The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
A. Sit with the client for a few minutes.
B. Administer an analgesic.
C. Inform the nurse manager.
D. Call the physician immediately.
Correct Answer: D. Call the physician immediately.
A headache may be an indication that an aneurysm is leaking. The nurse should notify the physician immediately. Unruptured cerebral aneurysms are asymptomatic and are therefore unable to be detected based on history and physical exam alone. However, when ruptured, they commonly present with a sudden onset, severe headache. This is classically described as a “thunderclap headache” or “worst headache of my life.” In 30% of patients, the pain is lateralized to the side of the aneurysm.
Option A: Sitting with the client is appropriate but only after the physician has been notified of the change in the client’s condition. A headache may be accompanied by a brief loss of consciousness, meningismus, or nausea and vomiting. Seizures are rare, occurring in less than 10% of patients. Sudden death may also occur in 10% to 15% of patients.
Option B: The physician will decide whether or not an administration of an analgesic is indicated. The decision to treat is multifactorial and depends on the size, location, age, and comorbidities of the patient, as well as whether or not there is a rupture. The treatment can be divided into 2 categories: surgical and endovascular.
Option C: Informing the nurse manager isn’t necessary. Interestingly, 30% to 50% of patients with major SAH report a sudden and severe headache 6 to 20 days prior. This is referred to as a “sentinel headache,” which represents a minor hemorrhage or “warning leak.”
No comments:
Post a Comment