Berry Aneurysms - Case Study Example

? Berry Aneurysms Berry Aneurysms Arteries have thickened walls that withstand the pressure of blood pumped from the heart to the body to supply body cells with oxygen and other nutrients. However, there are cases when the artery walls are damaged because of trauma, genetically inherited conditions or even medical problems, resulting in a weakened artery wall that cannot withstand the blood pressure effectively. The force of blood pumped from the heart towards the arteries for supply to the entire body causes balloon-like swellings at the weakened areas, which is known as an aneurysm (National Institute of Health, 2011). An aneurysm usually balloons and may rupture as the forces increase, which would lead to rupturing of the arterial wall and interior bleeding, a situation that is usually fatal and leads to death. Consequently, berry aneurysms results from rupture of arterial walls in the brain with fatal consequences that may cause brain death. The condition is usually caused by defects in the tunica media muscles and lack of enough support from the brain parenchyma, which creates unprecedented stress to the arterial walls causing rupture (Liebeskind, 2013). Therefore, cerebral aneurysm occur incases were the strength of the internal elastic membrane of the adventitia and the tunica media are compromised mainly resulting from abnormal arterial structure at arterial bifurcations, which results in rupture of the vessels at these sections due to blood pressure (Liebeskind, 2013). Causes of Berry Aneurysms Various conditions may lead to berry aneurysms, which include the following: Arterial malformations, aorta coarctation, inherited polycystic kidney diseases and other vascular problems. Others include sickle cell anemia, fungal infections, Marfan syndrome, hypertension among others (Liebeskind, 2013). However, not much is known about the actual causes of the aneurysms and the formation processes leading to ballooning and rupture, but smoking that leads to vascular changes and hypertension are major some of the major predisposing factors (Jonathan et al., 2006). The main characteristic of aneurysms is reduction in the tunica media leading to arterial structural defects. When acted upon by hemodynamic forces the reduced membranes causes formation of balloon like structures at the branching parts of the arteries mainly at the lower part of the brain (Jonathan et al., 2006). Epidemiology Most berry aneurysms are small in that 60% to 80% of all cases may not rupture, meaning they pose much less danger to the patient (Connolly & Solomon, 2004). It is estimated that between 10 and 12 million adults in America have intracranial aneurysms, with berry aneurysms accounting for about 90% of all these cases (Liebeskind, 2013). Those over fifty years of age, females and cigarettes smokers are at a higher risk of the aneurysms (Vega et al., 2002). Consequently, as Vega et al noted, berry aneurysm are responsible for the highest cases of mortality and morbidity affecting about 90% of all intracranial aneurysms. However, more cases are being reported in younger patients and especially in cocaine, users or those with smaller arterial diameters (Nanda et al, 2000) Presentation Most aneurysms do not have any symptoms and they may not be reported until they rupture; hemorrhage through a fatal medical emergency remains the single most prevalent clinical presentation in most cases, accounting for about 58% of patients (Yamaura, Onno & Hirai, 2000). However, patients report acute headaches at the onset, which in some cases may also be associated with brief sessions of unconsciousness, vomiting, meningismus and nausea. These hemorrhages are also misdiagnosed as most patients have milder symptoms that indicate a warning leak before the aneurysm ruptures (Vega et al., 2002). Studies have reported rupture rates of between 1.4 to 1.9 %, though the rates are higher in aneurysms of more than 10mmm diameter. However, rupture has also been reported in cases where the aneurysms are less than 5 mm in diameter, which calls for more vigilance in detecting the aneurysms; resonance screening is advocated for anyone with a familial history, or with the above symptoms (Jonathan et al. 2006). Berry aneurysms occur in about 70 to 80 % of all subarachnoid hemorrhages (SAH) that are spontaneous. Aneurysmal SAH ins most cases has fatal consequences with about 10% of individuals with this conditions dying before reaching a medical facility as blood vessels burst in the brain (Liebeskind, 2013). Rupturing of blood vessels in the brain leads to fatal conditions that range from brain death to permanent brain damage, with about 40-49% of affected individuals dying within three months from diagnoses and 25% dying within 24 hours of diagnoses (Liebeskind, 2013). However, early surgical operations have proved to be important in lowering mortality and morbidity rates with aneurysmal ruptures having a morbidity/mortality rate of between 30 and 35% (Liebeskind, 2013). Nursing Care There is a raging debate regarding the need to care for brain dead patients, with some arguing on the positive and some on the negative of this nursing practice (Hardwig, 1991). The debate is centered in nursing ethics on the need to respect the wishes of the patient and their families. Despite arguments against extending the intensive care of a brain dead patient as being of less value (Hardwig, 1991), there is need to ensure the body organs of the patient remain in their best functional condition, in case the family decides to donate the organs of the patient (Pallard, 2011). Consequently, to ensure effective and proper functioning of the body organs of the dead-brain patient, the nurse has to maintain the organs in their best operating conditions. Below is the treatment care that the nurse has to undertake and observe before the family arrives for any further deliberation on the patient. In caring for the patient, the nurse has to rush her into the intensive care unit and administer intubation and mechanical ventilation due the decreased mental status of the patient that may have compromised the patient’s airways (O’Danniel & Nacul, 2010). In this case, the nurse has to ensure adequate ventilation and oxygenation without overlooking the cerebral and intracranial pressures (Alexander et al., 2007). After this, the nurse may use positive end-respiratory pressure in a cautious manner, though this may lead to a decrease in the blood pressure in the patient, which may cause cerebral ischemia (Meunch et al., 2005). The nurse has to consider pressure-controlled ventilation and has to undertake serious monitoring on any physiological changes that the patient shows (Hickey, 2003). The nurse may use a scanner to detect the extent of the hemorrhage and monitor oxygen saturation, blood gases and carbon dioxide saturation levels in deciding on the amount of oxygen to supplement (O’Donnell & Nacul, 2010). Moreover, the nurse has to optimize the blood pressure factors in the patient. This would entail careful and precise titration of vasoactive drugs. Most neurological injured patients develop favor, which requires the nurse to obtain the required cultures and put in place cooling mechanism, which may include use of cooling blankets or catheters to ensure the patient remains at a controlled body temperature (Kowalski et al, 2004). Another nursing care has to ensure controlled blood glucose in the patient. If needed, there has to be carefully titrated insulin that maintains the right glycemic conditions, in addition to regular and frequent blood glucose monitoring; such monitoring as well as insulin therapy has proved critical in decreased mortality and morbidity rates in such critically ill patients (Irwin & Rippe, 2008). In addition, the nurse has to ensure the right electrolyte balance to prevent any possible complications if the patient is administered with any hyperosmolar therapy, which has to be guided by the pulmonary artery pressures (Mayor & Rincon, 2005). It is important that the nurse place electrodes of an EEG near the patient’s skull, to detect any brain activity; an active brain will show variations of waves in the EEG (Irwin & Rippe, 2008), which may highlight whether the brain is ultimately or has some low degree of activities. Research has shown that a dead brain may not necessarily indicate a cessation of all brain functions, as some brain functions may be active in such people, some of which include water and temperature regulations and electrolyte balance (Truog & Robbinson, 2003). However, the patient has lost most of the vital brain functions that are critical in controlling body functions. In other words, some brain dead patients may survive for many years after with all other body functions intact, except for the brainstem and regaining consciousness due to the death of vital brain areas that control the necessary functions (Sade, 2011). There is need for the nurse to treat the patient as any other patient in the ICU, as they wait for their families to arrive. Nurses have an obligation to prevent any occurrence of nosocomial infections, pressure ulcers or deep thrombosis, and together with the nutritionist, they have to plan and administer the right nutrients to the patient (Presciutti, 2006). The nurse has in addition to monitor the output from the patient, which entails monitoring the urine output with much care; this may require insertion of a catheter to guarantee accurate monitoring (Kowalski et al, 2004). After caring for the patient, the nurse has a duty to care for the family members as they arrive in ensuring healthy psychosocial and spiritual needs are met (Presciutti, 2006). This would entail the nurse keeping the family informed about the condition of the patient, all the therapies that the nurse has undertaken to stabilize the patient and comforting them (Presciutti, 2006) Brain vs. cardiac death and decision-making Brain death patients are not necessarily dead, which means using brain death diagnosis to proclaim a patient dead may not be reliable (Sade, 2011). As discussed, many patients who have met the criteria of being brain dead have had some brain functions that continued for many years when they were in a life-supporting machine. Therefore, some brain functions may actually continue despite patient being brain dead. Brain death in this case has to be considered as case where the brain areas that coordinate body functioning have seized working (Barnat, 1999). Therefore, organ donation decisions may not be based on brain death as the patient may not be actually dead, but may live for many years after. Similarly, patients who have suffered cardiac death may not be permanently dead. In some cases, a patient may suffer cardiac death though some brain functions may still progress (Sade, 2011). Consequently, to term one as really dead, the patient has to portray an irreversible cessation of both circulatory and respiratory functions, which has to be proved as a permanently irreversible cessation (Sade, 2011). There are cases where patients were pronounced dead for about 10 to 15 minutes or even longer, and had their heart resuscitated successfully (Bernat, 1999). Consequently, for a person to be declared permanently dead such a person has to be removed from a life supporting machines, placed in the operating room for much longer for all circulation and respiratory functions to stop permanently (Bernat, 2010). At such a moment, the patient is declared dead and any decision on organ donor may be commenced. Therefore, though upon declaration of being brain dead the role of a nurse changes from life supporting to organ preserving (Pearson et al., 2001), decisions in organ donation may not be based on such declaration of brain or cardiac death as some patients have proved to live beyond such cases. Therefore, as Morton, Lloyd-Williams & Peters (2008) noted, the final decision has to be based on the family decision. In the case above, considering the family of the patient had not arrived, such decision may not be made, as the patient is still alive. The family has to make the decision between prolonging the life of the patient in the life-supporting machine though brain or cardiac dead, and removing the patient from the life-supporting machine, as according to neurologists such people are dead and any more intensive care would be on behalf of the family and not the patient (Alexander et al, 2007). Organ Donation The need for healthy organs in the US has risen over the recent few years the demand for organs has increased with a serious shortage of organ donors. Through organ transplantation in advanced technologies, it is possible to deal with life-long problems affecting the heart, lungs, liver and kidneys, which has changed and elongated the life of many in the US (Collins, 2005). Consequently, the organs of a brain dead patient have to be properly maintained to ensure they remain hemodynamic, stable and at their best functionality (Davis & Lemke, 1987). The families of a brain dead patient are approached with numerous requests to consider donating such organs at an impressive price to sustain the life of a less ill patient (Morton, Lloyd-Williams & Peters, 2008). However, the entire debate revolving around organ donation has different ramifications to the family and the critical care-nursing practitioners. In nursing, it becomes uncomfortable and difficult for a critical care nurse to divulge information about the brain death of a patient to their families. There is a huge psychological impact to nurses as they face such family members to divulge information about a brain dead patient, and suggesting a possibility of donating their organs, which makes the role of such a nurse difficult and a delicate balancing act (Murthy, 2009). Moreover, nurses are confronted with serious ethical versus professional issues in declaring a person fit for organ donation. For instance, though nurses in their training have the knowledge that extending the intensive care of a brain dead patient may not be of any value to them, such nurses are supposed to hold such patients for long in a care that is supposed to benefit the family psychologically than the patient (Hardwig, 1991). Most families in this case perceive the entire debate around organ donation as unethical, while some have a belief that a patient has to be retained in the life-supporting machine until they are dead. In some cases, this may take years, and the patient’s organs would deteriorate with time (Mortin et al., 2008). Lack of enough knowledge and social issues surrounding organ donations make many family members to perceive the practice suspiciously, with many families refusing to entertain such a discussion. Consequently, well performing organs that could have helped a patient are not utilized. This is also compounded with the ethical problem of removing a patient from a life supporting machine though brain dead when many families protest such an attempt. As a result, critical care nurses in such a case are more concerned with comforting a believed family, but do not focus on maintaining the health of the patient’s organs for donation (Kim et al., 2006). This is because, the entire organ donation practice has to revolve around the critical care nurse, who is faced with many challenges in the process; the issue becomes, ethically, morally, and emotionally sensitive (Davis & Lemke, 1987). In addition, some nurses are overwhelmed with the situation and fail to take care of the organs, which make the organs to malfunction. The process of caring for brain dead patients and the organ donation process is emotionally and physically stressful, as the nurse has to be involved in critical thinking in ensuring the organs remain viable (Calvin et al., 2007). The process is further affected by family beliefs in organ donation practices and the perception they have regarding the entire brain death occurrence. Moreover, poor palliative care that does not emphasize on caring for the patient and their family influences the organ donation process. Some nurses apply the wrong methods to engage with the patient’s family in preparing and informing them about the brain dead patient, which makes the family unresponsive to the organ donation issue due to resulting shock and poor handling by nurses (Morton, Lloyd-Williams & Peters, 2008). References Alexander, S., Gallek, M., Presciutti, M. & Zrelak, P. (2007). Care of the Patient with Aneurysmal Subarachnoid Hemorrhage. Glenview, IL: American Association of Neuroscience Nurses. Bernat, J.L. (1999). Refinements in the definition and criterion of death. In: Youngner SJ, Arnold RM, Schapiro R, editors. The Definition of Death. Baltimore: The Johns Hopkins Press Bernat, J.L. (2010). Review How the distinction between "irreversible" and "permanent" illuminates circulatory-respiratory death determination. J Med Philos. 35(3), 242-55. Calvin, A. O., Kite-Powell, D. M., & Hickey, J. V. (2007). The neuroscience ICU nurse's perceptions about end-of-life care. The Journal of Neuroscience Nursing: Journal of the American Association of Neuroscience Nurses, 39, 3, 143-50. Collins T.J. (2005) Organ and tissue donation: a survey of nurse’s knowledge and educational needs in an adult ITU. Intensive & Critical Care Nursing. 21, 226–233. Connolly, E.S. & Solomon, R.A. (2004). Management of unruptured aneurysms. In: Le Roux PD, Winn HR, Newell DW, eds. Management of cerebral aneurysms. Philadelphia: Saunders. Davis, K. M., & Lemke, D. M. (1987). Brain Death: Nursing Roles and Responsibilities. Journal of Neuroscience Nursing, 19, 1, 36-39. Hardwig, J. (1991). Treating the Brain Dead for the Benefit of the Family. The Journal of Clinical Ethics, 2(1), 53-56. Irwin, R. S., & Rippe, J. M. (2008). Irwin and Rippe's intensive care medicine. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Jonathan, L., Brisman, M.D., Song, K.J. & Newell, M.D. (2006).Cerebral Aneurysms. 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Intracranial Aneurysms: Current Evidence and Clinical Practice. American Family Physician, 66(4), 601-609. Yamaura A, Ono J, Hirai S. Clinical picture of intracranial non-traumatic dissecting aneurysm. Neuropathology, 20, 85–90. Read More