CASE PRESENTATION ON ANTERIOR COMMUNICATING ARTERY ANEURYSM(ACOM)(UNRUPTURED)

1. 1
M.M. COLLEGE OF NURSING
CASE PRESENTATION
ON
ANTERIOR COMMUNICATING ARTERY (ACOM) ANEURYSM
PRESENTED BY
ABHILASHA CHAUDHARY

2. 2
HISTORY TAKING

3. 3
HISTORY TAKING
Identification of the patient
Patient name- Mustkeen
Age / gender- 45 years/ male
Religion- Hindu
Marital status- Married
Occupation- labour (farming)
Date of admission -07 march, 2017
Ward- NeuroICU
Ip no-170307137
Address -Saharanpur
Education- Illiterate
Provisional diagnosis- Anterior Communicating artery (ACOM) aneurysm
Final diagnosis-Pterional Craniotomy with right ACOM aneurysm clipping
Chief complain
Complain duration
Headache since 2days

4. 4
History of present illness
Patient was apparently well 5 days back. There was sudden intense headache on mid frontal area for half an hour . patient was taken to nearby
hospital of saharnapur and medication was given and CT scan was done but they were not able to clearly diagnose and was referred to Mullana
after 1 day of stay on 07 march. In emergency patient had chief complain of headache and Investigations were done along with CT scan and was
diagnosed as ACOM aneurysm then patient was admitted to Neuro ICU at 3: 00 pm via emergency.
Medical history
Past medical history
No any history of Hypertension, kidney disesease , heart disease or any other disease.
Past surgical history
No any surgical history
Personal history and habits
Hygiene and exercise-
Hygiene satisfactorily maintained.Clothes clean.
Active and Passive exercise done daily .
Activities and hobbies
Patient is active and there is no particular habit.
Patient can ambulate with the help of support.
Sleeping pattern
Sleeping pattern is good . patient sleeps 6-7 hr at night and 1-2 hr at day.
History of substance use
No any history of alcoholism
History of smoking(Bidi) since 30 year. Take 10- 12 bidi per day.

5. 5
Dietary pattern
Dietary pattern is disturbed . patient is on soft diet. Patient take (daliya, porridge, curd, biscuits, milk, tea)
Bowel and bladder habit
Urine output is normal . patient is on catheterization.
Bowel habit disturbed
Stool not passed since 5 days.
Family history
Index
Female
Male
Patient
45
yr
38
yr
19 yr
 No family history of related illness.
 Patient has adopted child because of infertility.

6. 6
PHYSICAL EXAMINATION

7. 7
PHYSICAL EXAMINATION
General appearance and behaviour
Body built- healthy
Gait – normal
Activity – normal but decreased
Appearance – fatigue
Vital
Temperature-98.6 degree Fahrenheit
Pulse -78beats per minute
Respiratory rate-24 breaths/minute
Blood pressure-120/70 mm of hg
NEUROLOGICAL EXAMINATION
GLASSGOW COMA SCALE
E-4
V-5
M-6
GCS-15/15

8. 8
Assessment Findings of physical examination
1)MENTAL STATUS
EXAMINATION
Observe appearance and
movement
 Posture
 Gait
 Motor movements
 Dress
 Hygiene
 Facial expression
 Speech
Observe mood
 Feelings
 Expressions
Observe thought,process and
perceptions
 Clarity and content
 Perceptions
Observe cognition
 Level of consciousness
 Memory
 Abstract reasoning –
Relaxed with shoulder back and both feet stable and was in supine position.
Coordinated and smooth with slight shuffling while walking.
Smooth, coordinated movements
Clothes fit and are appropriate for occasion and weather .
Skin clean, nails clean and trimmed
Good eye contact, smiles/frowns appropriately
Clear with moderate pace
Responds appropriately to topic discussed; expresses feelings appropriate to situations.
Expresses good feelings about self, others, and life verbalizes positive coping mechanisms (I have a good
family and will be back to work once I am fit )
Expresses full and free flowing thoughts during interview
Follows directions accurately; perceptions realistic .
Oriented to time, place and person(was able to say it’s day time, he is in hospital, and I am sister)
Remote Memory was intact( was not able to say exact birthdate and marriage date as patient verbalize
that” who remember those dates “ but was able to recall when he had adopted child, where he had worked.
Recent memory intact (was able to recall what he had ate day before yesterday and 24 hour activities)
Immediate memory intact- ( 1,3,5) able to recall
Abstract reasoning intact
“pet mae chuhae kudna”- patient replied “vuk lagna”

9. 9
 Ability make sound
judgement
 Ability to identify
similarities –
2)ASSESSMENT OF CRANIAL
NERVES
Cranial nerve- I(olfactory)
CN-II(Optic)
CN-III, IV,VI(Oculomotor)
Trochlear,Abducens)
CN-V(trigeminal)
CN-VII(Facial)
Nach na jane agan tedha- “ no reply”
Normal Judgement (why did you come to hospital?)
Patient- “ I had severe headache that’s why to visit the doctor.
What is the similarities between bird and aeroplane?
Patient- “both fly in sky”
What is difference between pen and copy?
Patient- pen sae likhtae hae aur copy mae likhte hae”
Patient was asked to smell spirit swab with each nostril
Unable to identify correct odor.
To assess vision
Bilateral normal vision with no any diplopia, blurr vision
Normal visual field
Extraocular movements(Eye moves in a smooth ,coordinated motion in all directions i.e 6 cardinal fields)
Pupillary response(pupil equal, round and reactive to light and accommodation)
Ptosis, nystagmus absent
Corneal reflex(Eyelid blink bilaterally)
Identifies light ,cold and sharp touch sensation to forehead , cheeks and chin)
On assessing masseter and temporal muscles as client clenches teeth(muscles contract bilaterally)
Identifies taste of food correctly
Symmetrical facial movements.

10. 10
CNVIII(Acoustic)
CNIX(glossopharyngeal)
CN-X(Vagus)
CN-XI(accessory)
CN-XII(hypoglossal)
3)MOTOR ASSESSMENT
4)SENSORY NERVE
ASSESSMENT
5)CEREBELLAR
ASSESSMENT
6)REFLEX ASSESSMENT
Not done as patient had bandage over head .
Bilateral symmetrical rise of soft palate and uvula, normal gag reflex and identifies correct taste.)
Not done (to avoid forceful activity)
Symmetrical tongue with smooth outward movement)
Relaxed and contracted muscles bilaterally. Normal muscle tone.
Power 5/5 bilaterally(normal strength) in upper and lower limb.
Primary sensation
Identifies area of light ,dull and sharp touch.
Cortical and discriminatory sensation
Sterogenesis(identifies correct object i.e key)
Graphesthesia (identifies correct stroke drawn on palm)
Kinesthesia( Identifies correct direction body part is moved)
Tap forefinger to thumb
And touches each finger to thumb
Romberg test,tandem walk,hop on each foot (not done as patient was unable to balance properly)
Bicep reflex
+2 bilaterally
Brachioradialis reflex
+2 bilaterally

11. 11
BRUDZINSKI SIGN
KERNIG SIGN
Tricep reflex
+2 bilaterally
Patellar reflex
+2 bilaterally
Achilles reflex
+2 bilaterally
Babinski reflex
not normal (fanning out of toes)
absent
absent
2)RESPIRATORY SYSTEM
Assessment Findings after physical examination
Inspection
Palpation
Percussion
Auscultation
Normal colour(pinkish),no bulging and retraction.
Swallow breathing, symmetrical chest movement,symmetrical chest expansion
Respiratory rate- 24 breaths/min
No pain and tenderness
Resonance heard over bilaterally
Vesicular sound heard over both lungs

12. 12
3)GASTROINTESTINAL SYSTEM
Assessment Findings of physical examination
Inspection
Auscultation
Percussion
Palpation
No any lesion and prominent abdomen vein.
Sunken, centrally located umbilicus
Contour- round
Symmetrical movement
No distension present
Soft click sound over upper right quadrant 4 per minute)
Absent of clicking sound over other quadrant.Decreased bowel sound.
Generalized tympany overall 4 quadrant
Non tender, no any masses, smooth
Liver and spleen not palpable
4)INTEGUMENTARY SYSTEM
Assessment Findings of physical examination
SKIN
NAIL
Colour- fair
Moisture- Dry
Temperature- 98.6 degree Fahrenheit
Texture – Rough and dry
Turgor – decreased
Edema – present over upper limb in right hand and both legs(minimal)
Clubbing
Colour-yellow and blackish

13. 13
HAIR AND SCALP Shape of the skull- normal ,round
Scalp – suture over frontal area,
Positive findings
CN I (olfactory)-was not able to differentiate smell.
Decreased bowel sound
Suture over frontal area of head
Edema present in upper limb(right hand) and minimal present in lower limb.

14. 14
DISEASE PROCESS

15. 15
ANATOMY
CEREBROVASCULAR CIRCULATION
The brain receives approximately 750 mL/min of blood, or 15% to 20% of the total resting cardiac output. The brain is supplied by two pairs of
arteries: the two internal carotid arteries and the two vertebral arteries. Cerebral circulation is also divided into the anterior and the posterior
circulation. The anterior circulationrefers to the common carotids and their distal branches including the internal carotid arteries, the middle
cerebral arteries, and the anterior cerebral arteries. The posterior circulation refers to the vertebral arteries, the basilar artery, and the posterior
arteries.
Circle of Willis
The circle of Willis, which is located at the base of the skull, is divided into anterior (carotid portion) and posterior. (vertebrobasilar portion)
circulation . The composition of each portion includes these elements:
• Middle cerebral arteries, the anterior cerebral arteries, and the anterior communicating artery, which connects the two anterior cerebral arteries
• Two posterior cerebral arteries; two posterior communicating arteries connect the middle cerebral arteries with the posterior cerebral arteries,
thus uniting the internal carotid system with the vertebral-basilar system.

16. 16

17. 17
DISEASE PROCESSS
CEREBRAL ANEURYSM
A cerebral aneurysm is a saccular outpouching of a cerebral artery. Intracranial saccular aneurysms or berry aneurysms account for
approximately 80% to 90% of all intracranial aneurysms.
These small, berry-like projections occur at arterial bifurcations in the circle of Willis, with other shapes such as pedunculated, sessile, and
multilobulated aneurysms occasionally seen.
ETIOLOGY
Book picture Patient picture
Congenital developmental defect Absent
Hypertension Absent
Atherosclerosis Absent
Head trauma Absent
Bacterial and fungal infection Absent
Cigarette smoking Present (since 30 years,10-12 bidi/day)
Alcohol Absent
Connective tissue disorder Absent
CLASSIFICATION
Book picture Patient picture
ACCORDING TO SIZE -
Small: to 10 mm Small (ACOM-6.7*6.7mm),MCA-4mm)
Medium: 10 to 15 mm -
Large: 15 to 25 mm -
Giant: 25 to 50 mm -
Super-giant:larger than 50 mm -

18. 18
ACCORDING TO SHAPE AND ETIOLOGY
Berry aneurysm(berry or saccular shaped with a neck or stem) ACOM sacular aneurysm is present
Fusiform aneurysm(an outpouching of an arterial wall, without a stem) MCA fusiform aneurysm is present)
Traumatic aneurysm( aneurysm resulting from a traumatic head injury) -
Mycotic (infectious) aneurysm(caused by septic emboli from
infections, such as bacterial endocarditis; may lead to aneurysmal
formation)
-
Charcot-Bouchard aneurysm(microscopic aneurysmal formation
associated with hypertension; involves the basal ganglia and
brainstem)
-
LOCATION
Cerebral aneurysms usually occur at the bifurcations and branches of the large arteries at the base of the brain (circle of Willis).
Book picture Patient picture
85% to 95% in carotid system
A-com -30%
Pos-com-25%
MCA-20%
Anterior communicating artery (ACOM) and middle cerebral
artery(MCA) is is affected.
5-15%in posterior circulation in vertebrobasilar arteries
Vertebral artery-10%
Basilar artery-5%
-
20-30% may have multiple aneurysm -

19. 19
SIGN AND SYMPTOMS OF UNRUPTURED ANEURYSM
Book picture Patient picture
Headache Present
Facial pain Absent
Neck stiffness and pain Absent
Alteration in consciousness Absent
Seizure Absent
Autonomic disturbances(vomiting,sweating,fever,chills) Absent
Visual symptoms (blurring of vision,diplopia) Absent
Symptoms asociated with ACOM aneurysm
Usually silent
Visual field defect
Akinetic mutism(neither movement nor speak)
Amnestic syndrome
Hypothalamic dysfunction
Absent
Absent
Absent
Absent
Absent
Absent
Symptoms asociated with MCA aneurysm
Aphasia
Hemiparesis
Hemisensory loss
Anosognosia(deficit of self awareness)
Visual field defect
Absent
Absent
Absent
Absent
Absent
INVESTIGATION
Book picture Patient picture
History taking and physical examination Done
CT scan Done (F/S/O saccular aneurysm arising from anterior communicating
artery with small fusiform aneurysm from left middle cerebral
artery(MCA).
MRI Not done

20. 20
Cerebral angiography saccular aneurysm arising from anterior communicating artery with
small fusiform aneurysm from left middle cerebral artery(MCA).
Lumbar puncture Not done
Transcranial doppler Not done
ECG Done (no report(report lost)
BLOOD STUDIES
Fibronegen and platelet Done
White blood cell count(WBC) Done
Hematocrit Not done
Electrolytes Done
Blood gases Done
Glucose Done -126 mg/dl
OTHER INVESTIGATIONS DONE IN THE PATIENT
Clinical parameters Normal value Patient value Remarks
LFT(LIVER FUNCTION TEST) ( (Date-07
march,2017
(Date-
08march,2017
Date (10
march,2017)
Total bilirubin 0-1.20mg/dl 0.30 - - Normal
Direct bilirubin 0-0.20 mg/dl 0.13 - - Normal
SGOT(serum glutamic oxaloacetic transaminase) 2-31U/L 62 - - Increased
SGPT(serum glutamic pyruvic transaminase) Up to 45 U/L 45 - - Normal
Alkaline phosphatase 54-141 U/L 68 - - Normal
Total protein 6.60-8.70g/dl 7 - - Normal
Albumin 3.50-5.20g/dl 3.4 - - Hypoalbunemia
RFT(RENAL FUNCTION TEST)
Urea 13-43mg/dl 53 37 - Uremia
Creatnine 0.70-1.40mg/dl 0.71 0.75 - Normal
Uric acid 3.60-7.70mg/dl 4.4(normal 3.4(decreased) -
Sodium 135-
145mmol/L
139 139 138 Normal

21. 21
Potassium 3.5-5.5 mmol/L 3.3 Hypokalemia 3.4 Hypokalemia) 4.3
Chloride 98-110 mmol/L 102 102 106 Normal
BLEEDING TIME (BT)
BT(bleeding time ) Up to 6 min 2.30 2.30 - Normal
BLOOD PROTHROMBIN TIME
Prothrombin time 11-16sec 18 15.0 -
Prothrombin time control 11-16sec 13 13.0 - Normal
INR 1.7 1.2 - Normal
CLOTTING TIME(CT) 6.30 -
DLC(DIFFERENTIAL LEUCOCYTE
COUNT)
Neutrophils 40-80% 66 72 - Normal
Lymphocytes 20-40% 30 24 - Normal
Eosinophils 1-6% 04 04 - Normal
HAEMOGLOBIN 13-17g/dl 13.6 10.5 - Normal
PLATELET COUNT 1.5-4.5
lakh/cumm
209*1000 140*1000 -
TLC(Total leucocyte count) 4000-
10000/cumm
8.9*1000 9.4*1000 - Normal
HHH(Hbsag, HCV,HIV) - Negative - - Negative
CROSS MATCHING - Blood group –O,
Rh positive
-- -
ABG 08/03/2017 09/03/2017
Ph 7.35-7.45 - 7.455 7.47
Pco2 35-45 - 37.9 44.1
PO2 - 187.4 120.4
SO2% 95-100 - 99.7 98.9
Hct - 37 46
Hb - 12.5 15.4
BEecf - 2.9 9.3
BEb - 3.6 9.0

22. 22
SBC -- 27.7 32.8
HCO3 22-26 -- 27.0(met.alk) 33.1(met.alk)
TCO2 - 28.1 34.4
A - 98.0 90.6
A-aDo2 - 1 1
a/A - 1.9 1.3
CT SCAN
07 march, 2017 There is c/o focal outpouching measuring approz 6.7*6.7 mm in size arising eccentrically from ACOM showing wide
neck with e/o saccular aneurysm. It shows intense enhancement on post contrast scan. No c/o non enhancing thrombus
seen.no e/o calcification is seen within its walls. A2 segment is seen to arise from the aneurysm and shows normal
caliber and enhancement.
There is fusiform dilatation of M1 segment of left MCA just before the bifurcation for a segment 4mm.
09 march , 2017 There is a focal hypodense area seen in the right posterior frontal region with associated partial effacement of
ipsilateral ventricle s/o infarct.
Aneurysm clips noted in right paraclinoid region
Extra-axial air seen in b/l frontal reion.
A small streak of intraaxial fluid collection seen in right fronto temporal region
Craniotomy defect seen in rightfronto tempo parietak region.
Retained secretion noted in nasopharynx.
Impression – infarct right frontal region with other post op changes as described.
10 march, 2017 Small focal infarct(17*15mm) in right posteriofrontal region with other post op changes as described.

23. 23
MANAGEMENT
Book picture Patient picture
MEDICAL MANAGEMENT
Calcium channel blocker(Nimodipine) Given tab.nimodipine 60mg*6hrly
Anticonvulsant (phenytoin) Given tab eptoin 100 mg*TDS
Stool softner Syp.evuct(lactulose 6 tsp with water HS
Corticosteroids Not given
Antacid Tab.pantop 40 mg OD
Sedatives Not given
Analgesic Given (diclofenac 75mg sos)
Heparin Not given
Replacement of minerals mg,potassium,calcium IV fluid NS/RL 500 ml
SURGICAL MANAGEMENT
Surgical clipping Rt.pterional craniotomy for ACOM aneurysm clipping
(Endovascular treatment)Coiling Not done
Ballon remodeling technique Not done
Stent placement Not done

24. 24
Other medication used for the patient
Name of drug Generic name Dose Route Frequency Class Action
Supacef Cefuroxime 750mg IV TDS 2nd
generation
cephalosporin
Binds to protein and causes cell wall
death of bacteria.
Amikacin Amikacin 750mg IV OD Aminoglycoside Inhibits protein synthesis of bacteria
esp.gram negative bacteria
Justin Diclofenac 75mg IV SOS NSAIDS To control pain(headache)
Mannitol Mannitol 100ml IV BD Diuretic (osmotic
agents)
Decreases cerebral edema and improves
CBF
PCM Paracetamol Oral SOS Acetaminophen Reduces fever and antinflammatory
action
Nimodipine nimodipine 60mg Oral QID Calcium channel
blocker
Prevent vasospasm and cross blood
brain barrier.
Eptoin Phenytoin 100mg Oral QID Antiepileptic class Given as a prophylaxis to prevent
seizure
Pantop Pantoprazole 40mg Oral BD Proton pump inhibitor To prevent gastric irritation
Supradyn multivitamin Oral BD Multivitamin To replace essential minerals
Evict Lactulose 6tsp Oral HS Laxatives prevent constipation and straining at
stool, which may leads to increas ICP
Dextran dextran 500 ML IV OD Volume expander Highly colloidal starch structure lowers
patelet and RBC adhesion.
Neb.Duolin Salbutamol+ipratropium
bromide
1:3ml Inhaltion TDS Bronchodilator

25. 25
Trade
name
Pharmacological
name
Action Dose and route Indication Side effects Nursing
responsibility
Inj.
Mannitol
MANNITOL Mannitol elevates
blood plasma
osmolality,
resulting in
enhanced flow of
water from tissues,
including the brain
and cerebrospinal
fluid, into
interstitial fluid and
plasma. As a result,
cerebral edema,
elevated
intracranial
pressure, and
cerebrospinal fluid
volume and
pressure may be
reduced. Mannitol
may also be used
for the promotion
of diuresis before
irreversible renal
failure becomes
established
Adult
Oliguria: 50-100 g as a
5-25% solution.
Intracranial/Intraocular
pressure: 0.25-2 g/kg
as 15-25% solution
administered for 30-60
minutes.
Children
Oliguria: 0.25-2 g/kg
as a 15-20% solution
for 2-6 hours
Intracranial/Intraocular
pressure: 1-2 g/kg as a
15-20% solution
administered for 30-60
minutes
 Promotion of
diuresis in
acute renal
failure .
 Reduction of
intracranial
pressure and
brain mass.
 Reduction of
high intraocular
pressure
 Promotion of
urinary
excretion of
toxic materials
Pulmonary
congestion,
fluid and
electrolyte
imbalance,
acidosis,
electrolyte
loss, dryness of
mouth, thirst,
marked
diuresis,
urinary
retention,
edema,
headache,
blurred vision,
convulsions,
nausea,
vomiting
Vital signs
Intake and output
Central venous
pressure
Signs and
symptoms of
dehydration (e.g.
poor skin turgor,
dry skin, fever,
thirst)
Signs of electrolyte
imbalance/deficit
(e.g. muscular
weakness,
paresthesia,
numbness,
confusion, tingling
sensation of
extremity and
excessive thirst)(for
increase ICP)
Neurologic status
and intracranial
pressure readings

26. 26
Trade
name
Pharmacolo
gical name
Action Dose and
route
Indication Side effects Nursing responsibility
Tab.
Eptoin PHENYTOI
N
central nervous
system agent;
anticonvulsant;
hydration
Pregnancy
Category: D
Reduced
voltage,
frequency, and
spread of
electrical
discharges
within the motor
cortex.
Adult: PO 15–
18 mg/kg or 1
g loading dose,
then 300 mg/d
in 1–3 divided
doses, may be
gradually
increased by
100 mg/wk
until seizures
are
controlled IV
15–18 mg/kg
or 1 g loading
dose, then 100
mg t.i.d.
Patient: PO/IV
15–20 mg/kg
loading dose,
then 5 mg/kg
or 250 mg/m2
in 2–3 divided
doses.
To control tonic-
clonic (grand
mal) seizures,
psychomotor and
nonepileptic
seizures (e.g.,
Reye's syndrome,
after head
trauma). Also
used to prevent or
treat seizures
occurring during
or after
neurosurgery. Is
not effective for
absence seizures.
CNS: Nystagmus,
drowsiness, ataxia,
dizziness, mental
confusion, tremors,
insomnia, headache,
seizures.
CV: Bradycardia,
hypotension,
cardiovascular
collapse, ventricular
fibrillation,
conjunctivitis,
diplopia, blurred
vision.
GI: Gingival
hyperplasia, nausea,
vomiting,
constipation,
epigastric pain,
dysphagia, loss of
taste,
Continuously monitor vital signs and
symptoms during IV infusion and for an
hour afterward.
Watch for respiratory depression.
Constant observation and a cardiac
monitor are necessary with older adults
or patients with cardiac disease.
Observe patient closely for neurologic
adverse effects following IV
administration. Have on hand oxygen,
atropine, vasopressor, assisted
ventilation, seizure precaution
equipment (mouth gag, nonmetal
airway, suction apparatus).
 Be aware that gingival hyperplasia
appears most commonly in patient and
adolescents and never occurs in patients
without teeth.
 Make sure patients on prolonged
therapy have adequate intake of vitamin
D-containing foods and sufficient
exposure to sunlight.

27. 27
Metabolic: Fever,
hyperglycemia,
glycosuria, weight
gain, edema,
transient increase in
serum thyrotropic
(TSH) level,
osteomalacia.
Skin: Alopecia,
hirsutism (especially
in young female);
Urogenital: Acute
renal failure,
Peyronie's disease.
Respiratory: Acute
pneumonitis,
pulmonary fibrosis.
Monitor diabetics for loss of glycemic
control.
Patient & Family Education
 Be aware that drug may make
urine pink or red to red-brown.
 Report symptoms of fatigue, dry
skin, deepening voice when
receiving long-term therapy
because phenytoin can unmask a
low thyroid reserve.
 Do not alter prescribed drug
regimen. Stopping drug abruptly
may precipitate seizures and
status epilepticus.
Trade
name
Pharmacol
ogical
name
Action Dose and
route
Indication Side effects Nursing responsibility
Inj.
AMIKACI Aminoglycosid Adult: IV/IM Bacterial CNS: ataxia,
 Assess patient for signs and

28. 28
Amikacin N
SULFATE
eantibiotics. 5–7.5 mg/kg
loading dose,
then 7.5
mg/kg q12h
Patient:
IV/IM 5–7.5
mg/kg loading
dose, then 5
mg/kg q8h or
7.5 mg/kg
q12h
Neonate:
IV/IM 10
mg/kg loading
dose, then 7.5
mg/kg q12–
24h
Infections.
Treatment of
serious gram-
negative bacillary
infections and
infections caused
by staphylococci
when penicillin or
other less toxic
drugs are
contraindicated.
vertigo.
EENT: ototoxicity
(vestibular and
cochlear).
GU:
nephrotoxicity.
F and E:
hypomagnesemia.
MS: muscle
paralysis (high
parenteral doses).
Neuro: increase
neuromuscular
blockade.
Resp: apnea.
Misc:
hypersensitivity
reactions.
symptoms of infection prior
to and throughout therapy.
 Instruct patient to continue
taking medication around
the clock until finished
completely, even if feeling
better.
 Keep patient hydrated
during therapy.
 Instruct patient to report
signs of hypersensitivity.

29. 29
NURSING CARE PLAN

30. 30
Nursing Diagnosis:-
1. Pain related to meningeal irritation secondary to bloodvessel swelling and surgery.
2. Impaired cerebral perfusion related to decrease blood supply secondary to aneurysm.
3. Risk for ineffective breathing pattern related to post intubation and prolong bedridden
4. Risk of infection related to surgery done.
5. Risk for fluid volume deficit less than body requirement related to disease condition and decrease fluid intakke
6. Anxiety related lack of knowledge regarding disease condition, the need for surgery.
7. Disturbed Body Image related to hair loss, and changes in the structure and function of the boy.

31. 31
ASSESSMENT DIAGNOSIS GOAL INTERVENTION RATIONAL EVALUATION
Subjective data: -
patient looks
restless not able to
give proper
history and gives
history of
decreased sleep.
Objective data:-
Restlessness,
irritability,
changes in vital
sign.
BP-120/70mmhg
Temp.-98.6.
f
Pulse:-
78beats/min.
Resp.:-
22breaths/min.
Presence of
ACOM aneurysm
and MCS
aneurysm
Impaired
cerebral
perfusion
related to
decrease
blood supply
secondary to
aneurysm.
Patient
will
maintain
brain
function
and would
not place
any sign of
sign of
ICP.
Neurological assessment done
every 2 hours to 4 hourly.
Assess vital signs every 2 hours
to 4 hours, record the irregular
breathing and heart rate and
rhythm and extent of the
pressure pulse.
Elevate the head of the bed 30
degrees.
Prepare oxygen and suction
equipment in place during the
period of disturbance of
consciousness (LOC).
Changes in cranial nerve function
showed ICP.
Assessment of vital signs are as often
as possible will help detect early
signs of ICP (such as tachycardia,
fluctuating blood pressure, and
respiration Cheyne-Stokes) or the
signs of the development of ICP.
Elevation head in the bed allow
gravity to increase the flow of
cerebral,will help to decrease ICP.
Equipment and suction mucus is
required when the patient has
seizures or apnea.
Patient
maintained
normal brain
functioning .

32. 32
ASSESSMENT DIAGNOSIS GOAL INTERVENTION RATIONAL EVALUATION
Objective data: -
patient has suture
on right frontal
area
Risk of
infection
related to
surgery
done.
Patient will
demonstrate
the absence
of infection
associated
with surgical
procedure
characterized
by a
temperature
less than 100
º F (37.8 º C)
and no signs
of swelling
of the wound
incision.
 Assess the patient's body
temperature , decreased
LOC, loss of appetite,
vomiting, increased
white blood cells, and
swelling or redness over
the surgical site.
 Monitor patient's body
temperature every 4
hours.
 Review the incision area
every 4 hours, see the
drainage of fluid from
the wound and the
swelling.
 Record the number and
type of discharge from
the incision wound.
 Give antibiotics
(amikacin,supracef) as
directed.
 This sign gives an indication
of infection.
 Increase in body temperature
is an early sign of infection.
 The position where the head
in the right position helps
prevent damage to the skin
or around the surgical site.
 Swelling around surgical
incision, pus in drainage-
may be an early sign of
infection in the site
 Antibiotic which
prophylaxis is usually given
during surgery and
continued at 48 to 72 hours
after surgery.
Patient
demonstrate the
absence of
infection
associated with
surgical
procedure
characterized by a
temperature less
than 100 º F (37.8
º C) and no signs
of swelling of the
wound incision.
No fluid comes
out through
incision.
.

33. 33
ASSESSMENT DIAGNOSIS GOAL INTERVENTION RATIONAL EVALUATION
Subjective data:-
Family members
of patient and
patient asking
about prognosis ,
Objective data:-
Patient looks
anxious and
worried
Anxiety
related to lack
of knowledge
refarding
disease
condition.
Family
members
and patient
will express
less
worriness
about
disease
condition
and surgery
performed.
Explaining about disease
condition, the basic purpose of
the surgery.
Also explain the purpose of the
various actions recommended
diagnostic tests and procedures
to be performed.
Give peri-operative measures,
including:
· Fasting
· Define an action of intra
venous medicines
· Transport the patient to the
surgery room
· Surgery timetable
· Long expected surgery
· Recovery room
· Monitoring vital signs.
Tell the family members to help
your patient to prepare to stay
hospitalization and surgery
Give a strengthening of the
explanation surgeon.
1. Provide an explanation will help
decrease fear and anxiety and
increase acceptance of the patient's
condition.
2. The explanation of this activity
will reassure family
members/patient that they should
be aware that the patient will live it
and help to provide encouragement
to participate in preparatory
activities, if possible.
3. Family members need time to
adjust to the information so they can
form the questions and express fears
and concerns.
4. Diagrams, videos, books, and
discussions may be more
appropriate in older patient.
5. Family members and patient
often receive too much information
in a short time. Repeat explanations
to help understanding the patient's
condition.
The parent’s
anxiety is reduced
to some extent
naw, as they are
able to express
their doubts about
their patient’s
condition.

34. 34
PROGNOSIS
10/03/2017 11/03/2017 12/03/2017 13/03/2017 14/03/2017
Admission day
Post-op day
GCS-(EVM)
Vitals
Temperature
Pulse
Respiration
Blood pressure
MAP
Spo2
Input/output-
RBS
Care provided
Foley’s catheter
CVP line
4rth day
2nd
day
(E-4,M-6,V-5)-15/15
98.6degree Fahrenheit
78beats/min
24 breath/min
120/70 mm of hg
96%without Oxygen
3840/3700=140+ve
balance
107mg/dl
Oral care
Chest physiotherapy
Active exercise
4rth day
Patent ,4rth day
5th
day
3rd
day
(E-4,M-6,V-5)-15/15
98degree Fahrenheit
82beats/min
26breath/min
140/80 mm of hg
100%without Oxygen
3350/2800=550+ve
balance
127mg/dl
Oral care
Chest physiotherapy
Active exercise
5th
day
Patent ,5th
day
6th
day
4 rth day
(E-4,M-6,V-5)-15/15
98.8degree Fahrenheit
80beats/min
28breath/min
130/70 mm of hg
98%without Oxygen
2900/2200=700+ve
balance
106mg/dl
Oral care
Chest physiotherapy
Active exercise
Ambulation
Foley’s removed
Patent ,6th
day
7th
day
5th
day
(E-4,M-6,V-5)-15/15
97.6degree Fahrenheit
76beats/min
24 breath/min
120/70 mm of hg
98%without Oxygen
2750/2600=150+ve
balance
110mg/dl
Oral care
Chest physiotherapy
Active exercise
Ambulation
-
Patent ,8th
day
8th
day
6th
day
(E-4,M-6,V-5)-15/15
98 degree Fahrenheit
82beats/min
20 breath/min
130/80 mm of hg
98%without Oxygen
2300/2000=300+ve
balance
120mg/dl
Oral care
Chest physiotherapy
Active exercise
Ambulation
-
Patent ,9th
day

35. 35
Drain
Diet –
Chief complain –
Specific instruction-
Red in
colour(approx.50 ml)
Semi solid diet
Headache
Drain out
Removed
Semi solid diet
Headache,unable to
pass stool
Iv fluid NS/RL
stopped
-
Normal diet
Headache,unable to
pass stool
CST
-
Normal diet
Headache,unable to
pass stool
CST
-
Normal diet
Headache,unable to
pass stool
Added lactulose

36. 36
BIBLIOGRAPHY
 Suddarth’s& Brunner,” textbook of medical surgical nursing”, volume-2,13th
edition. wolters-kluwer publishers;2003. page no.1250-
1275.
 Black JM,Hawks JH, editors.Medical surgical nursing.8th
ed.StLouis,Missouri:Mosby,An imprint of Elsevier:2009.P. 1488-1510
 Clinical neuroanatomy ,by snell, 7th
edition
 Clinical neuroanatomy by stephen g. Waxman, 25th
edtion
 Neuroanatomical basis of clinical neurology,byorhanarslan
 DoengesMe,MoorhouseMF,MurrAc,editors.Nursing care plan,9th
ed.Philadelphia:FA Davis company;2014 P.75-85