD (30 days)

• Tramadol hcl

100mg every 6hr (7 days)

Exercise:

Light stretching

• Flexing and extending very slowly of upper and lower extremities.

Rotating of the extremities at a very light and slow motion.
Chin to chest
• Touch chin to the chest slowly

Head to shoulder

• Flex the head to the right and to the left shoulder at a very slow movement.

Note: the exercise should be done with assistance of significant others at a very
slow motion to avoid further complication.

Treament:
 • Antihypertensive given orally once a day which is Losartan 50mg/tab
(30 days)

• Analgesic given orally every 6hr which is Tramadol 100mg (7days)

Health Teachings:

• Practice good hygiene

• Practice good preventive measures by eating proper diet

• Getting regular exercise and plenty of sleep

OPD Follow – up

• Instruct the patient and family to return to their attending physician for
scheduled follow up visit

• Instruct the patient to continue medication as prescribed

• Advise patient and family to report to the physician if any recurrence or

severity of symptoms, any adverse effects to the medication and any
development of complications

Diet

Low carbohydrate diet

• Reduce intake of rice

High fiber diet

• Eat fruits and vegetables

assist in the situation of the client.
Spirituality

• Encourage the patient to read the Bible and pray to God always, ask for
guidance and pray for the healing and restoration of health.

• Always seek spiritual advice and attend on Sunday masses.