Last updated on May 18th, 2022 at 10:36 am
Subdural Hematoma Nursing Care Plans Diagnosis and Interventions
Subdural Hematoma NCLEX Review and Nursing Care Plans
A subdural hematoma (SDH) is characterized by venous collection on the brain’s surface caused by vein rupture due to traumatic or nontraumatic injury. SDH develops as blood seeps between the dura and arachnoid layers.
Since bleeding increases intracranial pressure (ICP), it impairs cerebrospinal fluid absorption, decreasing nerve cell activity and perhaps resulting in brain stem compression or tissue death.
The most common cause of SDH is head injury. Occasionally, slight head trauma can result in SDH, particularly in vulnerable populations such as children and the elderly.
The term “shaken baby syndrome” is widely used to refer to SDH caused by intentional injury. It is characterized by repeated, intense, back and forth brain movement, causing fragile veins to rupture. If SDH is left unmanaged, this can be life-threatening.
Types of Subdural Hematoma
- Acute subdural hematoma. This type is frequently associated with compression patterns in the first 12 hours following trauma. This is the most dangerous variety of SDH. It is characterized by an elevation in ICP as a result of blood pooling, loss of consciousness, or shutdown. Patients may complain of increased disorientation, nausea, and memory impairment as the condition progresses.
- Subacute subdural hematoma. This type is characterized by a gradual onset of compression syndrome. Their clinical manifestations typically develop hours or days after trauma and are frequently less severe than ASDH.
- Chronic subdural hematoma. Older persons and those taking blood thinners are more likely to suffer from this sort of SDH. As the bleeding progresses, symptoms can take weeks or even months to show. Even modest head injuries can cause chronic SDH (CSDH)
Signs and Symptoms of Subdural Hematoma
- dizziness
- confusion
- headache
- lethargy
- seizure
- slurred speech
- irritability
- nausea and vomiting
- changes in mentation
- increased head circumference in infants
- dilated pupils
- changes in motor function
- balance problems
- ear and nasal CSF drainage
- delirium
Causes of Subdural Hematoma
- Head injury. A head injury due to accidental (e.g., car crash, falls) or non-accidental trauma (e.g., high-impact sports, physical engagement, assault) is the most prevalent cause of a subdural hematoma. This is because there is an increased risk of the blood vessels within the dura being ruptured by the abrupt impact. Depending on the size and position of the ruptured vessels, SDH can result in significant bleeding or even death. It also results in delayed symptoms in cases of significantly slower bleeding (seen in CSDH).
- Alcohol Consumption. Liver disease in long-term drinkers can lead to anomalies in the coagulation system, resulting in a higher risk of bleeding.
- CSF leakage. CSF leaks are a frequent complication following traumatic brain injury (TBI). This can result in tension, tear and rupture of small vessels, increasing the chance of developing SDH.
- Medications. Anticoagulation at typical concentrations raises the risk of cerebral bleeding. The majority of intracranial hemorrhages associated with anticoagulants cause intracerebral hematoma; the majority of the remainder are SDH.
Risk Factors to Subdural Hematoma
- Aging. The brain shrinks (atrophy) in some individuals, frequently as a result of age, whereas the subdural space expands, causing blood vessels to easily rupture. Subdural hematomas can last for days or weeks in individuals aged 50 and older.
- Anticoagulants
- Blood clotting disorders. Some disorders can impair blood clotting and increase an individual’s risk of SDH.
- Repeated falls or head injuries
Diagnosis of Subdural Hematoma
- Physical Examination. Diagnosis is possible based on the signs and symptoms presented. Patients with SDH exhibit primary loss of consciousness, followed by a recurrence due to cerebral compression. When identifying SDH, it is important to consider the common prevalence of cerebral symptoms over localized symptoms; however, these associations are inconsistent. The characteristics of hemispheric symptoms may indirectly support the notion of SDH.
- Close monitoring. A change in the patient’s mental state manifested as irritation or lethargy might be detected with close monitoring.
- Risk assessment. SDH is often found in elderly people who already have a higher or lower level of mental impairment due to involutional changes in the brain. TBI is often unnoticed and is usually overlooked; hence, chronic SDH (CSDH) has a latent phase (presenting in weeks or even months) prior to clinical symptoms, making diagnosis difficult. The clinical manifestations of SDH can also mimic those of an intracranial neoformation or an ischemic stroke (IS); thus, it is important to keep this in mind when making a diagnosis.
- Linear Echo. Detects and recognizes SDH by their lateralization
- Radiographic imaging. A CT or MRI scan of the patient’s head is typically performed by the attending physician to look for evidence of bleeding and determine its location. Both CT and MRI imaging modalities can provide information about the hematoma’s size, the duration of the bleeding, and midline shifting associated with increased ICP. However, an MRI examination better reveals the location and side of SDH.
- Angiography. A special dye is used in this diagnostic procedure to show the flow of blood via arteries and veins. It entails the insertion of the catheter in the groin and routing it into the arteries of the brain.
- Blood tests. To detect and assess bleeding problems, clotting function, and other probable sources of symptoms.
Treatment for Subdural Hematoma
- Craniotomy. ASDH and its subacute variety necessitate the removal of SDH via craniotomy. It entails the removal of a portion of the skull in order to provide access to SDH and alleviate surrounding pressure.
- Burr hole trephination. This surgical method involves drilling a hole into the skull and suctioning out blood surrounding the affected area.
- Medications. SDH less than 10 mm with absent compression typically does not require surgery. Anticonvulsants may be necessary in order to control or prevent seizures from occurring.
Prevention of Subdural Hematoma
- Wear protective devices during intense activities, work, driving, or sports (e.g., headgear, seat belts)
- Take all necessary safety precautions and avoid tripping
- Alcohol cessation
Subdural Hematoma Nursing Diagnosis
Subdural Hematoma Nursing Care Plan 1
Risk for Seizures
Nursing Diagnosis: Risk for Seizures related to penetrating injury to the brain secondary to subdural hematoma.
Desired Outcome: The patient will remain seizure-free and uninjured.
| Nursing Interventions Subdural Hematoma | Rationale |
| Monitor the patient for any signs of seizure activity. | SDH due to traumatic injury increases the risk of epileptic seizures. |
| Evaluate the patient’s seizure and note its characteristics (e.g., seizure onset, length, type, and behavior) | Documenting these characteristics enables the seizure type to be identified and treatment options better targeted. Additionally, it allows activity planning and identifies potential stressors that could aggravate a seizure attack. |
| Maintain the patient’s airway during seizure activity. | Maintaining patency of the airway is critical during a seizure episode since the patient may be unable to control muscle activity. In this case, the tongue could slip back into the upper airway and cause a blockage. |
| Evaluate the patient’s behavior and monitor for any indicators of imminent seizure. | To minimize injury and prepare for a seizure episode. Allows patients to safeguard against harm and notice changes that necessitate notice and further intervention |
| Implement seizure precautions such as padding the side rails, lowering the bed’s position, ensuring a suction cup is on hand and available, and providing head protection. | These adjustments help minimize the risk of injury during a seizure or postictal state. It also helps avoid further injury in the event of an attack while participating in an exercise. |
| Assist the patient in the event of a seizure. Turn the patient’s head to the side, suction if needed, and administer oxygen as prescribed. | These precautions safeguard the patient’s airway both during and following the seizure and contribute to preventing airway blockage and decubitus ulcer formation. |
| Administer anticonvulsants as directed and monitor therapeutic levels on a routine basis. | Antiepilepsy medicines (AEDs) aid in the control of seizures. |
Subdural Hematoma Nursing Care Plan 2
Decreased Intracranial Adaptive Capacity
Nursing Diagnosis: Decreased Intracranial Adaptive Capacity related to high intracranial pressure secondary to subdural hematoma, as evidenced by pain, hyperthermia, and fluid volume excess.
Desired Outcomes:
- The patient’s cerebral tissue perfusion will be optimal, as shown by a stable ICP and level of consciousness.
- The patient’s Glasgow coma scale score, sensory and motor function, and orientation will be normal or improving.
| Nursing Interventions Subdural Hematoma | Rationale |
| Assess the patient’s neurological condition using the Glasgow Coma Scales (GCS) and note any changes in the level of consciousness. | Deterioration might be indicated by subtle changes such as increased irritation, disorientation, and restlessness. The Glasgow Coma Scale (GCS) is used to objectively assess the degree of decreased consciousness in individuals undergoing acute medical or trauma rehabilitation. Responses are measured in terms of vocal responses, eye-opening, and muscular movement. |
| Routinely monitor the patient’s vital signs. | The ICP (intracranial pressure) rises and deforms the brain as a subdural hematoma forms in the subdural space. A change in LOC and VS may be a symptom of an increased ICP. |
| Examine the ears and nostrils for fluid leaks. | SH secondary to cerebrospinal leakage may occur following traumatic brain injury, lumbar or epidural puncture. In the absence of cerebral fluid collection, there may not be any signs of ICP |
| Administer supplemental oxygen as necessary. | In order to avoid hypoxia, it is necessary to maintain an oxygen saturation level of greater than 90%. |
| Review arterial blood gas results and maintain partial pressure of oxygen between 80 and 100 mmHg. | Cerebral blood flow (CBF) is directly correlated with the partial pressure of oxygen (pO2). The measurement of tissue pO2 is a useful tool for determining the degree of oxygenation in the tissue. During acute therapy for patients with traumatic brain injury (TBI), these levels are maintained closely to avoid persistent hypoxemia and hypercarbia, resulting in increased intracranial pressure. |
Subdural Hematoma Nursing Care Plan 3
Acute Confusion
Nursing Diagnosis: Acute Confusion related to elevated intracranial pressure and bleeding secondary to subdural hematoma, as evidenced by neurosensory changes, disorientation, impaired memory recall, and difficulty concentrating.
Desired Outcomes:
- The patient will verbalize orientation to time, place, and person.
- The patient will gain independence, enhance his or her ability to reason logically, and improve his or her concentration.
| Nursing Interventions Subdural Hematoma | Rationale |
| Assess the patient’s degree of consciousness on an as-needed basis. | Patients with ASDH are more prone to develop brain edema and increased ICP. Changes in mentation (e.g., changes in LOC, confusion) may be indicative of an increase in ICP. If a child has SDH and is not suitable for operation, their neurological state should be continually monitored by healthcare professionals. |
| Continuously reorient the patient to his or her surroundings. Remind the patient about upcoming appointments, prescriptions, activities, or dates and times. | Patients with ASDH may experience physical and cognitive impairment, including difficulties with memory and communication. Repetition of information may be important for individuals with memory impairments; it also helps to eliminate confusion and promotes comprehension. Informing the patient of their current situation may assist in relieving their anxiety and restoring their cognitive abilities. |
| Address the underlying source of confusion | Patients with SDH have elevated ICP, which results in severe headaches and confusion. ICP can be alleviated by limiting activity. Support may also be required since the patient may not tell the difference between reality and illusion. |
| Introduce oneself prior to any contact or procedure. Use brief and simple language to discuss the significance of care. | This measure aims to reorient and provide patients (prone to becoming confused and disoriented) with a means of communication. Individuals with SDH may find it challenging to comprehend or accept the circumstances in their own lives. Reducing anxiety and confusion can be accomplished by clearly explaining what the healthcare provider plans to do and why. |
| Provide adequate lighting in the patient’s environment | Prevents confusion and accidents as the ability to ambulate is decreased. |
| Promote continuity of care. Maintain as much consistency as possible in terms of personnel and atmosphere. | Orientation can be aided by creating a comfortable and familiar environment. Changes in staff and care environment, on the other hand, can worsen the patient’s disorientation and confusion. This measure also helps reduce the disorienting effects of being hospitalized. |
| If possible, urge family and friends to communicate with the patient via video calls or visitations. Establish daily schedules for brief contacts and activities with the patient. | Recall and reorientation can be aided by seeing and hearing familiar faces and sounds. Moreover, providing a non-threatening environment helps the patient establish a sense of security. |
Subdural Hematoma Nursing Care Plan 4
Deficient Knowledge
Nursing Diagnosis: Deficient Knowledge related to inexperience with head trauma and its complications secondary to subdural hematoma, as evidenced by non-compliance to the treatment regimen, frequent requests for information about medication, signs, and symptoms, and statement of misconceptions.
Desired Outcome: The patient will participate in the learning process and communicate his or her comprehension of the clinical terms and implications.
| Nursing Interventions Subdural Hematoma | Rationale |
| Evaluate the patient’s cognitive abilities and receptiveness to learning. | Short-term memory loss and behavioral and emotional abnormalities may arise from brain injury-induced SDH. As a result, it may be more difficult and take longer for them to concentrate and learn new information. |
| Evaluate the patient’s understanding of the condition and treatment plan. Explain the prescribed treatment and rationale for the condition. | When it comes to trauma-induced SDH, most patients and their loved ones have no or little prior knowledge of it. The majority of the time, these kinds of injuries result from events that occurred suddenly and unexpectedly. Providing pertinent information to the patient aids in clarifying misconceptions and alleviates some of the anxiety associated with them. Additionally, it recognizes the risk of seizures, how to manage them, and the stigma associated with the illness. |
| Allow the patient to ask questions and express concerns. | Clarification and identification of issues occur when misconceptions are expressed verbally. Obtaining and taking note of their concerns enables the nurse to design a more appropriate intervention or make necessary revisions. It may also serve as a basis for the patient to develop coping mechanisms. |
| Inform patients and family members of any changes in their health state frequently. | Families and significant others have a critical role in the patient’s recovery. Additionally, they can provide information regarding the patient’s pre-injury state and any educational or medical requirements that may be necessary before discharge. |
| Review long-term implications for situations that necessitate additional treatment or follow-up interventions, such as the need for neurological, physiological, occupational, or speech therapy and continued home assistance in the future. | Rehabilitation can be a lengthy process that extends beyond hospitalization. Once the patient is discharged from the hospital, family members may be expected to assume primary responsibility for their care. If a patient with SDH has considerable mental or cognitive impairment, a referral to a rehabilitation team may be warranted. |
| Educate the patient about the prescribed medication, including its proper administration, dosage, frequency, action, side effects, and outcomes. Provide written instructions and establish a schedule. | This measure shows how to follow treatment regimens to prevent disease-related seizures and infections. There is usually no infection in these hematomas; however, the CSDH can be an infection site for bacteria. When a patient exhibits signs of infection, it is prudent to suspect an infected hematoma. |
Subdural Hematoma Nursing Care Plan 5
Acute Pain
Nursing Diagnosis: Acute Pain related to tissue trauma secondary to subdural hematoma, as evidenced by headaches, frequent pain reports, grimacing, malaise, and increased sensitivity to stimuli.
Desired Outcomes:
- The patient will demonstrate pain reduction through improved symptom control and the use of comfort measures.
- The patient will be able to perform daily tasks without experiencing pain.
| Nursing Interventions Subdural Hematoma | Rationale |
| Examine any pain-related symptoms. | When determining the pain level, the nurse must consider all of the patient’s signs and symptoms. In some instances, patients may choose to disregard their discomfort; thus, non-verbal presentations of pain may be used for assessment. |
| Monitor the patient’s vital signs for deviations from typical values. Examine claims of malaise or fatigue, headaches, sore throats, soreness, and muscle aches. | VS are typically elevated in reaction to pain via the autonomic nervous system. These manifestations are brought about by inflammation or an increase in body temperature. |
| Examine for the presence of headaches. | If SH becomes chronic (possibly due to angiogenesis, rebleeding, inflammation, defective coagulation), the hematoma enlarges and may form granulation tissue. Since the meninges are pain-sensitive, when it is stretched or inflamed, they can trigger severe headaches |
| Determine the severity and frequency of a headache. Examine the causative factors, progressive features, and duration. | This measure provides information about the presence of traumatic and nontraumatic subdural hematoma (tumor). Headache is a very common complaint among children. |
| Educate the patient and SOs on the significance of nonpharmacologic interventions (e.g., relaxation techniques, cognitive behavioral therapy, progressive muscle relaxation, guided imagery, etc.) | Tenderness, local pain, and radiculitis are common symptoms of a spinal SDH. Nonpharmacologic approaches aid patients in concentrating on or focusing less on pain and may enhance analgesic effects by reducing muscle tension. |
| Conduct a thorough examination of pain. Ascertain the area, onset, features, course, frequency, quality, and pain intensity. Take notice of nonverbal cues. | The patient is the best source of information concerning their pain. By conversing with the patient to ascertain their pain level, the nurse can devise the most efficient pain management approaches. Additionally, this measure assists in identifying the problem and initiating successful treatment and serves as a valuable tool for determining treatment efficacy. |
| Assess the patient’s desire for pain relief. | While some patients may be content with the diminution in their pain intensity, others may ask for complete symptom elimination. |
| Prevent stimulation, maintain a controlled environment conducive to sleep, and limit visitors. | Convulsions can be triggered by sensory-evoked environmental stimulation such as noise, poorly adjusted light, and startlement. Stimulation has the tendency to elevate ICP and cause cerebral irritation, hence exacerbating the pain. |
| Assist the patient with range-of-motion exercises. Eliminate or reduce vasoconstricting activities. | Increased vasoconstriction exacerbates the patient’s headache. Joint stiffness and neck pain can be minimized by ROM. |
| Administer analgesics or pain killers as prescribed. | Used to relieve pain caused by non-traumatic causes of SDH (central nervous system tumors). Reduce or eliminate pain and inhibit sympathetic nervous system activity. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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