Question

A 70 year old male patient was just admitted to ICU after subarachnoid hemorrhage as a result of aneurysm rupture in the middle cerebral artery. His blood pressure is 180/ 100, his heart rate is 85 BPM, and his RR is 20. He complains of severe headache and lightheadedness.

Please develo NURSING INTERVENTION WITH RATIONAL for your interventions for this patient in the ICU.

Answer 1

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 bed 15 to 30 degrees or as ordered.
• Avoid any activity that suddenly increases blood pressure or obstructs venous return (eg, 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 legs for signs and symptoms of deep vein thrombosis tenderness, redness, swelling, warmth, and edema.

Relieving Sensory Deprivation

• Keep sensory stimulation to a minimum.
• 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

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.

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.

Symptoms include sudden severe headache, nausea, vomiting, decreased level of consciousness, and neurologic deficit.

Maintain seizure precautions. Also maintain airway and prevent injury if a seizure occurs. Administer antiseizure medications as prescribed (phenytoin [Dilantin] is medication of choice).