Cerebral Aneurysm—Treatment and Perioperative Nursing ... - AORN

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Wright JUNE 2007, VOL 85, NO 6TABLE 3Nursing Care Plan for a Patient UndergoingSurgery for Treatment of Cerebral AneurysmDiagnosisRisk fordecreasedcardiac outputrelated tocardiovascularfunction,anesthesia,and surgicalintervention.Nursing interventions• Identifies baseline cardiac and vascular statusand reviews diagnostic evaluations (eg,electrocardiogram [ECG], laboratory testresults).• Uses monitoring equipment to assess cardiacand vascular status (eg, ECG, arterialline, pulmonary artery catheter, Doppler).• Assesses peripheral pulses, skin pallor,numbness, and tingling of extremities.• Observes for signs and symptoms of hypovolemiain postoperative period related toblood loss.• Evaluates postoperative vascular function.Interim outcomecriteriaPatient’scardiovascularfunction ismaintained orimproved frombaseline levels,ensuringadequate bloodflow to thepatient’sextremities.OutcomestatementPatient isfree of signsand symptomsofdistalembolismand hypovolemia.Risk forinfectionrelated to thesurgicalprocedure.• Assesses skin integrity, sensory impairments,and susceptibility for infection.• Validates that preoperative antibiotic wasadministered according to facility policy.• Allows sufficient time for surgical prepsolution to dry before the patient is draped.• Minimizes length of invasive procedure byplanning care and obtaining necessaryequipment expeditiously.• Monitors sterile field and perioperativeteam members to ensure that asepsis ismaintained.• Initiates and maintains traffic control.• Classifies surgical wound (eg, class I).• Dresses wound at completion of procedure.Patientdemonstrates dry,nonreddened,nontender woundhealing byprimary intention.Patient isfree ofsigns andsymptoms ofhealth careassociatedinfection for30 daysafter theperioperativeprocedure.Risk of anxietyrelated toknowledgedeficit andstress ofsurgery.Risk forinjury relatedto positioning.• Identifies communication barriers andknowledge level (eg, expected outcomes,surgical risks and complications).• Assesses readiness to learn and copingmechanisms.• Explains sequence of events and reinforcesteaching about cerebral aneurysms, surgicaltreatment options, and recovery.• Provides instruction (ie, oral, written) forsurgical procedure and discharge, includingsigns and symptoms of postoperativehemorrhage.• Evaluates response to instruction.• Identifies physical alterations that may affectprocedure-specific positioning.• Places the patient in an anatomically correctposition and implements protectivemeasures to prevent tissue injury.• Uses supplies and equipment within safeparameters.• Evaluates for signs and symptoms of skinand tissue injury.Patient verbalizesunderstanding ofthe procedure,sequence ofevents, expectedoutcomes, andconcerns abouttreatmentdecisions beingdiscussed andparticipates indecision making.Patient’s skinremains intact,nonreddened, andfree from ecchymosisand thepatient maintainscirculation, sensation,and functionrelated to surgicalpositioning.Patientdemonstratesknowledgeof thephysiologicalandpsychologicalresponsesto theprocedure.Patient isfree fromsigns andsymptoms ofinjuryrelated topositioning.AORN JOURNAL • 1179
JUNE 2007, VOL 85, NO 6WrightFigure 5 • A cerebral angiogramis performed preoperatively andpostoperatively. Ideally, the procedureis performed in a suitedesigned for neuroradiography.The neurosurgeon clips the hairfrom the surgical area of the patient’shead, and the circulating nurse performsthe surgical skin prep. While thisis occurring, the scrub person drapesthe microscope. After the scrub personand surgeon drape the surgical area,the circulating nurse positions and connectsthe unipolar and bipolar ESUs,foot pedals (eg, bipolar ESU, powerdrill), and suction devices.The location of the surgical incisiondepends on the location of the cerebralaneurysm. After making the initial incision,the neurosurgeon applies scalpclips to the skin edges. He or she performssoft tissue separation from underlyingbone with an elevator and then attachesdura hooks to a separate Mayostand to secure the scalp flap. Afterdrilling burr holes into the cranium at thefour corners of the incision site, the neurosurgeonsaws between the burr holesand separates the bone flap from the underlyingdura with elevators and dissectorsin order to turn the bone flap.The circulating nurse moves the microscopeinto position, and the neurosurgeonuses it to locate and carefully isolatethe aneurysm and the blood vessels thatfeed it. Delicate movements are used toprevent disruption of surrounding braintissue. The neurosurgeon carefully separatesthe aneurysm from the surroundingtissue and then places one or more smallaneurysm clips across the neck of theaneurysm (Figure 6). The neurosurgeonthen closes the dura andreplaces the bone flap withscrews and plates. 10 He orshe then closes the scalp.The circulating nurse assiststhe neurosurgeonwith removing the neurosurgical,three-point headrestfrom the patient’shead and applying a cranialwound dressing.When the craniotomyis complete, the neurosurgeon performsa repeat cerebral angiogram to examinethe cerebral blood flow. The surgeonseals the femoral artery with an arterysealing device and applies pressure forseveral minutes before applying afemoral wound dressing.ENDOVASCULAR COILING PROCEDUREThe endovascular coiling procedureis performed by an interventional neurosurgeonor neuroradiologist. Theneurosurgeon or neuroradiologist insertsan endovascular catheter into thepatient’s femoral artery and performsa preprocedure cerebral angiogram tolocate the aneurysm. The surgeon orradiologist delivers heparinized salinesystemically via the femoral arteryduring the procedure. Aided by fluoroscopy,the surgeon or radiologistthreads the catheter to the aneurysmalsite. When the correct position is obtained,he or she introduces a detachablecoil into the lumen and uses anelectrical impulse to detach the coilfrom the catheter (Figure 7).One or more coils may be needed tofill the aneurysm sac. If the neck of theaneurysm is too wide to hold the coils,the surgeon or radiologist may place astent across the neck of the aneurysm.The stent allows for safe deposition ofthe coils without allowing a coil mass toprotrude into the main artery. The surgeonor radiologist removes the catheterwhen the coils have been successfully1180 • AORN JOURNAL
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Cerebral Aneurysm—Treatment and Perioperative Nursing ... - AORN

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