National Academy of Medical Sciences

Bir Hospital Nursing Campus

Mahabouda, Kathmandu
Post Basic Bachelor Of Nursing

CASE STUDY ON
SAH with Ruptured PCOM Aneurysm

Submitted to : Submitted by:

Respected Madam Bandana Thapa Alina Bhattarai
BHNC NAMS PBBN 2 nd year
Roll no : 01

2070/2014

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 Acknowledgements

It is worth praising that the nursing curriculum of bachelor level has included case study in its contents
which is obviously a great opportunity for students to learn more about disease and provide much
effective nursing care to patient.

This case study report on, case of, “SAH with Ruptured PCOM aneurysm” is prepared on the basis of
case study, which I had taken during my clinical posting in the Neuro ICU of Bir Hospital, NAMS,
Mahabouddha Kathmandu. These report has been prepared as a partial fulfillment for the Bachelor level
Nursing curriculum, Nursing Concept..

I am very grateful and would like to thank all those intellectual and well wishers who voluntarily helped
me to fulfill my objectives directly and indirectly. Without their help I would not have completed my
case study.

First of all, my special and sincere thanks to Respected Campus Chief Madam, BN 2 nd year Co-ordinator
Madam, Ms Yogeshwori Kasaju, Madam Bandana Thapa, Madam Pramila Shakya and other associated
teachers for providing me opportunity to practice my clinical duty in Neuro ICU of Bir HospitalL, BN
faculty members and all library staffs of Bir Hospital Nursing Campus, NAMS for their kind
cooperation and help in searching and providing necessities for case study.

My gratitude thanks to respected Madams for their continuous guidance, support, encouragement and
sedulous leadership throughout the case study.

My very special thanks to Hospital Director, Matron, and Ward In charge and all staffs of Neuro ICU
for permitting me to conduct case study and help during the entire case study.

I am also thankful to all my colleagues for their valuable commitment, suggestions, insight and sharing
of experience.

At last but not the least, I would like to express sincere thanks to my patient Sunita Magar and her
husband for his kind cooperation in providing information, allowing doing procedures, assisting in
providing nursing care to complete my case study successfully.

I still confess, as a student , I have learnt a lot from those work and take full responsibility for error and
omission.

Yours sincerely:

Alina Bhattarai.

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 Background

This case study report on “SAH with Ruptured PCOM aneurysm” is prepared on the basis of the study
performed during my seven weeks clinical in Bir Hospital. As well as this is done as a partial fulfillment
of Bachelor Of Nursing Curriculum in Hospital Nursing Practicum.

Aneurysms of the posterior communicating artery are the third most common circle of Willis aneurysm.
Nepal is the developing country even though vascular disease is taken as questionable matter, many
people has a concept that it does not need any medical seek. In world, Aneurysm is most leading cause
of mortality among vascular disease patient. In which predisposing factors include are smoking,
alcoholism and subroutine health check-up habit, sedentary lifestyle, not treated specially cardiac
infectious disease.

The whole case study focuses on patient holistic care. In this case study, I tried to find out any lack in
developmental task of my patient in comparing with book according to age. In this case study I applied
the knowledge of basic sciences, Nursing theory and other related courses to plan and implement
nursing care. I explained them about the disease condition, its causes, management and also provided
them discharge teaching. I also collaborated with patient, family and health team members in every
aspect related to patient health.

I have utilized the knowledge of teachers, colleagues as well as referred different books, websites,
record in preparing this case study. I have learned a lot from teachers and colleagues which made me
able to perform my task and prepare this case study.

As per bachelor of nursing curriculum, I was assigned various kinds of responsibilities in different
wards. I had to conduct one case study during seven weeks in hospital posting. For my case study, I
selected a case of “Ruptured PCOM aneurysm”. In future, as a middle level health care manager, this
study will help us to identify the aneurysm case and manage them on time and appropriately working
together with community which will contribute to the nation in reducing untimely mortality and
morbidity rate.

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 Table of contents: Page no.

 Objectives 05
 Patient’s profile 06
06
 History Taking
 Physical Examination 09
 Developmental Tasks of Young Adult and its Comparison with 15
Patient
 Anatomy and Physiology of Nervous System 16
 Disease Process: 21

 Introduction
 Causes and its comparison with patient
 Pathophysiology
 Types and its comparison with patient
 Signs and symptoms and its comparison with patient
 Diagnosis/Investigation and its comparison with patient
 Treatment
 Management
 Investigations done in my patient
 Drug plan
 Theory Application
 Application of Nursing Process
 Nursing Care Plans
 Daily Progress Notes
 Actions to Minimize the Stress of Hospitalization
 Health Teaching During Hospitalization
 Plan for Discharge Teaching
 Complications
 Bibliography.

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Objectives:
General Objective:

General objectives of this case study is to provide holistic care to patient through nursing process using
appropriate nursing theories and also considering patient socio-cultural background and traditional
philosophy and practices with the help of knowledge from basic science and fundamental nursing
knowledge.

Specific Objectives:
 To gain specific knowledge about specific disease.
 To learn to perform systemic and neurological examination methodically and correctly.
 To plan and implement comprehensive care of the client, using the knowledge gained from basic
science and nursing theory.
 To identify the cause, pathophysiology, clinical features and diagnostic evaluation of SAH and
PCOM aneurysm.
 To formulate nursing diagnosis and priorities nursing care plan according to patient’s needs.
 To provide individualized quality care to the patient by using a holistic nursing care and problem
solving approach.
 To establish rapport and gain the trust and co-operation of the patient and immediate family
members.
 To provide emotional and physical support to patient and his family during the treatment
process.
 To facilitate communication by providing proper counseling to the patient and his family
regarding her condition.
 To disseminate information to the patient as well as his relative about the illness and how to care
for the patient.
 To evaluate daily progress of the patient health and effectiveness of treatment.
 To work together with patient, family members and other health worker to plan the discharge and
follow up care.

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Patient’s profile
Biographic data:

Name of the patient : Sunita Magar

In patient number : 94385
Age/Sex : 42 years./Female

Address : Jhapa

Husband name : Ganga Bdr. Magar

Emergency no. : 9842752028

Ward : Neuro ICU

Unit Dr. incharge : GRS

Date of Admission : 2070/12/11 at 5 PM

Bed No. : 331
Diagnosis : SAH, Ruptured PCOM Aneurysm
Religion : Hindu
Ethnicity : Mongolian
Marital Status : Married
Occupation : Worker
Department : Neuro-Surgical

History taking:
Information obtained from:
 Her husband Ganga Bdr. Magar.
 At the time of history taking patient was unconscious.

 Her vital signs were as follows:

Height: 158 cm.
Weight: patient was unconscious.
Blood pressure: 110/60(left) 110/70(right)
Pulse rate: 78/min Respiration rate: 18/ min.

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Health history of patient

Chief complaints:
 Sudden onset of severe headache X 6 days
 Abnormal body movement X 6 days
 Rolling of eyes and frothing from mouth X 6 days.

History of present illness:

Patient was apparently well 8 days back, then she suddenly developed thunderclap headache with
multiple episodes of vomiting with generalized tonic-clonic seizure and bladder incontinence. She was
taken to local hospital and got better with medication but on next day her level of consciousness
decreased again and had multiple episodes of vomiting.

Past medical history: -

 She had been using Depo-Provera for family planning.
 No significant disease in the child hood.
 She had no history of trauma and major medical illness in the past.
 She had complete immunization schedule.
 Not any known allergy with medication and food
 No injuries or accident before
 No previous hospitalization.

Personal history:

 Drinking habit: No
 Smoking habit: No
 Rest and sleep pattern: well maintained
 Eating habit: Vegetarian diet, food not taken in scheduled time.
 Food allergies: No.

Family history:

 Type of family: Joint

 Family relationship: Not good (step family)
 No. of children: 1 daughter, 2 years old.

Family medical history:

 No any communicable disease and chronic disease in her family was dictated.
 No history of any chronic illness in their family.
 No history of genetic abnormal condition.

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Social history:
 father is farmer
 Mother is work as housewife
 House type – kachha.
 Water source tape water and they used direct tape water for drink.

Socioeconomic status:
She is from low class family .They use wood for cooking. They are staying in 2 roomed houses.

Family Tree

Index
- Male
- Female
- Client
Married

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General Physical examination (2070-12-13 at 3pm):
Physical examination is an important tool in assessing the patient’s health status. About 15%of the
information used in the assessment comes from the physical examination. Physical examination is
preferred to collect objective data, and to correlate it with subjective data. It also reveals additional
problems which the patient has not recognized.

While doing physical examination, I followed systematic approach of head to toe examination:

 Inspection
 Palpation
 Percussion
 Auscultation

On examination:

General appearance : Looks fair.

Level of consciousness : Unconscious.
Cleanliness : Unclean.
Hygiene : not good.

Physical Examination Findings:

Height – 158cm
B.P -110\70 mm of Hg
Temperature – 97.6 0
F
Pulse - 80\m
Respiration - 18\m
GCS: E1V1M1
Pupil bilateral: 2mm(both right and left) and reactive to light.
Hydration status: adequate.

Systemic physical examination :

Skin:

Inspection:

Fair complexion without cyanosis, rashes any patches or any lesion. No bleeding, laceration,
bruising or swelling over her body.

Palpation:

Warm and soft skin with even temperature all over her body. Has no sensation and motor function.
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 A. LYMPH NODES
No any palpable lymph nodes present over her body.

Head and face

Hair : Blackish, No dandruff Present,
No any scar, swelling, lump and injuries.
Face : comfortable
Sinuses : no swelling over the sinuses.
Eyes
Pupil : React to light
Pain : no pain or discharge from the eye.
Vision : patient is unconscious.
Opacity of lens : Transparent.
Blurred vision : No
Anemia : No
Jaundice : No
Eye Brows : symmetrical, well distributed. No eye brows fall

Eye Lids : No redness, edema, lesion or dropping.

Eye Lashes : outward and upward curled.

Conjunctiva : transparent

Ears
Normal shape and size, No any discharge.
Condition of mastoid area : No any sign of Inflammation
External ear canal : Normal
Hearing : unconscious.

Nose

 Normal shape and size, no any bleeding, Medially located. Nostrils uniform in size& do not
flare on respiration. Nasal septum is not deviated.
 No lesion, redness, tenderness or blockage of nasal pathways.

.
Mouth, Throat and Neck

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 Lips : Pink, no cracks or angular stomatitis.
Gums : pink without swelling or bleeding.
Teeth missing : no missing teeth, well distributed, white colour
Tonsils : Not enlarged.
Palate : Normal
Uvula : Normal.
Neck : No enlarged jugular vein, neck stiffness present.
Thyroid : Not enlarged and palpable.
Tongue : Pink, moist, no tongue tie present. No signs of injury.

Chest and Lung

Movement of chest : Moving equal during respiration
Tenderness : Not tender
Percussion : Resonant sound felt on Percussion.
Auscultation
Breath sound : No wheezing or crepitation
Respiration : normal, no nasal flaring, bilateral chest expansion.

Cardiovascular System
Chest pain : patient is unconscious
Pulse : 80/minute
Blood pressure : 110/70mm of Hg
Apical pulse : 80 beats/m. Auscultated by stethoscope,
Auscultation
Heart sound : Normal ( lub and dup)
Murmur : No.
 Apex beat heart on fifth intercostals space mid clavicular line.
 Peripheral pulses (brachial, radial, femoral, posterior tibial and dorsalis pedis) were
palpable.
 Apex beat is symmetrical with other peripheral pulses i.e. 80 per minute
 Pulse deficit not present
 Capillary refill time is less than 3 second.
 Palms of hands appear pink.
Gastro-intestinal system
Bowel habit : Normal
Vomiting : Not at present
Loss of appetite : she is unconscious
Diarrhoea : No.
Color of stool : Yellow.
Haematemesis : No

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 Constipation : No
Palpation
Liver : Not palpable.
Spleen : Not palpable.
Kidney : Not palpable.
Abdomen : Ovoid shaped abdomen. No scar of injury and operation.
Visible blood vessels. : No
Any abnormal masses : No
Auscultation for bowel sound : Present. Gurgling peristalsis movement audible on all the four
quadrants within 2 to 5 seconds.
Percussion:

 Dull sound over right and left hypochondriac and umbilical region.
 Tympanic sound present on other region.

Genito Urinary System

Pain on micturation : patient is unconscious.
Blood in urine : No
Color of urine : Light yellow. (Straw)
Urinary Retention : No
Back
Inspection:
 No any deformity on the back is seen (Kyphosis, scoliosis or lordosis).
Palpation:
 Bilateral equal expansion of back during respiration.
Percussion:

 Resonance sound present over the back.

Auscultation:

 Bilateral clear breathe sound heard over the back.

Upper and lower extremities:

 Both right extremities are of equal size, shape and symmetrical without any deformity.
 No redness, swelling or any tenderness.
 Range of motion was not able to assess.
 Capillary refill: less than 3 sec
 Color of nail bed: pink
 Peripheral pulses: present
 Normal temperature of extremities on palpation.

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Musculoskeletal system

 Normal body posture. No any deformity

 Level of consciousness: unconscious and disoriented to time, place and person
 Bicep and triceps, brachioradialis, abdominal reflex, knee-jerk, Achilles and plantar
reflexes are present.
 Kerning sign positive (left>right).
Nervous System
Convulsion : No.
Level of conscious : unconscious.
Orientation : not oriented to time, place and person.

Glasgow Coma Scale

Assessed behavior Criteria Points

score

Spontaneous--open with blinking at

4 points
baseline

-Opens to verbal command, speech, or

Eye Opening 3 points
shout
Response
-Opens to pain, not applied to face 2 points

-None 1 point

Verbal Response

-Oriented 5 points

-Confused conversation, but able to

4 points
answer questions

-Inappropriate responses, words

3 points
discernible

-Incomprehensible speech 2 points

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 -None 1 point

-Obeys commands for movement 6 points

-Purposeful movement to painful

5 points
stimulus

-Withdraws from pain 4 points

Motor Response
-Abnormal (spastic) flexion,
3 points
decorticate posture

-Extensor (rigid) response, decerebrate

2 points
posture

-None 1 point.

GCS in my patient: 3/15.

Findings of physical examination:

 My patient is unconscious.
 Her GCS is 3/15 pupil is 2mm of both eye and reactive too.
 Kerning sign positive.
 Neck stiffness present.

Developmental task of middle adulthood:

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Adulthood has no signpost to announce its onset (as adolescence is announced by puberty). In
technologically advanced nations, the life span is more than 70 years. Developmental psychologists
usually consider early adulthood to cover approximately age 20 to age 39 and middle adulthood
approximately 40 to 55.

Middle adulthood.

In middle adulthood, an important challenge is to develop a genuine concern for the welfare of future
generations and to contribute to the world through family and work. Erik Erikson refers to the problem
posed at this stage as generativity vs. self‐absorption(stagnation).

Robert Havighurst lists seven major tasks in the middle years.

 accepting and adjusting to physiological changes, such as menopause

 reaching and maintaining satisfaction in one's occupation
 adjusting to and possibly caring for aging parents
 helping teenage children to become responsible adults
 achieving adult social and civic responsibility
 relating to one's spouse as a person
 developing leisure‐time activities.

All the above mentioned developmental tasks are accomplished by the patient as she is worker as
occupation, lives with her husband, and daughters and she is one of the responsible member of
her village. Along with above, patient has mutual relationship with her husband but she has step
family too and spends her time in working and other leisure activities such as watching TV,
listening music etc.

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Anatomy and physiology:
The Brain

The brain is a spongy organ made up of nerve and supportive tissues. It is located in the head and is
protected by a bony covering called the skull. The base, or lower part, of the brain is connected to the
spinal cord. Together, the brain and spinal cord are known as the central nervous system (CNS). The
spinal cord contains nerves that send information to and from the brain.
Structure and function of the brain:

The brain is the body’s control centre. It constantly receives and interprets nerve signals from the body
and responds based on this information. Different parts of the brain control movement, speech,
emotions, consciousness and internal body functions, such as heart rate, breathing and body temperature.
 
The brain has 3 main parts: cerebrum, cerebellum and brain stem.

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Cerebrum:

The cerebrum is the largest part of the brain. It is divided into 2 parts (halves) called the left and right
cerebral hemispheres. The 2 hemispheres are connected by a bridge of nerve fibers called the corpus
callosum.
 The right half of the cerebrum (right hemisphere) controls the left side of the body. The left half of the
cerebrum (left hemisphere) controls the right side of the body.
 The outer surface of the cerebrum is called the cerebral cortex or grey matter. It is the area of the brain
where nerve cells make connections, called synapses that control brain activity. The inner area of the
cerebrum contains the insulated (myelinated) bodies of the nerve cells (axons) that relay information
between the brain and spinal cord. This inner area is called the white matter because the insulation
around the axons gives it a whitish appearance.

Cerebellum:

The cerebellum is the next largest part of the brain. It is located under the cerebrum at the back of the
brain. It is divided into 2 parts or hemispheres and has grey and white matter, much like the cerebrum.
 The cerebellum is responsible for:
 movement
 posture
 balance
 reflexes
 complex actions (walking, talking)
 collecting sensory information from the body

Brain stem:

The brain stem is a bundle of nerve tissue at the base of the brain. It connects the cerebrum to the spinal
cord and sends messages between different parts of the body and the brain.
 The brain stem has 3 areas:
 Midbrain
 Pons
 Medulla oblongata
 The brain stem controls:
 Breathing
 Body temperature
 Blood pressure
 Heart rate
 Hunger and thirst
 
Other important parts of the brain

Cerebrospinal fluid (CSF):

The cerebrospinal fluid (CSF) is a clear, watery liquid that surrounds cushions and protects the brain and
spinal cord. The CSF also carries nutrients from the blood to, and removes waste products from, the

17
brain. It is produced in the choroid plexus. It circulates through chambers called ventricles and over the
surface of the brain and spinal cord. The brain controls the level of CSF in the body.

Meninges:
The meninges are a series of membranes that cover the central nervous system. The meninges consist of
three layers: the dura mater, the arachnoid mater, and the pia mater. These layers cover the brain and
spinal cord with the primary function of protecting and nourishing the central nervous system.

The dura mater:

The dura mater is the outermost of the three layers making up the meninges. It is a thick, durable
membrane, and is closest to the skull. It is responsible for keeping in the cerebrospinal fluid, and for
surrounding and supporting the dural venous sinuses that carry blood from the brain to the heart.

The arachnoid mater:

The arachnoid mater is the middle layer of the meninges, and is named from its spider web-like
appearance. It provides a cushioning for the central nervous system.

The pia mater:

The pia mater is the innermost layer of the meninges. It envelopes and firmly attaches to the surface of
the brain and spinal cord. The pia mater contains blood vessels and capillaries that are responsible for
nourishing the brain.

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 Circle of Willis

The circle of Willis is formed by an arterial polygon as the internal carotid and vertebral systems

anastomose around the optic chiasm and infundibulum of the pituitary stalk. This communicating
pathway allows equalization of blood-flow between the two sides of the brain, and permits anastomotic
circulation, should a part of the circulation be occluded.

Gross anatomy
Vessels comprising the circle of Willis

1. left and right internal carotid arteries (ICA)

2. horizontal (A1) segments of the left and right anterior cerebral arteries (ACA)
3. anterior communicating artery (ACOM)
4. left and right posterior communicating arteries (PCOM)
5. horizontal (P1) segments of left and right posterior cerebral arteries (PCA)
6. basilar artery (tip)
The anterior circulation is comprised of vessels 1-3 and their branches; the posterior circulation arises
from vessels 4-6 and their branches.

The basilar artery divides at the upper border of the pons to form the left and right PCAs. From each
ICA, a PCOM arises at the anterior perforated substance and runs back through the interpeduncular
cistern to join the ipsilateral PCA. Each ICA also gives off an ACA. The ACAs are united by the
ACOM, a small vessel that runs in the chiasmatic cistern (below the rostrum of the corpus callosum), to
complete the circle.

The posterior communicating artery (PCOM) makes up the posterior linkage in the circle of Willis.
PCOM originates from the posterior aspect of the C7 (communicating) segment of the internal carotid
artery and extends posteriormedially to anastomose with posterior communicating artery and form part
of the circle of Willis. Each posterior communicating artery connects the three cerebral arteries of the
same side. Anteriorly, it connects to the internal carotid artery (ICA) prior to the terminal bifurcation of
the ICA into the anterior cerebral artery and middle cerebral artery. Posteriorly, it communicates with
the posterior cerebral artery.

Branches

PCOM gives off many fine, scarcely visible, perforating branches. The largest perforating branch is
called the premamillary (or anterior thalamoperforating) artery. 

Branches of the circle of Willis (supply optic chiasm and tracts, infundibulum, hypothalamus and other
structures at base of brain):

 medial lenticulostriate arteries (from A1 segment of ACA)

 thalamoperforating and thalamogeniculate arteries (from basilar tip, proximal PCAs and PCOMs)
 perforating branches (from the ACOM).

19
Fig: Circle of Willis

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Disease profile:

1. PCOM (Posterior Communicating Artery Aneurysm)

Introduction:
An aneurysm is a weak area in a blood vessel that usually enlarges. It’s often described as a
“ballooning” of the blood vessel.
A posterior communicating artery (PCOM) aneurysm is a bulging or ballooning of the arterial wall in an
area of focal weakness. The posterior communicating artery branches off the internal carotid artery as it
enters the brain, and the junction area of the PCOM and the internal carotid artery is the most common
site for a PCOM aneurysm. Interconnecting with other vessels to form an arterial circle at the base of the
brain, the PCOM is the second most common place for an aneurysm within this circle of Willis,
accounting for about 30 percent of brain aneurysms.
Aneurysms of the posterior communicating artery are the third most common circle of Willis aneurysm
(the most common are anterior communicating artery aneurysms) and can lead to oculomotor
nerve palsy.
An aneurysm can occur in any part of the body. They tend to most commonly occur on the wall of the
aorta - the large trunk artery that carries blood from the left ventricle of the heart to branch arteries. The
aorta goes down through the chest and into the abdomen, where it divides into the iliac arteries (two
branches).

There are two main types of aneurysms:

Aortic aneurysm - occurs in the aorta. Can be abdominal, or thoracic (higher up).
Cerebral aneurysm - occurs in an artery in the brain.
 
Brain aneurysms are all different. They vary in size, shape and location.
Size
 Small aneurysms are less than 5 mm (1/4 inch).
 Medium aneurysms are 6–15 mm (1/4 to 3/4 inch).
 Large aneurysms are 16–25 mm (3/4 to 1 1/4 inch).
 Giant aneurysms are larger than 25 mm (1 1/4 inch).
Shape
Aneurysms can be:
 Saccular (sac-like) with a well-defined neck
 Saccular with a wide neck
 Fusiform (spindle shaped) without a distinct neck

Epidemiology:
About 1.5 to 5 percent of the general population has or will develop a cerebral aneurysm.
Between 0.5 and 3 percent of people with a brain aneurysm may suffer from bleeding.

Causes (in book picture):

21
The following risk factors may increase your risk for an aneurysm or, if you already have an aneurysm,
may increase your risk of it rupturing:

 Family history. People who have a family history of brain aneurysms are more likely to have an
aneurysm than those who don't.
 Previous aneurysm. People who have had a brain aneurysm are more likely to have another.
 Gender. Women are more likely to develop a brain aneurysm or to suffer a subarachnoid
hemorrhage.
 Oral contraceptives.
 Race. African Americans are more likely than whites to have a subarachnoid hemorrhage.
 High blood pressure. The risk of subarachnoid hemorrhage is greater in people who have a
history of high blood pressure.
 Smoking. In addition to being a cause of high blood pressure, the use of cigarettes may greatly
increase the chances of a brain aneurysm rupturing.
 Weakness in the artery wall (usually present since birth)
 Arteriosclerosis (plaques of cholesterol, platelets, fibrin, and other substance form on the arterial
wall)
 Age at menopause influences cerebral aneurysm risk - a study published in the Journal of Neuro
Interventional Surgery found that early menopause raises the risk of cerebral aneurysm.
 Most cerebral aneurysms develop at the forks or branches in arteries because the walls in these
sections are weaker. They most commonly form at the base of the brain - but can form anywhere
in the brain. 

Causes in my patient:
 Gender (women)
 Unknown.

Clinical features:
Symptoms of a ruptured brain aneurysm often come on suddenly. are linked to how big the aneurysm is,
how fast it is growing and its location.

According to book In my patient

A sudden, severe headache that is different from past Present
headaches.

Neck pain.
Absent
Nausea and vomiting.
Present
Sensitivity to light.
Absent
Fainting or loss of consciousness.
Present
Seizures
Absent

22
 Confusion Present

A drooping eyelid Absent

Stiff neck Present

Diagnosis (according to book):

1. Computed tomography (CT) scan. A CT scan can help identify bleeding in the brain. Sometimes
a lumbar puncture may be used if your doctor suspects that you have a ruptured cerebral
aneurysm with a subarachnoid hemorrhage.
2. Computed tomography angiogram (CTA) scan. CTA is a more precise method of evaluating
blood vessels than a standard CT scan. CTA uses a combination of CT scanning, special
computer techniques, and contrast material(dye) injected into the blood to produce images of
blood vessels.
3. Magnetic resonance angiography (MRA). Similar to a CTA, MRA uses a magnetic field and
pulses of radio wave energy to provide pictures of blood vessels inside the body. As with CTA
and cerebral angiography, a dye is often used during MRA to make blood vessels show up more
clearly.
4. Cerebral angiogram. During this X-ray test, a catheter is inserted through a blood vessel in the
groin or arm and moved up through the vessel into the brain. A dye is then injected into the
cerebral artery. As with the above tests, the dye allows any problems in the artery, including
aneurysms, to be seen on the X-ray. Although this test is more invasive and carries more risk
than the above tests, it is the best way to locate small (less than 5 mm) brain aneurysms.

Diagnosis done in my patient:

 History taking
 Physical examination
 Blood investigations
 ECG
 CT scan.

Treatment (according to book):

Treatment may include lifesaving measures, symptom relief, repair of the bleeding aneurysm, and
complication prevention. For 10 to 14 days following an aneurysm rupture, the patient will remain in the
neuroscience intensive care unit (NSICU), where doctors and nurses can watch closely for signs of
renewed bleeding, vasospasm, hydrocephalus, and other potential complications.

1. Medication
Pain medication will be given to alleviate headache, anticonvulsant medication may be prescribed to
prevent or treat seizures, and a vasodilator will be prescribed to prevent vasospasm. Blood pressure is
lowered to reduce further bleeding and to control intracranial pressure.

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 2. Surgery
Determining the best surgical treatment for a ruptured aneurysm involves many factors, such as the size,
location, and type of aneurysm as well as the overall health of the patient and their medical history.
a. Surgical clipping: an opening is made in the skull, called a craniotomy, to locate the aneurysm.
A small clip is placed across the "neck" of the aneurysm to block the normal blood flow from
entering. The clip is made of titanium and remains on the artery permanently.

Figure 1.  A titanium clip is placed across the neck of an aneurysm. 

The arrow indicates bloodflow through the artery, but not the aneurysm.

b. Endovascular coiling: is performed during an angiogram in the radiology department and

sometimes requires general anesthesia. A catheter is inserted into an artery in the groin and then
passed through the blood vessels to the aneurysm. Through the catheter, the aneurysm is packed
with platinum coils or acrylic glue, which prevents blood flow into the aneurysm.

Figure 2. The aneurysm is packed with platinum coils by way of a small catheter. 
The arrow indicates bloodflow through the artery, but not the aneurysm.

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 c. Artery occlusion and bypass: if surgical clipping is not possible or the artery is too damaged,
the surgeon may completely block (occlude) the artery that has the aneurysm. The blood flow is
detoured (bypassed) around the occluded section of artery by inserting a vessel graft. The graft is
a small artery, usually taken from your leg, that is connected above and below the blocked artery
so that blood flow is rerouted (bypassed) through the graft. 

Figure 3. The aneurysm is blocked off between two clips and 

a bypass is sewn to detour blood flow around the aneurysm.

A bypass can also be created by detaching a donor artery from its normal position on one end,
redirecting it to the inside of the skull, and connecting it above the blocked artery. This is called a STA-
MCA (superficial temporal artery to middle cerebral artery) bypass.

Treatment done in my patient:

 Patient was kept in Neuro ICU
 Medicines was given through IV line
 Nimodipine to prevent artery spasm
 Painkillers to relieve headaches
 Laxatives to prevent straining during bowel movements.
 Plan for surgical intervention (craniotomy and aneurysm clipping) has been done.

2. SAH (Sub–arachnoid haemorrhage)

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Definition:
The term subarachnoid hemorrhage (SAH) refers to extravasation of blood into the subarachnoid space
between the pia and arachnoid membranes. This may occur spontaneously, usually from a
ruptured cerebral aneurysm, or may result from head injury. SAH is a form of stroke and comprises 1–7
percent of all strokes. It is a medical emergency and can lead to death or severe disability—even when
recognized and treated at an early stage. Up to half of all cases of SAH are fatal and 10–15 percent of
casualties die before reaching a hospital and those who survive often have neurological or cognitive
impairment.

Epidemiology
According to a review of 51 studies from 21 countries, the average incidence of subarachnoid
hemorrhage is 9.1 per 100,000 annually. Studies from Japan and Finland show higher rates in those
countries (22.7 and 19.7, respectively), for reasons that are not entirely understood. South and Central
America, in contrast, have a rate of 4.2 per 100,000 on average. Although the group of people at risk for
SAH is younger than the population usually affected by stroke, the risk still increases with age. Young
people are much less likely than middle-age people (risk ratio 0.1, or 10 percent) to have a subarachnoid
hemorrhage.[56] The risk continues to rise with age and is 60 percent higher in the very elderly (over 85)
than in those between 45 and 55. 
Risk of SAH is about 25 percent higher in women over 55 compared to men the same age, probably
reflecting the hormonal changes that result from the menopause, such as a decrease in estrogen levels.
Overall, about 1 percent of all people have one or more cerebral aneurysms. Most of these, however, are
small and unlikely to rupture.

Causes (according to book):

 Bleeding from an arteriovenous malformation (AVM)

 Bleeding disorder
 Bleeding from a cerebral aneurysm
 Head injury
 Unknown cause (idiopathic)
 Use of blood thinners

Risks include:
 Aneurysm in other blood vessels
 Fibromuscular dysplasia (FMD) and other connective tissue disorders
 High blood pressure
 History of polycystic kidney disease
 Smoking
 A strong family history of aneurysms may also increase the risk.

Causes of SAH in my patient:

 Bleeding from a cerebral aneurysm.

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Pathophysiology:
rupture of cerebral aneurysm.

Result in bleeding.

Mass of blood( hematoma)forms between the skull and brain which creates pressure on brain.

There is no room in the skull for the brain to expand, so the brain may shift as it swells.

The brain structures push together and create pressure.

Affect vision, speech, and consciousness.

The brain may also lose blood supply and die.

Sign and symptoms:

The main symptom is a severe headache that starts suddenly (often called thunderclap headache). It is
often worse near the back of the head. Many persons often describe it as the "worst headache ever" and
unlike any other type of headache pain. The headache may start after a popping or snapping feeling in
the head.

Other features are:

According to book In my patient

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  Decreased consciousness and alertness Eye discomfort in  Thunderclap
bright light (photophobia) headache.
 Mood and personality changes, including confusion and  Decrease
irritability
consciousness
 Muscle aches (especially neck pain and shoulder pain)
 Nausea and vomiting  Vomiting
 Numbness in part of the body  Stiff neck
 Seizure  Decrease in
 Stiff neck pupil size.
 Vision problems, including double vision, blind spots, or
temporary vision loss in one eye
 Eyelid drooping
 Pupil size difference
 Sudden stiffening of back and neck, with arching of the
back (opisthotonos; not very common)

Diagnosis (according to book):

Diagnosis of SAH usually depends on a high index of clinical suspicion combined with radiologic
confirmation via urgent non-contrast CT, followed by lumbar puncture or CT angiography of the brain.
After the diagnosis is established, further imaging should be performed to characterize the source of the
hemorrhage.
Laboratory studies should include the following:
 Serum chemistry panel
 Complete blood count
 Prothrombin time (PT)/activated partial thromboplastin time (aPTT)
 Blood typing/screening
 Cardiac enzymes
 Arterial blood gas (ABG) determination
Imaging studies that may be helpful include the following:
 CT (non-contrast, contrast, or infusion)
 Digital subtraction cerebral angiography
 Multidetector CT angiography
 MRI (if no lesion is found on angiography)
 Magnetic resonance angiography (MRA; investigational for SAH)
Other diagnostic studies that may be warranted are as follows:
 Baseline chest radiograph
 ECG on admission
 Lumbar puncture and CSF analysis

Diagnosis done in my patient:

 History taking
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  Physical examination
 Blood investigations
 ECG
 CT scan

Treatment (according to book):

The goals of treatment are to:

 Save your life
 Repair the cause of bleeding
 Relieve symptoms
 Prevent complications such as permanent brain damage (stroke).

Surgery may be done to:

 Remove large collections of blood or relieve pressure on the brain if the hemorrhage is due to an
injury
 Repair the aneurysm if the hemorrhage is due to an aneurysm rupture
 If the patient is critically ill, surgery may have to wait until the person is more stable.

Surgery may involve:

 Craniotomy (cutting a hole in the skull) and aneurysm clipping -- to close the aneurysm
 Endovascular coiling -- placing coils in the aneurysm and stents in the blood vessel to cage the
coils reduces the risk of further bleeding
 If no aneurysm is found, the person should be closely watched by a health care team and may
need more imaging tests.

Treatment for coma or decreased alertness includes:

 Draining tube placed in the brain to relieve pressure

 Life support
 Methods to protect the airway
 Special positioning
 A person who is conscious may need to be on strict bed rest. The person will be told to avoid
activities that can increase pressure inside the head, including:
 Bending over
 Straining
 Suddenly changing position

Treatment may also include:

 Medicines given through an IV line to control blood pressure
 Nimodipine to prevent artery spasm
 Painkillers and anti-anxiety medications to relieve headache and reduce pressure in the skull
 Phenytoin or other medications to prevent or treat seizures
 Stool softeners or laxatives to prevent straining during bowel movements.

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 Treatment done in my patient:
 Medicines was given through IV line
 Nimodipine to prevent artery spasm
 Painkillers to relieve headaches
 Laxatives to prevent straining during bowel movements.
 Plan for surgical intervention (craniotomy and aneurysm clipping) has been done.

Complications

 Older age and more severe symptoms can lead to a poorer outcome.
 People can recover completely after treatment. But some people die even with treatment.

Possible Complications
 Repeated bleeding is the most serious complication. If a cerebral aneurysm bleeds for a second
time, the outlook is much worse.
 Changes in consciousness and alertness due to a subarachnoid hemorrhage may become worse
and lead to coma or death.

Other complications include:

 Complications of surgery
 Medication side effects
 Seizures
 Stroke.

Prevention
Identifying and successfully treating an aneurysm can prevent subarachnoid hemorrhage.

Management (according to book)

Management involves general measures to stabilize the patient while also using specific investigations
and treatments. These include the prevention of rebleeding by obliterating the bleeding source,
prevention of a phenomenon known as vasospasm, and prevention and treatment of complications.[1]
Stabilizing the patient is the first priority. Those with a depressed level of consciousness may need to
be intubated and mechanically ventilated. Blood pressure, pulse, respiratory rate, and Glasgow Coma
Scale are monitored frequently. Once the diagnosis is confirmed, admission to an intensive care
unit may be preferable, especially since 15 percent may have further bleeding soon after admission.
Nutrition is an early priority, with oral or nasogastric tube feeding being preferable
over parenteral routes. In general, analgesia (pain control) is restricted to less-sedating agents such
as codeine, as sedation may impact on the mental status and thus interfere with the ability to monitor the
level of consciousness. Deep vein thrombosis is prevented with compression stockings,
intermittent pneumatic compression of the calves, or both. A bladder catheter is usually inserted to

30
monitor fluid balance. Benzodiazepines may be administered to help relieve distress. Antiemetic drugs
should be given to awake persons.
Patients with poor clinical grade on admission, acute neurologic deterioration or progressive
enlargement of ventricles on CT Scan are, in general, indications for the placement of an external
ventricular drain by a neurosurgeon. The external ventricular drain may be inserted at the bedside or in
the operating room. In either case, strict aseptic technique must be maintained during insertion. In
patients with aneurysmal subarachnoid hemorrhage the EVD is used to remove cerebrospinal fluid,
blood, and blood byproducts that increase intracranial pressure and may increase the risk for cerebral
vasospasm.
Management done in my patient:
 Admission to intensive care unit was done
 Blood pressure, pulse, respiratory rate GCS are monitored regularly.
 To maintain nutrition, IV fluids were given and from 3rd day NG feeding was also done.
 For analgesic, tab. Codeine was given.
 Deep Vein Thrombosis and bedsore was prevented by changing position regularly.
 A bladder catheter was inserted to monitor fluid balance.
 EVD was done to remove cerebrospinal fluid, blood and blood byproducts that
increase intracranial pressure and may increase the risk for cerebral vasospasm.

Nursing management done in my patient:

1. Maintaining the airway:

As patient was not able swallow and lacks pharyngeal reflexes, to prevent accumulation of
secretions, elevation of the head of the bed to 30* was done, patient was kept in lateral position
to prevent from aspiration and also oral suctioning was done including physiotherapy too.

2. Maintaining fluid balance and managing nutritional needs:

Hydration status was assessed by examining tissue turgor and mucous membranes, assessing
intake/output records and analyzing laboratory data. Fluids need was met initially by giving the
required fluids intravenously and later on NG feeding was also done.

3. Protecting the patient:

For protection of the patient, side rails was provided and raised all the times. Care was taken to
prevent injury from invasive lines and equipment. Protection of patient’s dignity was done my
providing privacy during procedures and not speaking negatively about patient’s condition or
prognosis.

4. Providing mouth care:

The mouth was cleaned and rinsed carefully to remove secretions and crusts and to keep the
mucous membranes moist.

5. Maintaining skin and joint integrity:

Assessment of patient’s skin was done regularly while turning the patient. After turning, the
patient is carefully repositioned to prevent ischemic necrosis over pressure areas. Passive

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 exercise of the extremities was also done. Back care was also provided regularly to prevent
pressure sore.

6. Preserving corneal integrity:

The cornea is likely to become irritated or scratched, leading to keratitis and corneal ulcer, so the
eyes was cleansed with cotton balls moistened with normal saline to remove debris and
discharge.

7. Preventing urinary retention:

To prevent from urinary retention, foley’s catheter was inserted and was checked regularly
whether the tube has been kinked or blocked or not and catheter care was provided to prevent
from infection.

8. Promoting bowel function:

Immobility and lack of dietary fiber may cause constipation so stool softner was provided with
tube feeding.

9. Meeting family needs:

The families were provided considerable time, assistance and support to accept the patient
condition. Accurate information was provided about the patient’s condition, listened to their
feeling and concerns and they were supported in their decision making process about post-
hospitalization management and placement.

10. Monitoring and managing potential complications:

Vital signs and respiratory functions were monitored closely to detect any signs of respiratory
failure or distress. Chest physiotherapy and suctioning was done to prevent respiratory
complications. Factors that contribute to impaired skin integrity (eg; incontinence, inadequate
dietary intake, pressure on bony prominence, edema) were addressed. Patient was also monitored
for deep vein thrombosis. To prevent from complication, back care, positioning, etc was done.

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