Aneurysm Precautions


Bed rest and initiation of aneurysm precautions are important measures to prevent complications in the patient with aSAH. The purpose of aneurysm precautions is to prevent elevations in blood pressure, which could lead to rebleeding. Medical opinion about the strictness of aneurysm precautions has changed in the last decade. Previously, patients were placed on strict bed rest for weeks after a SAH. Current thinking is that extreme limitations that prohibit the patient from watching television, listening to the radio, reading, or having visitors, in fact adds to patient stress, thus increasing the risk of rebleeding rather than reducing it.

Strict aneurysm precautions may produce sensory deprivation, making it difficult to determine whether patient behavioral changes are due to sensory deprivation or to deterioration in the patient's neurological condition. Therapeutic interventions include providing the patient with a pleasant private quiet room, television, radio, reading material and visitations with persons who have a calming influence. It is extremely important for the nurse to work with patients so that they understand and accept the need for a limited number of visitors and restrict visits to those individuals who will have a calming influence on the patient.

Aneurysm Precautions

Airway & Breathing

SAH may result in serious complications from apnea to dysphagia
Anticipate the need for: suction, oxygen, intubation, ventilation.
Semi-fowler positioning can improve respiratory tidal volume
Sims positioning may be appropriate for unconscious patients at risk from fluid aspiration.

Circulation

Monitor BP, Arterial, CVP
Normovolumia fluids as ordered
Monitor I/O
DVT
  *sequential compression device
  *compression stocking

Neuro assessment
Level of consciousness, pupillary size - shape - reaction; motor function, cranial nerve deficits, nuchal rigidity, back pain. Immediately notify physician of status change.
Intracranial pressure

Elevated ICP secondary to SAH:
  *decreases cerebral perfusion
  *bradycardia and respiratory depression
Monitor: ICP, HR, MAP, CPP (cerebral perfusion pressure)
Elevate the head 15 - 30 degrees as ordered to promote venous return
Avoid Valsalva maneuver which increases ICP by increasing thoracic pressure and jugular venous pressure.

Manage blood pressure

Abrupt elevation of BP can dislodge the clot sealing the rupture. Rebleeding significantly increases morbidity and mortality. Avoid vagal manuevers such as: coughing, sneezing, straining at stool and exertion.
Oral (only) calcium channel blocker nimodipine for neuroprotective effect.

Monitor BP
 * SBP: 20 to 30 mm Hg above normal but <160mm Hg
 *Assist with position change
 *Avoid rectal temperatures
 *Sedation as ordered
 *Stool softeners

Pain management PRN
Pain and anxiety initiate a sympathetic response which can increase BP and heart rate.
  * Analgesia and sedation as ordered
Provide comfortable calming environment

Assess patient tolerance of stimulation
  *Bedrest as ordered
  *Explain importance of reducing tension
  *Remove telephone
  *Limit visitors
  *Subdued lighting (photophobia)

  *Avoid caffeine and stimulants

Anticipate seizure activity

Monitor patient for seizure activity
  *Explain importance of reporting symptoms
  *Administer anticonvulsants per orders
  *Initiate seizure precautions: padded siderails up, Semi-Fowler position
  *Avoid prone positioning

Anticipate cerebral vasospasm

Highest frequency within 14 days of bleed.
  
*Administer Nimodipine per order.

Normothermia
Normothermia is believed to be neuroprotective by reducing cerebral metabolic stress.  Fever is a common complication of hemorrhagic stroke. Antipyretic, surface cooling, and intravascular cooling may be used but shivering should be avoided.

 

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