Medical-surgical Nursing Demystified

(^226) Medical-Surgical Nursing Demystified

• Diffusion/perfusion MRI or MRA (magnetic resonance angiography) shows
  vessel structure.


• Single photon emission computed tomography (SPECT) shows the perfu-
  sion of blood flow to a specific area of the brain.

TREATMENT

• Surgical repair of the aneurysm.


• Monitor level of consciousness and neurologic status.


• Administer corticosteroid drugs to reduce inflammation:
  
  
  • dexamethasone
  
  
  
  


• Administer anticonvulsant drugs to reduce seizure risk due to irritation of
  brain:
  
  
  • phenytoin, phenobarbital
  
  
  
  


• Administer stool-softener drugs to decrease need to strain (straining increases
  intracranial pressure):
  
  
  • docusate sodium
  
  
  
  


• Bed rest until otherwise ordered by physician, nurse practitioner, or physi-
  cian assistant.


• Elevate head of bed 30 degrees.

NURSING DIAGNOSES

• Ineffective tissue perfusion


• Decreased intracranial adaptive capacity

NURSING INTERVENTION

• Monitor the patient’s neurological function for changes—typically use
  Glasgow Coma Scale or similar tool to grade response to stimuli (highest
  score 15).
  
  
  • Eye-opening response spontaneous^4
    to sound 3
    to pain 2
    none 1