PREPARED BY: TONI P TENI STAFF NURSE, ICU DEPARTMENT

CASE PRESENTATION ON

SUBARACHNOID HEMORRHAGE

CASE NO: 193525 NAME: XYZ AGE: 24YRS SEX: MALE DIAGNOSIS:H/O FALL WITH HEAD

INJURY, SAH,CRANIOTOMY DONE FOR LEFT SIDE SAH,#C2,#T9-T12-L1,# RIGHT ZYGOMATIC ARCH.

DOA: 01/01/2013

I. DEMOGRAPHIC DATA

An assessment is conducted starting at the head and proceeding in a systemic and efficient downward (head to toe). The procedure varies according to age, belief, religion of the subject, the severity of illness of the patient, the location of the examination, the priorities and procedures.

PHYSICAL ASSESSMENT

The patient is 24 years of age, MALE, approximately weighs 50kg.

He is unconscious on ventilator support. GCS 3/15, with the following Vital Signs:

BP= 120/70 mmHg PR=110 bpm RR= 20 mts Temp=37.4 C⁰ SPO²= 98%

General Assessment:

Warm. Laceration on the right ear and left knee. Redness on the right hand.

Head: Scalp swelling in right parietal area. No palpable masses and lesions.

Skin:

Patient is unconscious. On fully sedation. On ventilator

Eyes: Redness on the right eyes. Pupils – R-1MM reactive. L-5MM fixed and dilated.

Ears: No unusual discharges noted.

Level of Consciousness and Orientation:

No unusual nasal discharges.

Neck and Throat:No palpable lymph nodes.

No masses and lesions seen.

Chest and Lungs:B/L good air entry.

Clear breath sounds.

Nose:

Tachycardia

Abdomen:Soft abdomen

USG report:

Minimal free fluid in the abdomen

Genitals:Minimal pubic hair.

No usual bleeding

Heart:

Extremities: Pulse full and equal No lesions noted

PAST MEDICAL HISTORY 24YRS Yemeni patient H/O fall down from

height, admitted the patient in ER via RED CROSS ambulance. On the time of admission in ER patient was unconscious and agitated, GCS 3/15, patient was intubated and sedated, after all investigation (BLOOD+CT) patient shifted to ICU.

III. PATIENT HISTORY

Received the patient from ER , patient was intubated and sedated, keep the patient in ventilator IPPV mode FIO2-100%,RATE-18,TV-450,PEEP-5,patient is on Propofol,Morphin, Nimbex and Midazolam infusion fully sedation. CT Scan of Brain shows subarachnoid hemorrhage along left fronto-parieto-temporal areas diffuse brain edema evidenced by sulcal and cisternal effacement associated with midline shift to right side 15 mm and compression of the lateral and third ventricles. Patient prepared for urgent craniotomy, consent taken, 4 PRBC arranged, PAC done, head shave done and patient shifted to OT.

PRESENT MEDICAL HISTORY

After craniotomy with evacuation of SAH received the patient in ICU. Patient is on ventilator and fully sedated. After surgery pupils left 4MM nonreactive and right 2MM reactive. Maxillofacial, ENT, Opthalmo consultation done. Cervical collar and DVT pump applied. After all management patient was improved and patient was extubated and fully conscious, pupils B/L 2MM reactive. Patient was shifted to surgery ward.

DRUG DOSE

ROUTE

ACTION

INJ:AUGMENTIN 1.2GM I/V ANTIBIOTIC (GENERATION-2)

INJ:CEFTRIAXONE

2GM I/V ANTIBIOTIC (GENERATION-2)

INJ:RISEK 40MG I/V H2RECEPTER

INJ:MANNITOL 100ML I/V DIURATICS

INJ:PHENYTOIN 100MG I/V ANTICONVELCENT

IV. MEDICATION

TEST PATIENT VALUE NORMAL VALUE

UREA 6.1 1.8 TO 8.3

CREATININE 63.5 58 TO 110

SODIUM 140 135 TO 150

POTASSIUM 3.3 3.5 TO 5.0

MAGNESIUM 0.75 0.65 TO 1

WBC 13.72 4.23 TO 9.07

HGB 12 13.7 TO 17.5

PLT 197 163 TO 337

PT 13.6 10.9 TO 16.3 SEC

INR 1.00 2 TO 4

APTT 34.2 27 TO 39 SEC

CALCIUM 2.27 2.20 TO 2.55

V. INVESTIGATION

There is subarachnoid hemorrhage along left fronto-parieto-temporal areas.diffuse brain edema evidenced by sulcal and cisternal effacement associated with midline shift to right side 15 mm and compression of the lateral and third ventricles.

CT Chest with IV Contrast: Suspected fracture is seen in the left scapula

CT Lumbosacral Spine: Compression fracture is seen in the body of L1

Non Contrast CT Brain:

Fracture is seen in the right lamina of T9 Compression fracture is seen in the bodies of T9

and T12 Fracture is seen in both transverse processes of T9

CT Cervical Spine: Normal Study

USG Abdomen: Minimal free fluid in the abdomen

CT Thoracic Spine:

In subarachnoid hemorrhage (SAH), ruptured vessels lead to bleeding into the subarachnoid space. The blood mixes with the cerebrospinal fluid, and can be irritating to the meninges. Blood quickly fills the area immediately surrounding the brain and spinal cord (called the subarachnoid space). This space contains the cerebrospinal fluid. The fluid cushions and bathes the brain and spinal cord.

VII. INTRODUCTION

Subarachnoid hemorrhage: A bleeding into the subarachnoid, the space between the arachnoid and the pia mater, the innermost membrane surrounding the central nervous system. Subarachnoid hemorrhage typically occurs when an artery breaks open in the brain, such as from a ruptured aneurysm.

Subarachnoid hemorrhages are classified into two general categories: traumatic and spontaneous.

VIII. DEFINITION

IX. ILLUSTRATION

X. ANATOMY AND PHYSIOLOGY

The meninges is the system of membranes which envelops the central nervous system. In mammals, the meninges consist of three layers: the dura mater, the arachnoid mater, and the pia mater. The primary function of the meninges and of the cerebrospinal fluid is to protect the central nervous system.

Dura mater: The dura mater (also rarely called meninx fibrosa) is a

thick, durable membrane, closest to the skull. It consists of two layers, the periosteal layer which lies closest to the calvaria (skull), and the inner meningeal layer which lies closer to the brain. It contains larger blood vessels which split into the capillaries in the pia mater. The dura mater surrounds and supports the large venous channels (dural sinuses) carrying blood from the brain toward the heart.

Arachnoid mater: The middle element of the meninges is the

arachnoid mater, so named because of its spider web-like appearance. It provides a cushioning effect for the central nervous system. The arachnoid mater is a thin, transparent membrane. It is composed of fibrous tissue and, like the pia mater, is covered by flat cells also thought to be impermeable to fluid.

The arachnoid and pia mater are sometimes together called the leptomeninges.

The pia mater [is a very delicate membrane. It is the meningeal envelope which firmly adheres to the surface of the brain and spinal cord. It is a very thin membrane composed of fibrous tissue covered on its outer surface by a sheet of flat cells thought to be impermeable to fluid. The pia mater is pierced by blood vessels which travel to the brain and spinal cord, and its capillaries are responsible for nourishing the brain.

Spaces: The subarachnoid space is the space which normally exists between the

arachnoid and the pia mater, which is filled with cerebrospinal fluid. Normally, the dura mater is attached to the skull, or to the bones of the

vertebral canal in the spinal cord. The arachnoid is attached to the dura mater, while the pia mater is attached to the central nervous system tissue. When the dura mater and the arachnoid separate through injury or illness, the space between them is the subdural space.

• Pia mater:

• Aneurysm: a balloon-like bulge or weakening of an artery wall that ruptures, releasing blood into the subarachnoid space around the brain.

• Arteriovenous malformation (AVM): an abnormal tangle of arteries and veins with no capillaries in between. The weakened blood vessels can rupture and bleed

• About 1% of people have a congenital defect which affects their blood vessels in the brain. Some blood vessels have weak and thin walls.

• There is a greater risk of an aneurysm rupturing if you smoke, drink alcohol regularly in large quantities, and suffer from hypertension (high blood pressure) and do not control it properly.

• A severe head injury can also be a cause of a subarachnoid hemorrhage

• Traumatic brain injury. Traumatic SAH usually occurs near the site of a skull fracture or intracerebral contusion.

XI. ETIOLOGY

VI. PATHOPHYSIOLOGY

The main symptom is a severe headache that starts Stiff neck Nausea Vomiting Slurred speech Depression, confusion, delirium, and possibly apathy Impaired consciousness, sometimes total loss of consciousness Seizures (in about 1 in every 14 cases) Sometimes there may be intraocular hemorrhage (bleeding into the eyeball) Some patients may find it hard to lift an eyelid Sharp increase in blood pressure Other symptoms: Mood and personality changes, including confusion and irritability Muscle aches (especially neck pain and shoulder pain) Vision problems, including double vision, blind spots, or temporary vision loss in

one eye Pupil size difference

XII. SIGNS AND SYMPTOMS

Nursing intervention includes: 24 hours vital sings observation will be monitored and documented. Assess neurological status especially pupils through Glasco coma

Scale daily. Helps the patient to do ADL activities Give all due medication on time Institute safety of the patient: Fall prevention:- Side rails up Bed in low position Prevent infection and other potential complications Provide client and family education about treatment and recovery of the

patient.

XIII. INTERVENTION

Treatment for SAH varies, depending on the underlying cause of the bleeding and the extent of damage to the brain. Treatment may include lifesaving measures, symptom relief, repair of the bleeding vessel, and complication prevention.

For 10 to 14 days following SAH, the patient will remain in the neuroscience intensive care unit (NSICU), where doctors and nurses can watch closely for signs of renewed bleeding, vasospasm, hydrocephalus, and other potential complications.

XIV. TREATMENT

Medication: Pain medication will be given to alleviate headache, and

anticonvulsant medication may be given to prevent or treat seizures, antibiotics give to prevent infection after surgery.

Surgery: If the SAH is from a ruptured aneurysm, surgery may be

performed to stop the bleeding. Options include: Surgical clipping: an opening in the skull (craniotomy) is made

to locate the aneurysm. A small titanium clip is placed across the neck of the aneurysm to stop blood flow from entering.

Endovascular coiling: a catheter is inserted into an artery in the groin during an angiogram. The catheter is advanced through the blood stream to the aneurysm. Platinum coils or liquid glue (Onyx) are packed into the aneurysm to stop blood flow from entering.

Hydrocephalus Rebleeding Delayed cerebral ischemia from vasospasm Intracerebral hemorrhage Intraventricular hemorrhage Left ventricular systolic dysfunction Subdural hematoma Seizures Increased intracranial pressure Myocardial infarction

XV. COMPLICATIONS

Headache associated with vascular disease like subarachnoid hemorrhage. Risk for infection related to surgery. In effective feeding pattern related to Impaired ability of the patient to co-

ordinate swallow response resulting inadequate nutrition, Impaired swallowing, Deficient fluid volume, Imbalanced nutrition less than body requirement, Risk for electrolyte imbalance.

Impaired urinary elimination due to urinary retention, bowel incontinence. Impaired sleep pattern related due to impaired physical mortality, Risk for

activity intolerance, Ineffective peripheral tissue perfusion, Self care deficit. Alteration in consciousness due to decreased nerve and brain function. Risk for fall due to semiconscious. Risk for developing pressure ulcers due to prolonged bed ridden. Disturbed sensory perception (photophobia) related to severe headache. Self-care deficit due to weakness and numbness in body part.

XVI. PRIORITIZATION OF NURSING PROBLEMS

Remain on modified bed rest Take medication prescribed. Follow up regularly Take adequate nutrition Maintain personal hygiene Maintain skin care Regularly checkup vitals.

XVIII. NURSING HEALTH TEACHING

SAH is a medical emergency which is prevented if the risk factors are reduced. In case of head injury, the patient brought immediately to the hospital and give immediate care, we can save the life. The manifestations and recovery depend on the location and severity of the damage or bleeding in the patient brain.

XIX. CONCLUSION

Wikipedia. Medical and surgical nursing book volume 1

and 2 of Brunner. Luck man and Sorensen’s Medical-Surgical

Nursing a Physiologic Approach 4th edition Lippincott Manual of Nursing Practice 9th edition.

XX. BIBLIOGRAPHY

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