A Case Study Presentationon

Subarachnoid Hemorrhage 

Presented by:Asma AlzahraniAsma AlshehriNada Atallah

Layla Ali AkamRawan AlmarwaniShrog Mfleh Alblwi

Jawaher AlharbiNorah AhmedKhlood alatwi

Why we choose this case ?

General Objectives:The primary concern of this Case Study Presentation is to further enhance the understanding of Subarachnoid Hemorrhage in congruence with the learned concepts of the Nursing students. 

• Specific Objectives:This case presentation seeks to provide different information about the disease being considered with the ff. specific objectives:Give a brief introduction about Subarachnoid Hemorrhage together with the clinical manifestations.Present the clients demographic and health history. Present the abnormal results of the physical assessment and compare it to the normal.Present the different laboratory test and results done to the clients with its interpretation. 5. Discuss the normal Anatomy and Physiology of Central Nervous System. 6. Explain the Pathophysiology of Subarachnoid Hemorrhage. 7. Discuss the drug study. 8. Present a Nursing Care Plan. 9. Show a Discharge Planning that the client may use upon discharge to the hospital.

I. IntroductionStatistics ( incidence and prevalence)II. Patient/Case Presentationa. Assessmentb. Demographicsc. Lifestyled. Family historye. Medical History:III. Anatomy and PhysiologyIV. Medical Management l Interventionsa. Medicationsb. Medical interventionsc. Diagnostic and laboratory testsV. Nursing InterventionsV. Conclusion & RecommendationVI. References

Outline:

A subarachnoid hemorrhage is an uncommon type of stroke caused by bleeding on the surface of the brain. It is a very serious condition and can

be fatal

SAH : fourth most frequent cerebrovascular disorder-following athero-thrombosis, embolism and

primary intra-cerebral hemorrhage.

CAUSE: Excluding head trauma, the most common cause of SAH is rupture

of vascular aneurysm.

introduction:

Subarachnoid Hemorrhage:Bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space

Definition:

• The doctors have confirmed that the main caused by the presence stretch in one of the main arteries feeding the brain, and that in 90% of cases as there are up to 5% of normal people are predisposed to occurrence of this expansion, and there are 10 people out of every 100 thousand people each year enter the stage It is called infiltration bloody phase, which precedes the bleeding or explosion, and the best treatment of these cases before entering into this phase where increasing the chances of successful surgical treatment to 99% if caught early.

10-12% die before receiving medical attention.

Incidence and Prevalence

Many risk factors have been implicated in the pathogenesis of aneurysmal SAH. They include:

arterial hypertension

atherosclerosis

alcohol use

smoking

race

gender

age

analgesic use

body mass index

drug abuse

oral contraceptive use

size of unruptured aneurysm

collagen vascular disease

and other genetic factors:

a. the incidence of aneurysmal SAH increases with age reaching a peak in the sixth decade of life.b. sex: in adults, woman are affected more than men by a ratio of 3 : 2c. aneurysmal SAH is rare in children and boys are affected more than girls by a ratio of 3 : 1d. race: African-Americans are at a higher risk than white Americans e. the critical size of aneurysms determining the risk of rupture is reported to be between 5 and 7 mm .f. 11% of patients with either a ruptured or unruptured aneurysm had a family history of cerebrovascular disease(compared with 4% of matched controls)

Subarachnoid hemorrhage can be caused by:•Bleeding from an arteriovenous malformation (AVM)•Bleeding disorder•Bleeding from a cerebral aneurysm•Head injury•Unknown cause (idiopathic)•Use of blood thinnersSubarachnoid hemorrhage caused by injury is often seen in the elderly who have fallen and hit their head. Among the young, the most common injury leading to subarachnoid hemorrhage is motor vehicle crashes.

Causes:

•Aneurysm in other blood vesselsAn aneurysm is an abnormal widening or ballooning of a portion of an artery due to weakness in the wall of the blood vessel•Fibromuscular dysplasia (FMD) and other connective tissue disorders•High blood pressure•History of polycystic kidney diseasePolycystic kidney disease is a kidney disorder passed down through families in which many cysts form in the kidneys, causing them to become enlarged.•Smoking•A strong family history of aneurysms may also increase your risk.

Risks Include:

Internal carotid artery

Posterior communicating artery

aneurysm

subarachnoid hemorrhage (SAH) is classified according to 5 grades, as follows• Grade I: Mild headache with or without meningeal irritation• Grade II: Severe headache and a nonfocal examination, with or

without mydriasis• Grade III: Mild alteration in neurologic examination, including mental

status• Grade IV: Obviously depressed level of consciousness or focal deficit• Grade V: Patient either posturing or comatose

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 symptoms:Decreased consciousness and alertnessEye discomfort in bright light (photophobia)Mood and personality changes, including confusion and irritabilityMuscle aches (especially neck pain and shoulder pain)Nausea and vomiting

Symptoms:

Symptoms continuation…

•Numbness in part of the body•Seizure•Stiff neck•Vision problems, including double vision, blind spots, or temporary vision loss in one eye

•Other symptoms that may occur with this disease:

•Eyelid drooping•Pupil size difference•Sudden stiffening of back and neck, with arching of the back (opisthotonos; not very common)

Signs include:•A physical exam may show a stiff neck•A brain and nervous system exam may show signs of decreased nerve and brain function (focal neurologic deficit)

•An eye exam may show decreased eye movements -- a sign of damage to the cranial nerves (in milder cases, no problems may be seen on an eye exam)

Exams and Tests

Other tests that may be done include:

•Cerebral angiography of blood vessels of the brain

•CT scan angiography (using contrast dye)•Transcranial Doppler ultrasound -- to look at blood flow in the arteries of the brain

•Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) (occasionally)

The goals of treatment are to:•Save life•Repair the cause of bleeding•Relieve symptoms•Prevent complications such as permanent brain damage (stroke)

treatment

• How well a patient with subarachnoid hemorrhage does depends on a number of different factors, including:

• Location and amount of bleeding• 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.

Prognosis:

•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

Possible Complications

Anatomy

Physiology

PATHOPHYSIOLOGYModifiable Risk Factors

>HPN>Smoking

>excessive intake of foods high in fats and

cholesterol

Non-modifiable Risk Factors>Advanced Age

>Gender>Heredity

Triggering Factors>Sudden extreme emotion

Arterio venous malformationCerebral aneurysm rupture

Bleeding into the brain tissue and subarachnoid space

Blood Clots in the Subarachnoid Space

Brain Compression

 Blood supply interruption

Tissue Necrosis

 Neuronal Death

Increase Intracranial Pressure

Ttotal Paralysis

 Regional ParalysisEpileptic Seizure : increase

intraocular pressure= blindness

Death

Coma

Case Description

Name: S.M Date of birth: December 14, 1984Age: 31 yearsGender: FemaleMarital status : MarriedAdmission Date: 25/02/2015Diagnosis: Subarachnoid hemorrhage

Chief complaint: Headache, hypertension and projectile vomiting .

Demographic profile:

Family History : Her father had hypertension.

Medical history:

Past Medical History:None

Present Medical History :

High blood pressure

v/s:BP:145/95 mmHg

Temp: 36.8 cPR:88beat/min

RR: 21brearh/min GENERAL APPEARANCE :

alert of patient is reduce or low ,uncooperative

Physical assessment:

1-skull

2-scalp

3-eyes

4-nose

5-throat

6-skin

7-neck region

8-lungs

12-upper and lower extremities

11-abdomen

10-breast

9-heart

Physical assessment:

Analysis Actual finding Technique used Body parts

Normal The skull is normocephalic and symmetrical to the body with prominences in frontal and occipital area ,symmetrical in

all place .

Inspection,palpation

1-Skull

Normal White ,no mass, lumps, scar ,and lesions no area of

tenderness is observed.

Inspection 2-Scalp

Analysis Actual finding Technique used Body parts

Not normal indicates

Low level of conscious

Dilated pupils and no reaction to light , she have some discharges

around the lacrimal area.

Inspection 3 -Eyes

Normal Midline symmetrical and patent , no discharge.

Inspection 4-Nose

Analysis Actual finding Technique used Body parts

Normal Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition.

Inspection 5 -Throat

Normal normal color, texture and turgor with no lesions or eruptions.

Generally uniform skin temperature.

Inspection, palpation

6 -Skin

Analysis Actual finding Technique used Body parts

Normal Symmetrical and straight ,no palpable lumps, and supple, trachea is on midline of neck , and spaces are equal on both sides.

Inspection, palpation

7-Neck region

Normal Clear to auscultation and percussion without rhonchi, wheezing or diminished breath sounds.

Auscultation, percussion

8-Lungs

Analysis Actual finding Technique used Body parts

Normal Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are

warm and well perfused .

Auscultation 9-Heart

Normal No tenderness,Masses,Nodules and discharge .

Inspection, Palpation

10-Breast

Analysis Actual finding Technique used

Body parts

Normal Positive bowel sounds. Soft, no distended, non tender. No guarding or

rebound. No masses, uniform color ,rounded symmetrical

Inspection, Auscultation,Percussion,

Palpation

11-Abdomen

Normal Both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity.

Inspection 12-Upper and lower extremities

Normal Values: Result:132-146mmol/L 124 (Sodium: (1

3.6-5.0mmol/L 4.2 Potassium:

98-107mmol/L 92 (Chloride:(2

22-29mmol/L 25 Enzymatic bicarbonate:

Hyponatremia

Hypochloremia

1

2

electrolytes

Normal Values : Result:4.0-11.0 10^3/Ml 14.51 (WBC (1

3.8-4.8 10^6/Ml 4.40 RBC

12.0-16.0g/dl 12.9 Hemoglobin

36.0-45.0% 37.5 HCT 82.7-89.4 85.2 MCV

31.5-34.5g/dl 34.4 MCHC

leukocytosis 1

hematology

Normal Values: Result: 0.74-0.99mmol/L 0.79 Magnesium

0.81-1.58mmol/L 1.01 Phosphate

2.12-2.52mmol/L 2.33 Calcium

Miscellaneous Chemistry

Normal Values: Result:2.5-6.4mmol/L 1.66 Urea nitrogen

53-155mmol/L 37 Creatinine

Renal Function Test

Medical Management

•Grade I or II SAH:•In patients with a suspected grade I or II subarachnoid hemorrhage (SAH), emergency department (ED) care essentially is limited to diagnosis and supportive therapy.

•Early identification of sentinel headaches is key to reduced mortality and morbidity rates. Use sedation judiciously.

•Secure intravenous access, and closely monitor the patient's neurologic status

Emergency Department Care

• Grade III, IV, or V SAH:• In patients with a grade III, IV, or V subarachnoid hemorrhage (SAH) (ie,

altered neurologic examination), ED care is more extensive.• Address the patient's airway, breathing, and circulatory status (ABCs). In

addition, reliable neurologic examinations before and after initial treatment are critically important to optimizing management and to deciding on the appropriate neurosurgical intervention.

• Intubation• Endotracheal (ET) intubation of obtunded patients protects them from

aspiration caused by depressed airway protective reflexes. Also intubate to hyperventilate patients with signs of herniation.

• Precautions• Avoid excessive or inadequate hyperventilation. Target the partial

pressure of carbon dioxide (pCO2) at 30-35 mm Hg to reduce elevated ICP. Excessive hyperventilation may be harmful to areas of vasospasm.

• Avoid excessive sedation. It makes serial neurologic exams more difficult and has been reported to increase ICP directly. However, avoid any increase in ICP due to excessive agitation from pain and discomfort.

Surgery may be done to:•Neurosurgery 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 spasms•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

Adjunctive Therapies and Measures• Keep the patient's core body temperature at 37.2°C• Consider antiemetics for nausea or vomiting.• Elevate the head of the bed 30° to facilitate

intracranial venous drainage. Emergent ventricular drainage by the neurosurgeon may be necessary.

• Maintain the patient's serum glucose level at 80-120 mg/dL; use sliding or continuous infusion of insulin if necessary.

• Fluids and hydration• Do not over hydrate patients because of the risks of

hydrocephalus.• Patients with subarachnoid hemorrhage (SAH) may

also have hyponatremia from cerebral salt wasting.

Seizure prevention•Prophylactic use of anticonvulsants does not acutely prevent seizures after subarachnoid hemorrhage (SAH), but use anticonvulsants in patients who have had a seizure or if local practice dictates routine use.

•Begin with anticonvulsants that do not change the level of consciousness (ie,phenytoin first; use barbiturates or benzodiazepines only to stop active seizures).

• Diagnosing a subarachnoid hemorrhage • If it's thought that patient have had a subarachnoid

hemorrhage, patient will need to have a brain scan in hospital as soon as possible.

• A computed tomography (CT) scan is used to check for signs of a brain hemorrhage. This involves taking a series of X-rays, which a computer then makes into a detailed 3D image.

• In some cases, a subarachnoid hemorrhage is not picked up by a CT scan. If a CT scan is negative, but your symptoms strongly suggest you have had a hemorrhage, a test called a lumbar puncture will usually be carried out.

• A lumbar puncture involves a needle being inserted into the lower part of the spine, so that a sample of the fluid that surrounds and supports the brain and spinal cord (cerebrospinal fluid) can be taken out. It will then be analysed for signs of bleeding.

Other tests include:•Magnetic Resonance Imaging (MRI) scan, using radiowaves to get clear detailed images of the brain

•Cerebral Angiography—an exam that uses a X-ray and injected dye to detect blood flow in the brain

•Transcranial ultrasound to detect blood flow in the arteries within the brain

In our case : •Investigation : •CBC analysis •Urine analysis •Pt ,PTT

•Diagnostic procedures :•ECG•CT brain •MRI • chest x ray

Special order :

•Elevate the head of the bed 30° .•Normal saline 70ml \hour•Regular soft diet •Keep oxygen saturation between 95 to 98 % .

Special order:

DRUG STUDY

NURSING RESPONSIBILITIES SIDE EFFECTS INDICATIONS/ CONTRAINDICATION

DOSAGE/ ROUTE/

FREQUENCY

DRUG NAME

Do not exceed 4gm/24hr. in adults Do not take for 10 days for pain in adults, or more than 3 days for fever in adults.

Extended-Release tablets are not to be chewed.Monitor CBC, liver and renal functions.Assess for fecal occult blood and nephritis.

Avoid using OTC drugs with Acetaminophen.

Take with food or milk to minimize GI upset.

Report N&V. cyanosis, shortness of breath and abdominal pain as these are signs of toxicity.

Report paleness, weakness and heart beat skipsReport abdominal pain, jaundice, dark urine, itchiness or clay-colored stools.

Phenacetin may cause urine to become dark brown or wine-colored.

Report pain that persists for more than 3-5 daysAvoid alcohol.

This drug is not for regular use with any form of liver disease.

Minimal GI upset.MethemoglobinemiaHemolytic AnemiaNeutropeniaThrombocytopeniaPancytopeniaLeukopeniaUrticariaCNS stimulationHypoglycemic comaJaundiceGlissitisDrowsinessLiver Damage.

-INDICATIONSAnalgesic-antipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diathesesCONTRAINDICATION

Renal InsufficiencyAnemiaSpecial Concerns:

Liver toxicity (hepatocyte necrosis)

ROUTE IVDOSAGE60mgFREQUENCYQ6h

GENERICNAME:

Paracetamol

BRANDNAMEAcetaminophen

CLASSIFICATIONAnalgesics (nonopioid) -Muscle Relaxants -Anti-pyretic

NURSING RESPONSIBILITIES SIDE EFFECTS INDICATIONS/ CONTRAINDICATION

DOSAGE/ ROUTE/

FREQUENCY

DRUG NAME

Assess patient for pain and limitation of movement; note type, location, and intensity prior to and at the peak following administration. Administer after meals or with food or an antacid to minimize gastric irritation. Instruct patient to take with a full glass of water and to remain in an upright position for 15-30 min after administration. Teach patient to report blurred vision, ringing of ears that may indicate toxicity. Advise patient to report change in urine pattern, edema, increased pain in joints, fever, blood in urine that may indicate nephrotoxicity

Gastrointestinal - Abdominal discomfort, heartburn, abdominal cramps, nausea, vomiting and diarrhea. Central Nervous System - Headache, dizziness and drowsiness.

Genitourinary - Blood in urine, decrease in urination and kidney

failure .

-INDICATIONSprescribed for painful

Relieve pain after surgical interventioninflammatory conditions

CONTRAINDICATION to patients with gastrointestinal bleeding, ulcer, severe kidney, liver disease, bleeding disorders, and hypersensitivity

ROUTEIV

DOSAGE40MGFREQUENCYOD

GENERICNAME:

Nimesulide

BRANDNAMENexen

CLASSIFICATIONAnalgesic, antipyretic

Non steroidal Anti-Inflammatory AgentsNSAID

NURSING RESPONSIBILITIES SIDE EFFECTS INDICATIONS/ CONTRAINDICATION

DOSAGE/ ROUTE/

FREQUENCY

DRUG NAME

Assess condition before therapy and reassess regularly thereafter to monitor

drug’s effectiveness>Monitor pt for any adverse GI

reactions,nausea,vomiting,diarrhea>,Assess for adverse reactions>

for pt. with hepatic encephalopathy :regularly assess

mental condition>monitor I & O>

monitor for Inc.glucose level in diabetic pts

Abdominal discomfort associated with Flatulence and intestinal cramps.Nausea,vomiting,

diarrhea on prolonged use.

-INDICATIONSPrevention and 

treatment of portal-systemic encephalopathy (PSE), including stages of hepatic precoma and comaCONTRAINDICATION toPatients who require a low galactose diet

ROUTEPo

DOSAGE15 ML

FREQUENCYOD

GENERICNAME:

Lactulose

BRANDNAMECephulac

CLASSIFICATIONhyperosmotic laxative

Nursing managment

evaluation intervention palnning Nursing diagnosis scientific explanation

assessment

Evaluate patient pain scale if it is reduced or not.

-Assess for signs and symptoms of headache(statements of same, restlessness, irritability, grimacing, rubbing head, avoidance of bright lights and noises, reluctance to move)Rational:to assess whether the client felt the pain of acute or chronic -Assess patient's perception of the severity of the headache using a pain intensity rating scale.Rational:It is important to help patients express as factually as possible - Assess the patient's pain pattern (e.g. location, quality, onset, duration, precipitating factors, aggravating factors, alleviating factors).Rational:Different etiologic factors respond better to different therapies

after 3hrs of nursing intervention the patient will reduce of pain as evidenced by:1. verbalization of the same2. relaxed facial expression and body positioning

Acute pain related to stretching or compression of cerebral vessels and tissue associated with increased intracranial pressure

leakage of blood from an aneurysm in the brain

accumulation of blood between the arachnoid and pia mater

elevation of the pressure in the cranium

Subjective:I have a severe headache” as verbalized by patientObjective:Behavior: showing symptoms pain.Changes in the ability to perform daily activities.pain scale:5of 10 .

First:

intervention

-Assess the degree of making a false step in person from the patient, such as isolating themselves,Note the influence of pain such as: loss of interest in life, decreased activity, weight lossPosition patient in semi fowler position.Rational:Pain that has been chronic and long-standing may have devastating emotional effects on the patient and these emotional complications may make effective treatment of the pain more difficult. -Encourage patient to rest in bed.Rational:to reduce the intensity of pain.-Provide quite and calm environment. -Teach relaxation and deep breathing techniquesRational:to reduce tension and create a feeling more comfortable.-Give the hot moist compress / dry on the head, neck, arms as needed. Rational:Hot moist compresses have a penetrating effect. The warmth rushes blood to the affected area to promote healingMassage the head / neck / arm if the patient can tolerate the touch.Rational:to decreases muscle tension and can promote comfort-Use the techniques of therapeutic touch, visualization, and stress reduction and relaxation techniques to another.Rational:Techniques used to bring about a state of physical and mental awareness and tranquility. The goal of these techniques is to reduce tensions, subsequently reducing pain.-Instruct the patient to use a positive statement "I am cured, I'm relaxing, I love this life“, Instruct the patient to be aware of the external-internal dialogue and say "stop" or "delay" if it comes up negative thoughts. Collaboration for providing analgesic as doctor order..Rational:The use of a mental picture or an imagined event that involves use of the five senses to distract oneself from painful stimuli.

evaluation

intervention palnning Nursing diagnosis

scientific explanation

assessment

After 2 hrCerebral function improved; neurological deficits stabilized.

Assess factors related to individual situation for decreased cerebral perfusion and potential for increased ICP.Rationale: Assessment will determine and influence the choice of interventions. Deterioration in neurological signs or failure to improve after initial insult may reflect decreased intracranial adaptive capacity requiring patient to be transferred to critical area for monitoring of ICP, other therapies.

After 2 hr patient will able to Maintain improved level of consciousness, cognition, and sensory function.

Ineffective Cerebral Tissue Perfusion related to hemorrhage

the inadequacy of blood flow through the cerebral vasculature to maintain brain function

Subjective:“Why am I here, what happened to me "as verbalized by patient

Objective:-Altered level of

consciousness ;-Changes in

sensory responses

Second:

intervention

-Closely assess and monitor neurological status frequently and compare with baseline.Rationale: Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of impending thrombotic CVA.-Evaluate pupils, noting size, shape, equality, light reactivity.Rationale: Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined -Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.Rationale: Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.Assess higher functions, including speech, if patient is alert.Rationale: Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration or increased ICP.-Position with head slightly elevated and in neutral position.Rationale: Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing interventions and provide rest periods between care activities. Limit duration of procedures.Rationale Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhageAssess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity Rationale: Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased ICP or cerebral injury, requiring further evaluation and intervention.Administer supplemental oxygen as indicated.Rationale: Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema formation.

evaluation

intervention Planning Nursing intervention assessment

After 1 hourPatient was able acceptance of self in situation and awareness of own coping abilities

Assess extent of altered perception and related degree of disability. Determine Functional Independence Measure score.

Rationale: Determination of individual factors aids in developing plan of care/choice of interventions and discharge expectations.

Determine outside stressors: family, work, future healthcare needs.

Rationale: Helps identify specific needs, provides opportunity to offer information and begin problem-solving. Consideration of social factors, in addition to functional status, is important in determining appropriate discharge destination.

After 1 hourPatient Verbalize acceptance of self in situation and Verbalize awareness of own coping abilities.

Ineffective Coping related to

vulnerability, cognitive perceptual changes.

Subjective: Inability to make decisions

Objective:Inability to cope/difficulty asking for help

Third:

evaluation intervention planning Nursing intervention assessment

Encourage patient to express feelings, including hostility or anger, denial , depression, sense of disconnectedness

Rationale: Demonstrates acceptance of patient in recognizing and beginning to deal with these feelings.

Identify previous methods of dealing with life problems. Determine presence of support systems.

Rationale: Provides opportunity to use behaviors previously effective, build on past successes, and mobilize resources.

Monitor for sleep disturbance, increased difficulty concentrating, statements of inability to cope, lethargy, withdrawal.

Rationale: May indicate onset of depression, which may require further evaluation and intervention

evaluation intervention planning Nursing intervention assessment

.

Refer for neuropsychological evaluation and/or counseling if indicated.

Rationale: May facilitate adaptation to role changes that are necessary for a sense of feeling/being a productive person.

Discharge Plan• Activity You will need to have someone with you for the next several days to

watch for worsening of symptoms (see below) and to allow you to rest. Start with light activity around the house for the first 3 days you are

home. Gradually increase your activity starting with short walks 1-2 times

per day. Avoid contact sports, skating, bike riding, or other such activities for 6

weeks. Encourage pt to do passive range of motion • Nutrition :Instruct the relative to feed pt on time with proper food low in NaLow in cholesterol low in fat and give citrus fruits ,moderate in fluid

intake and increase fiber diet to improve health. Ffollow the diet prescribed by the doctor.

Recommendations:

Medications Take your medications as prescribed and

gradually decrease pain medications as your pain improves.

Instruct pt and their relative to follow medication regimen

Educate and instruct the patient and her family to monitor BP and PR before giving medication

Follow-up Follow up with your primary care physician for all

medical issues.

Call your doctor or return to the emergency room if you experience any of the following symptoms:

. • Clear or bloody drainage from your nose or ears • Worsening headache • Changes in vision or differently sized pupils • Seizure activity or jerking / twitching of the face, arms, or legs • Sleepiness or difficulty waking up • Memory loss • Irritability • Nausea or vomiting that won’t stop • Confusion or difficulty talking • A fever above 100 degrees F • Arm, leg, or facial weakness • Difficulty walking, loss of balance, and dizziness • Stiff neck

• Subarachnoid hemorrhage (SAH) is a pathologic condition

that exists when blood enters the subarachnoid space

• The most common cause of SAH is trauma

• The most common cause of spontaneous SAH is an

aneurysmal bleed (65-80%)

• •Sudden explosive headache may be the only symptom in

a third of patients.

•Of patients who present with a sudden explosive headache

as the only symptoms, around 10% have SAH

Conclusion:

References:

• Naggara ON, White PM, Guilbert F, et al. Endovascular treatment of intracranial unruptured aneurysms: systematic review and meta-analysis of the literature on safety and efficacy. Radiology. 2010;256:887-897.

• Reinhardt MR. Subarachnoid hemorrhoid. J Emerg Nurs. 2010;36:327-329.

• Tateshima S, Duckwiler G. Vascular diseases of the nervous system: intracranial aneurysms and subarachnoid hemorrhage. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC. Bradley’s Neurology in Clinical Practice. 6th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 51C.

• Zivin J. Hemorrhagic cerebrovascular disease. In: Goldman L, Schafer AI, eds. Goldman's Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 415.

• http://www.strokecenter.org/professionals/brain-anatomy/blood-vessels-of-the-brain/

THANKYOU