A NURSING CARE PLAN IN ANEURYSM

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A Nursing Care Plan Presented to

The Faculty of the Nursing Department
Jo Ann Dela Cerna, RN, MN

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In Partial Fulfilment of the

Requirements in NCM 216 RLE
Operating Room/Perception and Coordination Nursing Rotation

By:

Janielle Christine T. Monsalud

BSN 3H, Group 3

May 18, 2021

 Name: C.A. Age: 30 years old Sex: Female Room and Bed No. 3-7
Chief Complaint: Altered level of consciousness Diagnosis: Cerebral Aneurysm Doctor’s Name: Dr. Ruiz
DAT
E& CUES NEED NURSING PATIENT INTERVENTIONS IMPLEMENTATION EVALUATION
TIME DIAGNOSIS OUTCOME
M Subjective: Ineffective Tissue Within the 8 1. Assess the
A “Asa na diay ko? A Perfusion (Cerebral) hours of nursing patient’s vital signs 1 Monsalud,
Y Diba balay naman C related to increased care, the patient and neurological Janielle
ni?” as verbalized T intracranial pressure will be able to: status at least every 4 Christine, St.N
1 by the patient. I (ICP) as evidenced hours, or more
8 V by drowsiness, a. Patient will frequently if there is a
Objective: I hallucinations and maintain cerebral change in them.
2 - Irritability T irritability. tissue perfusion R: To assist in
0 - Drowsiness Y by an increased creating an accurate
2 - Visual / level of diagnosis and monitor
1 Hallucinatio R Rationale: consciousness effectiveness of
ns E Blood flow to the (awake and alert) medical and surgical
8 S brain is called and orientated treatment for cerebral
A GCS: 11 T cerebral perfusion with persons, aneurysm.
M ICP: 28 mmHg pressure. Blood places and
pressure and things. 2. Prepare the patient
Vital Signs: intracranial pressure for surgery as
Temp: 37 degrees affect the cerebral b. Patient’s blood instructed by the
Celsius perfusion pressure. pressure will surgeon. 3
BP: 200/120 If the blood pressure remain high R: To remove the
PR: 80 bpm is low and/or the enough to cerebral aneurysm,
RR: 20 rpm intracranial pressure maintain cerebral which is the
is high, the blood perfusion underlying cause of
flow to the brain may pressure but low the patient’s
be limited. This enough to increased ICP.
causes decreased prevent increased
cerebral perfusion bleeding or 3. Administer osmotic
pressure. cerebral swelling. diuretics (ex. 4
Mannitol) as
c. Patient’s prescribed.
Reference: intracranial R: To promote blood
The University of pressure (ICP) flow to the brain and
Iowa. (2018, will remain to reduce cerebral
October 10). What is between 5 to 15 edema.
cerebral perfusion mmHg.
pressure? University 4. Observe the patient
of Iowa Hospitals & for any signs and
Clinics. symptoms of
https://uihc.org/healt increased ICP, such
h-topics/what- as headache,
cerebral-perfusion- vomiting, and 2
pressure. decreased alertness.
R: To facilitate early
detection and
management of
increased ICP.
Increased ICP can be
life-threatening as it
may lead to brain
damage, stroke or
coma.

5. Elevate the head of

the bed at 30
degrees.
R: To promote venous
drainage from the
patient’s head to the 6
rest of the body in
order to decrease
ICP.

6. Take Vital Signs

every 1 to 2 hours
initially, then every 4
hours after patient 5
becomes stable.
R: To detect early
signs of increased
cerebral perfusion
pressure or ICP.

7. Take measures to
ward off infection.
R: To prevent
increased metabolic
and oxygen demands 8
that can interfere with
the brain’s metabolic
needs.

8. Keep the patient’s

head in neutral
alignment.
R: To keep the carotid
flow unobstructed,
thereby promoting 7
perfusion.