Subarachnoid Hemorrhage Nursing Care Plans Diagnosis and Interventions
Subarachnoid Hemorrhage NCLEX Review and Nursing Care Plans
Subarachnoid hemorrhage (SAH) is a subtype of hemorrhagic stroke marked by cerebral hemorrhage in the subarachnoid space (between the fluid-filled region of the membrane layers of the pia mater and the arachnoid).
The most prevalent cause is traumatic injury and rupture of saccular-like aneurysms, which has a substantial mortality risk.
Signs and Symptoms of Subarachnoid Hemorrhage
- double vision
- difficulty speaking or problems with speech
- neck stiffness
- sudden, severe headache
- loss of consciousness
- decreased receptivity
- sudden weakness
- sleep disturbances
Causes of Subarachnoid Hemorrhage
- Traumatic injury. The most prevalent cause is head trauma. It is often referred to as traumatic SAH, involving blood leakage into the subarachnoid space. Aneurysm rupture. Aneurysms are bulges or sac-like venous pouches located in the intracranial arteries of the brain. An unstable or ruptured aneurysm between the pia mater and arachnoid, known as the subarachnoid space, can cause SAH and affect the ventricular system. Aneurysmal SAH is a subtype of stroke that can result in permanent disability or death. Among the lifestyle factors that contribute to aneurysm formation include smoking and drinking.
- Arteriovenous malformation (AVM). It is a less common complication of SAH that involves the abnormal web architecture of arteries and veins, or the weakening of both, leading to blood leaks in the subdural space.
- Vasculitis. Involves the inflammation of blood vessels, which affects the structure and integrity of vessel walls. It is frequently associated with infections, allergic reactions, and connective tissue disorders. Immune complex deposition (such as fibrin) underlies the pathophysiology of vasculitis, and in severe cases, it can progress to necrosis. Neurological dysfunction can signal the onset of the disease.
- Brain tumors. Tumor vascularization around the blood vessels in the brain can impair normal circulation and may lead to bleeding. Common complications include hemorrhagic and ischemic stroke.
- Sickle cell anemia. Patients with this condition may suffer from SAH due to arterial rupture, but in some cases, the aneurysm may not be identifiable.
- Blood clotting disorders. These increase the risk of bleeding in the brain.
Risk Factors to Subarachnoid Hemorrhage
- History of cerebral aneurysm
- Substance abuse
- Family history of polycystic kidney disease
Complications of Subarachnoid Hemorrhage
- Vasospasm. A complication of SAH in which arterial narrowing and the development of delayed cerebral ischemia (DCI) occurs. It reduces distal blood flow to the brain and is often attributed to hemoglobin breakdown, initiating the release of inflammatory mediators, which may result in thrombosis with vasospasm, arteriolar constriction, and ischemia. Severe cases of vasospasm can lead to DCI and prompt more extended hospitalizations and presentations of neurological deficits.
- Hydrocephalus. A complication of SAH manifested by obstruction of cerebrospinal fluid (CSF) pathways, malabsorption of CSF, and obstruction of arachnoid granulations. The abnormal reabsorption of the CSF by the arachnoid villi leads to an inflow of blood, which may require invasive procedures for treatment. Pathological obstruction of the CSF flow is attributed to the activation of the inflammatory process, ensuing tissue necrosis. For patients who have had previous brain trauma, the formation of blood clots within the ventricles prevents CSF flow, although CSF production and reuptake are normal in the ventricular system.
- Rebleeding. Occurs when the aneurysm ruptures within 24 hours of being sealed. It is the most significant complication resulting in poor patient outcomes and mortality, primarily caused by neurologic complications (e.g., DCI, seizures, respiratory failure).
- Brain herniation. Surgical procedures such as lumbar puncture and CSF drainage can lead to inadequate CSF perfusion or frequent leaks. This can precipitate brain herniation (also known as brain sag) as a complication since it reduces intracranial pressure (ICP).
Diagnosis of Subarachnoid Hemorrhage
- Patient History. A family history of polycystic kidney disease, aneurysms, or a previous injury may be indicative of SAH. During the medical interview, risk factors should also be asked to establish preventive treatment or management.
- o Computed tomography (CT) scan. First-in-line method to rule out the presence of an aneurysm or determine its location. However, a negative CT result necessitates a lumbar puncture as a confirmatory test since its sensitivity decreases over time.
- CT angiography. Performed after SAH diagnosis has been implemented. It demonstrates the potential cause of aneurysm or bleeding as it can visualize the architecture of surrounding vessels and intracranial aneurysms.
- Magnetic resonance imaging (MRI). A pre-imaging procedure to screen for the presence of aneurysms.
- Digital subtraction angiography. This diagnostic test is a gold standard procedure that provides accurate visualization and characterization of vascular abnormalities. It can also diagnose abnormal vascular morphology, arterial narrowing, and cerebral perfusion.
- Grading Scales. Assesses neurological function using different clinical classifications or scales (e.g., Glasgow Coma Scale, Fisher grading scale). It may involve objective measurement of motor function, consciousness level, and neurological deficits.
- Lumbar puncture. Procedure for conclusively ruling out the presence of SAH. However, visualization of an intracerebral clot during a CT scan should mandate the avoidance of LP since it can lead to death and compression of the brain stem.
Treatment of Subarachnoid Hemorrhage
- Drug therapy. Before more intrusive procedures are initiated, drugs such as loop diuretics, antihypertensives, and antiepileptics are used to control and stabilize the patient’s condition.
- Antihypertensives. The likelihood of rebleeding is highest during the first 24 hours of initial bleeding, and the sudden central sympathetic activation in aneurysmal SAH usually results in hypertension. Invasive procedures for the treatment of SAH require control and maintenance of blood pressure (BP) since it increases the risk of rebleeding. For instance, the placement of a temporary clip may require decreased BP to manipulate the artery more easily. Meanwhile, calcium channel blockers are excellent first-line antihypertensives that inhibit vasoconstriction and demonstrate neuroprotective properties against ischemia.
- Analgesics. For the treatment of pain and alleviation of anxiety.
- AVM embolization. Involves the insertion of a catheter into the femoral artery to infuse a special agent, inhibiting the blood supply of AVMs.
- Endovascular coiling. Involves the insertion of a catheter into the blood vessels to occlude aneurysms. It also aids with SAH clearance by preventing rebleeding.
The primary focus of care and management for SAH is to prevent rebleeding and aneurysms. However, hydrocephalus and vasospasms are significant complications of this condition that also necessitate management to improve prognosis. Interventions to address these challenges in the clinical setting involve the following:
- External vascular drain (EVD). Used to manage intracranial pressure and hydrocephalus following SAH. This procedure includes the aseptic installation of EVD, where a drainage tube (catheter) is inserted under the skin to drain CSF into a sterile collection system.
- Fibrinolytics. Increases the rate of CSF clearance
- Erythropoietin (EPO). Aneurysmal SAH can cause cerebral vasospasm as a complication. Management may require treatment with EPO as it reduces cerebral infarct and vasospasm.
Prevention of Subarachnoid Hemorrhage
- Early recognition of brain aneurysm and routine screening for patients with a family history
- Smoking and alcohol cessation
- Blood pressure control
- Increase hydration
- Eating a nutritious diet
- Patient education
Follow-up Care For Patients With Subarachnoid Hemorrhage
A follow-up appointment should be scheduled one month later, and CT scans are obtained to assess neurologic recovery and monitor for problems such as delayed hydrocephalus. Additional neuroimaging may be necessary, depending on the aneurysm’s configuration and appearance following discharge. Other types of ongoing rehabilitation or follow-up care for recovery assistance include:
- Physical therapy. Exercises supervised by a physical therapist intended to promote activity tolerance.
- Occupational therapy. Assists the patient in adjusting, performing a range of tasks, and maintaining fundamental skills for daily living. Through the use of splints or assistive devices, activity pacing and extremity function can be enhanced.
- Psychotherapy. A mental health practitioner assists the patient in adjusting to psychological distress. It facilitates the development of healthy coping mechanisms by teaching tolerance and acceptance tactics.
- Speech therapy. Focuses on improving communication skills
Nursing Diagnosis for Subarachnoid Hemorrhage
Nursing Care Plan for Subarachnoid Hemorrhage 1
Nursing Diagnosis: Risk For Ineffective Cerebral Tissue Perfusion related to cerebral vasospasms, secondary to subarachnoid hemorrhage.
Desired Outcome: The patient will demonstrate an improved level of consciousness, stabilized vital signs, and the absence of neurologic deficits.
|Nursing Interventions for Subarachnoid Hemorrhage
|Assess the patient’s neurologic and respiratory status (e.g., airway patency, pattern)
|Neurologic deficits of SAH consist of altered levels of consciousness, seizures, stroke-like symptoms, and confusion. Maintaining airway patency can aid with cerebral function and reduce ICP. This intervention also facilitates early recognition of deterioration and state of the patient’s cerebral perfusion and allows for prompt treatment of complications (e.g., hydrocephalus, vasospasm)
|Obtain BP measurements in both arms.
|Hypertension is often a risk factor for SAH and stroke, and fluctuations in BP increase the incidence of cardiovascular events. Moreover, it identifies the patient’s eligibility for fibrinolytic therapy to reduce the incidence of delayed ischemic neurologic deficit.
|Monitor the patient’s heart rate (HR)
|An elevated heart rate usually suggests an increased risk of cardiovascular events following SAH. Besides decreasing cerebral perfusion, SAH can also lead to neuronal death (brain damage), which can be assessed through changes in HR and dysrhythmias.
|Review the patient’s CT scan with the medical team.
|This is an initial diagnostic test used to determine the presence or absence of SAH. Moreover, this neuroimaging identifies the potential cause of ischemic or hemorrhagic stroke (e.g., intracranial mass, tissue occupying lesion).
|Slightly elevate the patient’s head using pillows to maintain a neutral position.
|Promotes venous drainage and cerebral perfusion and minimizes stress and contracture formation.
|Ensure the patient’s environment is calm and conducive to relaxation. Appropriately regulate the number of visitors, activities, and operations. Arrange each activity with consideration to the patient’s rest schedule.
|Vigorous stimulation of the senses and prolonged activity increases ICP, which is directly proportional to the risk of bleeding.
|Emphasize the need to refrain from smoking
|Smoking increases the risk of SAH and strokes. Counseling, the provision of smoking cessation information, and encouragement to quit smoking should be included in patient education.
|Administer antihypertensives as prescribed.
|Decreases the risk of bleeding, improves patient outcomes by reducing ischemic neurologic deficits, and lowers BP through vasodilation.
Nursing Care Plan for Subarachnoid Hemorrhage 2
Nursing Diagnosis: Impaired Physical Mobility related to cognitive dysfunction, secondary to subarachnoid hemorrhage, as evidenced by the incapacity for deliberate movement, reduced muscle control, and restricted range of motion.
Desired Outcome: The patient will preserve muscle strength and function of the compensating body part.
|Nursing Interventions for Subarachnoid Hemorrhage
|Determine the extent of impairment and functional abilities of the patient using a scale from 0 to 4.
|Provides information on the choice of intervention for patients with spastic paralysis.
|Evaluate for shoulder subluxation (partial separation/dislocation of shoulder joint), tenderness, and pain.
|Subluxation is a typical complication for post stroke patients caused by traumatic SAH. This intervention also identifies the cause of swelling, impaired shoulder movement, and regional pain.
|Avoid pulling the affected arm and ensure it is supported on a firm surface when the patient assumes a seated position. Using scapular motion, direct the movements of the upper extremities.
|Prevents subluxation, which occurs when the muscles are unable to support the arm’s weight. Patients in bed should be positioned slightly forward to prevent shoulder movement and allow stabilization.
|Assist or encourage the patient to frequently change positions every 2 hours, and advise him/her to use the stronger extremity for support when moving the affected side.
|This intervention reduces the risk of tissue injury and muscle atrophy resulting from poor circulation induced by reduced mobility. In order to shift from a prone to a supine position, the unaffected limb should be moved first, followed by the affected limb. Before assuming a side-lying position, placing a pillow between the limbs can provide muscle relaxation and maintain the pelvis in a neutral position. Avoid acute flexion of the upper thighs and knees to improve venous return and avoid muscle stiffness and edema.
|Stress the significance of active and passive range of motion exercises to the extremities (e.g., gluteal, quadriceps exercises, the extension of limbs and feet)
|These measures maintain and improve circulation and muscle strength. It also prevents contractures and deterioration of muscle mass
Nursing Care Plan for Subarachnoid Hemorrhage 3
Nursing Diagnosis: Impaired Verbal Communication related to neuromuscular impairment, secondary to subarachnoid hemorrhage, as evidenced by poor articulation, lack of speech modulation, inability to comprehend speech, and incapacity to identify and interpret words.
Desired Outcome: The patient will demonstrate comprehension of communication difficulties and effectively adopt alternative communication techniques.
|Nursing Interventions for Subarachnoid Hemorrhage
|Assess for mental aberration and aphasia (difficulty maintaining meaningful conversation). Employ a Boston Diagnostic Aphasia Examination (BDAE) instrument.
|Aphasia is defined by the inability to communicate verbally and comprehend speech. The patient may suffer from cerebral vasospasm (attributed to trauma-induced SAH and ischemia), leading to neurological deterioration (e.g., aphasia, changes in mentation). There are many factors to consider when developing a treatment plan for a patient with aphasia, including their level of impairment and their ability to comprehend health-related content.
|Assess for the presence of dysarthria.
|Aphasia may be complicated or exacerbated by dysarthria. It is a speech disorder where the muscles involved in articulation and speech become paralyzed, injured, or weak. This disease results in the inability to articulate, pronounce, resonate, and impose motor control.
|Monitor the patient’s ability to follow simple commands by asking them to close and open their eyes, open their mouth, raise their hand, and touch the right ear or left ear. Give them basic words and sentences to repeat.
|The inability to follow simple instructions may indicate neurodegeneration caused by SAH.
|Actively listen for inconsistencies and errors in communication and refrain from criticizing or reacting to the patient’s attempts to communicate. Maintain a calm demeanor and offer feedback whenever possible.
|Due to the loss of sensitivity and awareness to monitor verbal output, the patient may not understand why their comments are illogical or why others may not respond appropriately to their statements. This intervention also provides healthcare professionals the opportunity to clarify meaning and provide information about paraphrastic errors.
|Offer alternative modes of communication (e.g., hand gestures, use of symbols, pictures)
|Assists patients with an underlying deficit in communicating their wants and needs.
Nursing Care Plan for Subarachnoid Hemorrhage 4
Nursing Diagnosis: Acute Pain related to disease-related headaches and muscle stiffness occurring with disuse, secondary to subarachnoid hemorrhage, as evidenced by verbalized pain in the shoulders, neck, and back
Desired Outcome: The patient will notice a decline in pain, as indicated by a low pain score.
|Nursing Interventions for Subarachnoid Hemorrhage
|Have the patient rate the degree and duration of pain on a scale ranging from 0 (no pain) to 10 (extreme pain). Observe nonverbal indicators of pain, such as muscle tension, facial grimacing, diminished motor activity, restlessness, and guarding behavior.
|This assessment allows the healthcare provider to compare and quantify the degree of pain to deliver the necessary pain relief or determine if relief has been achieved.
|Examine the patient’s shoulder and neck for stiffness and pain.
|Presentations of the disease can include headaches, neck and shoulder stiffness, and pain in both. SAH is a variant of hemorrhagic stroke, which can produce pain as a complication associated with aneurysm, trauma, and ischemia. Hemiplegic shoulder pain typically manifests as a distressing complication, decreasing quality of life and impeding the patient’s executive functions and overall rehabilitation.
|Assess for the presence of central poststroke pain (CPSP)
|SAH-related stroke often causes neuropathic pain or CPSP and sensory abnormalities. CPSP is typically not treated by analgesics alone but requires a multimodal therapy that includes antidepressants and anticonvulsants.
|Assist with repositioning the patient and avoid lifting the affected arm or shoulder.
|Lifting the afflicted or flaccid arm might be painful. The use of appropriate force, pressure, or friction-reducing assistive device (especially for heavy patients) can also help turn or position the patient in bed and prevent overstretching of the affected side or shoulder.
|Encourage the patient to perform several therapeutic range-of-motion techniques.
|SAH can have a significant impact on a patient’s mobility and functioning, reducing their independence and capacity to perform specific tasks. This intervention enhances muscle strength and encourages early mobilization, improving health outcomes. Moving the hemiplegic arm may be performed by holding the humerus while remaining in external rotation to produce greater flexion. However, incorrect handling can lead to rotator cuff injury or tear.
Nursing Care Plan for Subarachnoid Hemorrhage 5
Nursing Diagnosis: Ineffective Coping related to a situational crisis, secondary to subarachnoid hemorrhage, as evidenced by an unwillingness to seek assistance, inappropriate adoption of unhealthy coping mechanisms, and incapacity to fulfill role expectations.
Desired Outcome: The patient will verbalize comprehension, acceptance, and proper use of coping mechanisms.
|Nursing Interventions for Subarachnoid Hemorrhage
|Assess the patient’s health and burden perception. Utilize a measurement tool such as the Functional Independence measure.
|Identifies health-related behavioral issues affecting the physiological and psychological autonomy required to accomplish specific tasks, such as self-care. This intervention also aids in the development of an individualized care plan and discharge guidelines.
|Discuss the losses associated with dysfunction and overall health deterioration. Evaluate the patient’s statements and take note of their ability to demonstrate a realistic assessment of the situation and understand their current health status.
|Communication enables the healthcare provider to understand the value and meaning of autonomy to the patient. Some patients may have difficulty accepting and controlling their diseases, while others may adapt more readily. It also facilitates problem-solving to provide better care, treatment, and prohibitions.
|Assess the patient’s statement of rejection and attitudes, such as referring to the affected side as dead and refusing to comply with treatment or alleviate anxiety.
|Suggests negative feelings, altered self-concept, and erosion of body image.
|Set short-term goals that are attainable to allow for repetition and provide psychological and physiological support. Include the patient’s significant others in the planning process and discuss the relevance, strengths, and deficits of the care plan.
|These measures enhance the patient’s support system through the involvement of significant others. This intervention also increases patients’ compliance to treatment and their confidence in self-care and management.
|Acknowledge fears and concerns empathetically, and maintain a realistic perspective on the situation.
|A matter-of-fact approach is an effective communication scheme that nurses use to clarify and control the situation without any power struggles. Consistency and firmness is the hallmark of this attitude. Incorporating words like weak or affected side instead of using terms like dead allows the patient to feel more hopeful and accepting of the situation.
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