Subarachnoid hemorrhage (SAH) is a life-threatening condition characterized by bleeding into the subarachnoid space between the brain and surrounding tissues. This nursing diagnosis focuses on identifying symptoms, preventing complications, and providing critical care to patients with SAH.
Causes (Related to)
Subarachnoid hemorrhage can occur due to various factors that affect cerebral circulation and vascular integrity:
- Ruptured cerebral aneurysm (most common cause)
- Arteriovenous malformations (AVMs)
- Head trauma
- Risk factors such as:
- Hypertension
- Smoking
- Family history
- Age (40-65 years)
- Female gender
- Contributing conditions including:
- Connective tissue disorders
- Polycystic kidney disease
- Excessive alcohol consumption
- Cocaine use
Signs and Symptoms (As evidenced by)
SAH presents with distinctive signs and symptoms that nurses must recognize for immediate intervention.
Subjective: (Patient reports)
- Sudden, severe “thunderclap” headache
- Neck pain or stiffness
- Photophobia
- Nausea
- Vision changes
- Confusion
- Dizziness
Objective: (Nurse assesses)
- Altered level of consciousness
- Positive Kernig’s and Brudzinski’s signs
- Focal neurological deficits
- Elevated blood pressure
- Irregular pupillary response
- Vomiting
- Seizure activity
- Abnormal posturing
- Meningeal irritation signs
Expected Outcomes
The following outcomes indicate the successful management of SAH:
- The patient will maintain a stable neurological status
- The patient will demonstrate an improved level of consciousness
- The patient will maintain adequate cerebral perfusion
- The patient will avoid complications (vasospasm, rebleeding)
- The patient will show improved mobility and function
- The patient will verbalize understanding of the condition and management
- The patient will participate in a rehabilitation program
Nursing Assessment
Monitor Neurological Status
- Perform Glasgow Coma Scale assessment
- Check pupillary response
- Assess motor and sensory function
- Monitor mental status
- Document changes in consciousness
Assess Vital Signs
- Monitor blood pressure frequently
- Check heart rate and rhythm
- Assess respiratory pattern
- Monitor temperature
- Record neurological vital signs
Evaluate Pain Status
- Assess headache intensity
- Monitor pain patterns
- Document pain characteristics
- Evaluate response to interventions
- Track analgesic effectiveness
Monitor for Complications
- Check for signs of vasospasm
- Assess for hydrocephalus
- Monitor for seizure activity
- Watch for signs of rebleeding
- Evaluate for neurogenic pulmonary edema
Review Risk Factors
- Document medical history
- Assess lifestyle factors
- Check family history
- Review medication history
- Monitor comorbidities
Nursing Care Plans
Nursing Care Plan 1: Decreased Intracranial Adaptive Capacity
Nursing Diagnosis Statement:
Decreased intracranial adaptive capacity related to subarachnoid hemorrhage as evidenced by increased intracranial pressure and altered level of consciousness.
Related Factors:
- Cerebral bleeding
- Increased intracranial pressure
- Cerebral edema
- Altered cerebral blood flow
Nursing Interventions and Rationales:
- Monitor neurological status q1-2h
Rationale: Allows early detection of neurological deterioration - Maintain head elevation at 30 degrees
Rationale: Promotes venous drainage and reduces ICP - Minimize environmental stimuli
Rationale: Reduces metabolic demands on brain tissue
Desired Outcomes:
- The patient will maintain stable ICP readings
- The patient will demonstrate an improved level of consciousness
- The patient will show stable neurological signs
Nursing Care Plan 2: Acute Pain
Nursing Diagnosis Statement:
Acute pain related to increased intracranial pressure as evidenced by severe headache and neck pain.
Related Factors:
- Meningeal irritation
- Increased intracranial pressure
- Cerebral vasospasm
- Inflammation
Nursing Interventions and Rationales:
- Administer prescribed pain medications
Rationale: Controls pain while monitoring neurological status - Implement environmental modifications
Rationale: Reduces stimuli that may exacerbate pain - Monitor pain patterns and characteristics
Rationale: Helps evaluate treatment effectiveness
Desired Outcomes:
- The patient will report decreased pain intensity
- The patient will demonstrate improved comfort
- The patient will maintain optimal neurological status
Nursing Care Plan 3: Risk for Ineffective Cerebral Tissue Perfusion
Nursing Diagnosis Statement:
Risk for ineffective cerebral tissue perfusion related to vasospasm and increased intracranial pressure.
Related Factors:
- Cerebral vasospasm
- Altered cerebral autoregulation
- Hypovolemia
- Blood pressure fluctuations
Nursing Interventions and Rationales:
- Monitor cerebral perfusion pressure
Rationale: Ensures adequate brain tissue oxygenation - Maintain euvolemia
Rationale: Prevents decreased cerebral blood flow - Monitor for signs of vasospasm
Rationale: Enables early intervention
Desired Outcomes:
- The patient will maintain adequate cerebral perfusion
- The patient will show no signs of neurological deterioration
- The patient will maintain stable vital signs
Nursing Care Plan 4: Anxiety
Nursing Diagnosis Statement:
Anxiety related to acute illness and uncertain prognosis as evidenced by expressed concerns and physiological responses.
Related Factors:
- Life-threatening condition
- Uncertain prognosis
- Hospitalization
- Fear of death or disability
Nursing Interventions and Rationales:
- Provide clear, concise information
Rationale: Reduces fear of the unknown - Maintain calm environment
Rationale: Minimizes anxiety triggers - Include family in care planning
Rationale: Provides a support system
Desired Outcomes:
- The patient will demonstrate reduced anxiety
- The patient will use effective coping strategies
- The patient will verbalize understanding of the condition
Nursing Care Plan 5: Risk for Falls
Nursing Diagnosis Statement:
Risk for falls related to neurological deficits and altered mobility.
Related Factors:
- Altered consciousness
- Motor deficits
- Visual disturbances
- Balance impairment
Nursing Interventions and Rationales:
- Implement fall precautions
Rationale: Prevents injury - Assist with mobility
Rationale: Ensures safe movement - Maintain bed in a low position
Rationale: Minimizes injury risk
Desired Outcomes:
- The patient will remain free from falls
- The patient will demonstrate safe mobility practices
- The patient will participate in safety measures
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Lee K, Choi HA, Edwards N, Chang T, Sladen RN. Perioperative critical care management for patients with aneurysmal subarachnoid hemorrhage. Korean J Anesthesiol. 2014 Aug;67(2):77-84. doi: 10.4097/kjae.2014.67.2.77. Epub 2014 Aug 26. PMID: 25237442; PMCID: PMC4166392.
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- Rinkel GJ, Klijn CJ. Prevention and treatment of medical and neurological complications in patients with aneurysmal subarachnoid haemorrhage. Pract Neurol. 2009 Aug;9(4):195-209. doi: 10.1136/jnnp.2009.182444. PMID: 19608769.
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