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Joanne’s Berry Aneurysm Case

Pathophysiology of berry aneurysm and how rupture can lead to brain death 2

Nursing care of berry aneurysm case 4

a. Assessment 5

b. Airway and oxygenation 5

c. Blood pressure management 6

d. Intracranial pressure monitoring 6

e. Management of fever 6

f. Laboratory data 6

g. Intravenous fluids 7

h. Nutrition administration 7

i. Activity 7

j. Deep vein thrombosis prophylaxis 7

k. Medications 7

i. Care of the intubated patient 8

Differentiation between brain death and cardiac death in relation to end of life decision making 8

Brain death 8

Cardiac death 9

Key issues surrounding organ donation 9

Organ donation 10

Organ harvesting 10

Brain death vs. cardiac death 10

Legal/ ethical issues of donation/ harvesting 10

Grief counseling 11

Access to organs 11

References 11

Pathophysiology of berry aneurysm
and how rupture can lead to brain death

Aneurysm results when an arterial blood vessel suffers a focal dilatation. In case of intracranial aneurysm luminal forces such as shear stress, high blood pressure and turbulence are responsible for the pathogenesis. In the clinical decision-making process luminal characteristics like morphology and sac size are usually considered as essential. Even as several clinical aspects are emphasised in case of intracranial aneurysm, it is generally held that it is the vessel lumen that should be implicated as pathology underlying the growth, formation and rupture of a particular aneurysm. It has also been stated that intracranial aneurysm is not a stand-alone disease but is, in fact, a constitution of a number of diseases as evidenced by histopathological and morphological research into the field. In other words intracranial aneurysm is a shared manifestation of a number of underlying conditions, each one of which has a unique presentation of its own. More often than not vessel wall morphology contributes greatly to how intracranial aneurysm manifests and/ or behaves in different individuals. Therapeutically, the approach taken depends largely on the morphology and pathology of the vessel wall (Krings et al, 2011).

Vessel curves or bifurcations are normally the sites where berry aneurysms arise. These normally occur in the age range of 40 to 70 years but exceptions are always there; as was in case of Joanna, who was only 32 years of age. As mentioned earlier the pathogenesis or pathophysiology of berry aneurysms is as a result of multiple factors. There is compelling evidence that states that degenerative histological changes as well as hemodynamic factors in the parent wall contribute to their formation.

The destruction and finally the loss of media occur in the early phases of berry aneurysm formation. The media being referred to here is the internal elastic layer which is lost completely after disruption. Even as the mechanisms underlying these changes have not been completely understood, it is generally believed that atherosclerotic changes are responsible for such degeneration. The degeneration is enough to result in saccular changes, which is one of the most prominent features of berry aneurysm. Saccular dilation occurs because of hemodynamic forces working on these vessel walls. Furthermore it is also linked to intracranial circulation reduced peripheral resistance which results in augmented pulse pressure as blood flow in the vessels is more rapid. The combination of both triggers saccular dilation. It has been observed in experiments that extracellular matrix organisation is disrupted when the degenerated vessel walls undergo hemodynamic stress (Kittelberger, Davis & Stehbens, 1990).

Laminar necrosis takes place when endothelium is damaged in aneurysmal sacs on account of turbulent blood flow. Since necrosis takes place in the walls, it becomes easier for aneurysm to spread further. To rupture is the inevitability of an aneurysm but just in case it does not, mural thrombus formation sets in its partial healing process. Scarring of the wall takes place since thrombus gets organised within the vessel. This is followed by platelet aggregation, collagen formation, deposition of fibrous material and invasion of fibroblasts. When repeat hemorrhages occur in the wall, a vicious cycle of repetitive healing, which is abnormal and further growth of aneurysm take place. Steinberg (1995) is of the opinion that giant aneurysms seen in some patients are a result of such repetitive cycles.

Nearly ten percent of all berry aneurysm cases have been reported in posterior circulation and the rest ninety percent in anterior circulation. Normally ruptured aneurysm’s mean size has been put at 8.6 mm and 4.7 mm for an unruptured one. As many as eighty percent of symptomatic ones are below 12 mm in dimension and long back Suzuki (1979) has remarked that around 15 percent of all cases suffer from multiple aneurysms. One particular feature of saccular aneurysms is that they become symptomatic only after rupture, embolic events or mass effect. Research done so far implicates hemodynamic factors for precise pathophysiology of the rupture.

A number of risk factors have been linked to berry aneurysm’s growth and rupture and evidence is getting accumulated by the day. Qureshi et al (1998), Qureshi et al (2000) and Quereshi et al (2001) have stated that multiple aneurysm cases and large size of aneurysms can be attributed to smoking. Alcohol, on the other hand, triggers aneurysm rupture. Hypertension is supposed exacerbate a rupture and further lead to its growth. Besides this, there are several conditions that have been associated with a greater propensity for berry aneurysms. These conditions include polycystic kidney disease, coarctation of the aorta, and disorders like Ehlers-Danlos syndrome, apart from various connective tissue disorders. The conditions that further increase the risk include alpha-glucosidase deficiency, alpha 1-antitrypsin deficiency, arteriovenous malformation (AVM), arteriovenous malformation (AVM), female gender, fibromuscular dysplasia, hereditary hemorrhagic telangiectasia, Klinefelter syndrome, Noonan’s syndrome, and tuberous sclerosis.

Even though any arteries within the brain can suffer from aneurysm, a berry aneurysm typically affects arteries which are located in the front part of the brain. These arteries are responsible for supply oxygen-rich blood to rest of the brain. When aneurysms rupture, hemorrhagic strokes occur. The bleeding arteries cut off oxygenated blood supply to the brain as a result of which brain tissues and cells are deprived of the desired oxygen supply. This is further aggravated by pressure build-up in the tissues that surround the ruptured site resulting in extreme swelling and irritation. Over a period and with continued oxygen deprivation brain cells become dead, resulting in brain death.

Nursing care of berry aneurysm case

Care for berry aneurysm is a multi-unit task and involves patient care units, institutions and registered nurses to provide effective and safe care to adults on a path to recovery after an aneurysm attack. Registered nurses must be equipped with comprehensive knowledge on the biological processes occurring after and during the rupture. Several evidence-based guidelines have been provided to accomplish this task. Since there is always a risk association of secondary injury in berry aneurysm patients, the onus is on the nurses to prevent such injuries by basing their nursing practice on empirical evidence. This maximises recovery. Nurses, along with other healthcare professionals, are supposed to recognise and know the underlying clinical components, act judiciously and begin early treatment. Certain benchmarks have been set to execute the management in a timely and effective fashion. These include accurate diagnosis and early recognition, stabilize patient after the aneurysm has occurred, make efforts to prevent complications, recognise complication as a early as possible, initiate treatment and rehabilitation.

When an aneurysm takes place the most important focus should be to prevent rebleed. There are many instructions for nursing on how to prevent such an occurrence but one of the most important is to secure aneurysm. Before that is taken care of nurses are supposed to have a thorough knowledge of different ‘grades’ of patients. Some patients need more definitive treatment than others. For example, definitive treatment is warranted immediately in case of good-grade patients. These patients have low Fisher grade or low Hunt and Hess scores on admission. Initiation of triage and treatment will largely depend on the extent of neurological treatment (Bederson, et al., 2009). Even as methodologies of treating an aneurysm are beyond the scope of this paper, but it must be noted that two primary options are normally resorted to when aneurysms are supposed to be treated. One of aneurysm neck clipping and craniotomy, with ligation done only rarely and second is endovascular coiling. Nursing care is common normally until up to 1-2 days post-hemorrhage in case of unsecured aneurysm but this care can also be extended in case of patients in whom aneurysm securement has been delayed.

The job is vested more in the neurosciences nurses than any other since they are best equipped both in knowledge and expertise in management and monitoring of aneurysm patients, maximising outcomes by preventing secondary injuries. The care is normally divided into two parameters. One is preaneurysm securement and another postaneurysm securement.

a. Assessment

Soon after the patient is admitted to the intensive care unit complete and possibly hourly neurological exam checks including hemorrhagic monitoring, Glasgow Coma Scale, and National Institutes of Health Stroke Scale are to be carried out. The results have to be compared to the baseline so that deterioration and rebleed can be detected effectively.

b. Airway and oxygenation

Patients showing decreased mental states may be needing mechanical ventilation since these patients must be presenting with acute lung injuries or compromised airways. Although different modes of ventilation have been suggested, but goal for all remains the same i.e., adequate ventilation through oxygenated air supply without compromising both cerebral perfusion and intracranial pressures. Blood pressure has to be continuously monitored since end-expiratory pressure of 5cm H2O has been seen observed not to decrease the blood pressure. This poses a threat of cerebral ischemia (Meunch et al., 2005). Nurses are encouraged to monitor hourly breath sounds as aneurysm patients under management are at risk of developing pneumonia and atelectasis. They need to discourage coughing since it can result in further rupture of aneurysms leading to a very difficult situation to handle.

c. Blood pressure management

Relationship between blood pressure and aneurysmal rebleed is under investigation, however it is generally held that pivotal to preventing rebleed is timely management of blood pressure. Blood pressure control even before aneurysm securement is very essential and the range must be kept between 90-140 mm Hg (Suarez et al., 2006).

d. Intracranial pressure monitoring

Aneurysm results in a large blood load on account of which the patient stands at a risk of increased intracranial pressure. Surgically, in order to avert this, a subarachnoid bolt or ventricular catheter is inserted. Nurses have to recognise poor clinical grade on admission with progressive enlargement of ventricles and acute neuroliogic deterioration as these are clear indications for use of such devices (Mayberg et al., 1994; Rordorf, Ogilvy, Gress, Crowell, & Choi, 1997; Suzuki, Otawara, Doi, Ogasawara, & Ogawa, 2000).

e. Management of fever

Acetaminophen must be administered to bring about fever reduction in febrile patients presenting with temperature greater than 38.8 degree centigrade. Normothermia can be achieved with every 4-6 hr dosage of the drug (Suarez et al., 2006).

f. Laboratory data

It is important to monitor overall patient status through laboratory data as soon after the rupture takes place a number of pulmonary and cardiac imbalances take place. Electrolyte and fluid imbalances are common in soon after aneurysmal rupture. Nurses must continuously procure laboratory data on electrolytes and basic metabolic chemistry, creatine phosphokinase (CPK) isoenzymes and cardiac troponin, coagulation factors, complete blood count, type and screen and urine chemistry and toxicology.

g. Intravenous fluids

In berry aneurysm patients nurses have to make sure that patient maintains euvolemia, whcih is the central venous pressure of 5-8 mm Hg. In order to accomplish this, normal saline can be infused. The pressure rate can be between 80 and 100 cc/hr (2–3 L of 0.9% NaCl per 24 hours (Mayer et al., 2005).

h. Nutrition administration

No food is to be given to the patient by mouth. This also includes fluids and medication. Conduction of a bedside swallow evaluation is a must to reach any long-term decision regarding this. Nurses are supposed to take extreme care in case of comatose, stuporous and preoperative cases. On day 2 after hemorrhage parenteral nutrition can be gradually initiated.

i. Activity

Activity is impossible immediately after the rupture and subsequent admission of the patient in the intensive care unit. Even slight activity can increase both intracranial pressure and blood pressure. Nurses must ensure that the environment maintained around the patient is quiet and visitors discouraged.

j. Deep vein thrombosis prophylaxis

Berry aneurysm patients are immobilised on account of deprived activity, which puts them at a risk of deep venous thrombosis (DVT). Nurses are recommended to provide these patients with pneumatic compression devices or thigh-high stockings. This must be done as early as possible.

k. Medications

First and foremost anticoagulants like heparin should be avoided at least until the aneurysm is secured. Other medications which should be, should not be or should be used judiciously are ones that are from groups of seizure prophylaxis, stool softeners, painkillers, sedatives, antiemetics, and gastrointestinal hemorrhage prophylaxis. Postaneurysm securement is typically ion the same lines but management and administration of these things determined by the improvement in the condition of the patient.

i. Care of the intubated patient

Registered nurse is responsible for the care of intubated patient and the same involves high levels of precision and expertise. She is to ensure that patent airway is always maintained optimally. That means being alert enough to monitor the patient for respiratory effort, facial expressions, vital signs, colour and ECG tracing. The tracheostomy or endotracheal tube has to be firmly in position but not so tightly that lesions are created in the pressure area. That apart, the registered nurse has to make sure that patient’s bedside emergency equipment in fully functional and error-free. Ventilation tube should not be kinked and cardiac monitor and ventilation monitor must be plugged into alternate pwoer supply so as to provide backup if power fails.

Differentiation between brain death and cardiac death
in relation to end of life decision making

Brain death

When brain activity ceases to exist, it leads to brain death, which is an irreversible process. There is absolute loss of involuntary control, which is necessary to sustain life. This happens because on account of oxygen deprivation to the brain cells, cerebral neurons suffer total necrosis. It must be noted that brain death is not the same as persistent vegetative state. What is important in Jaonne’s case, who is brain dead, is that her organs can be removed for donation. It can be presumed that in her case the heart is still continuing working, but not optimally so as there is absence of respiratory effort. many jurisdictions use brain death as a legal indicator of death. When physically examined a brain dead person shows no evidence of brain function clinically. There are no cranial nerve reflexes and no response to pain. Some of the reflexes that are checked include corneal reflex, pupillary response, oculocephalic reflex, no spontaneous respirations and no response to calorific reflex test. When an EEG is taken of a brain dead person, it shows flat activity. On account of the legal aspects that have been modified from time to time in case of exploring confirmatory definitions and determination of brain death, a rigorous protocol is normally followed in order to ascertain that a person is brain dead. Completely irreversible and total absence of brain function should be established before declaring a person brain dead. This is because any error of judgment has serious legal implications (Randell, 2004).

Cardiac death

Myerburg (2005) has defined cardiac death as «natural death from cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of acute symptoms». Cardiac death should not be confused with cardiac arrest as the latter means impairment of cardiac pump function, which may be reversible. In adults above 30 years of age coronary artery atheroma has been cited as the most common cause of sudden cardiac death. When postmortem is conducted on such persons, it reveals chronic high-grade stenosis in a particular (at least one) segment of major coronary artery.

In each case, either that of being brain dead or cardiac dead, Joanne’s husband has a tough decision to make. It is because this decision, despite the odds involved, is fraught with emotional, relational and spiritual undercurrents. Joanne is brain dead, which is an irreversible process, and nurses are duty-bound to make her family aware of what it actually means to be brain dead. They have to make the family understand that come what may, Joanne cannot be revived and is as good as dead. Nurses have convince the family that end of treatment does not mean lack of care on either family’s part or hospital’s part. It simply means end of suffering for the patient, who is no more able to perceive it, and for the family, which is and will continue doing so until Joanne is relieved of the present state in which she is in.

Key issues surrounding organ donation

There are many issues surrounding organ donation. The hardest part of organ donation is when a decision is to be reached by a relative of someone who has died, as is the case in Joanne’s husband. In Australian context organ donation is an accepted part of the country’s medical practice. In this case it is the sole prerogative of her husband to decide whether or not to donate her organs. This is because in the case study it is not mentioned clearly whether or not she had expressed any previous willingness to her husband to donate her organs after her death. In this case her husband can decide in favour or against the decision to donate her organs.

Organ donation

Organ donation is a process by which organs from a living or a dead person can be donated to a recipient in need of such organ for transplantation. The removal of organs involves a surgical procedure and organ to be transplanted into a recipient has to be matched for a number of factors.

Organ harvesting

Organ harvesting is a procedure which enables medical scientists to preserve organs for reuse when the need arises. Organ harvesting, even though being an accepted practice in medical science, is still mired in controversies and ethical debates. It is noteworthy that a brain dead donor’s organs are preferred for harvesting as against a cardiac dead person. This is because after heart stops beating, organs cannot be harvested. Joanne is brain dead.

Brain death vs. cardiac death

Legally brain dead person is dead but if the patient is receiving mechanical ventilation it is possible to keep vital organs functional and alive. This normally is the case when formalities are waiting for transplantation to take place. Organ donations, normally, take place when the person is brain dead. However, different nations follow different rules and regulations on this issue.

Legal/ ethical issues of donation/ harvesting

Most of the legal issues surrounding organ donation pertain to organ donation after cardiac death, in which case availability of organs increases. The most important issues, as raised from time to time in this country, is that consent decisions should be based on both patients’ medical interests and their wishes. Probably on account of these issues Australia is not a befitting match for other wealthy nations where organ donors outnumber the donors in Australia.

Grief counseling

In Joanne’s husband’s case, who has lost a loved one, grief counseling is the job of the registered nurse. In instances when the aggrieved person has lost the very person who could have been a support at the time of grief, support can be provided effectively by grief counselors. The nurse has to provide such a support that it results into a healthy resolution. The process of counseling has to be un-interruptive since any interruption might take the aggrieved person back to where he started grieving.

Access to organs

Different countries have different systems in place to manage donor-recipient matching. There are also informal ways of choosing a recipient for a donor, which is often determined by the wishes of the deceased person. That is called targeted donation. The family of the deceased donor names a specific person to be the recipient. Over the recent past the growth of medical tourism is attributed to access to organ transplantation as one reason.


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