Subarachnoid Hemorrhage

ESTALILLA, MELCHIZEDEK P.
BSN - IV
Objectives

General Objectives for us students:

 Formulate a researchable problem or disease
 Identify and utilize our resources
 Learn the nature of the disease
 Symptoms, pathophysiology and intervention for each
altering problem encountered.
 Specific Objectives:
STUDENT-NURSE CENTERED
 History of the patient.
 Potential problems
 Anatomy and physiology of the organ affective.
 Pathophysiology of the condition.
 Clinical and classical signs and symptoms
 Holistic nursing care in the care of patient
 Impart health teachings to patient and family members
PATIENT – CENTERED
 After 8 hours of student nurse-patient interaction, the
patient and the significant others will be able to:
 Explain the goals of the frequent position changes.
 Enumerate the position for proper body alignment.
 Discuss the different therapeutic exercises.
 Understand the importance of proper nutrition.
 Participate attentively during the discussion.
Introduction

 A Stroke, cerebrovascular accident, or what is now

being termed as “brain attack” is a sudden loss of
brain functions resulting from disruption of blood
supply to a part of the brain resulting from pathologic
blood vessels. It denotes an abnormality of the brain.
 Thrombotic

 Embolic

 Hemorrhagic
Patient profile
 Patient Derek Consider Subarachnoid
 40 years old Hemorrhage VS CNS
 Male
Infection S/P Head Injury
(August 2019) To Rule
 11/08/78
Out Electrolyte Imbalance
 Filipino
 C/C: Intermittent
 Roman Catholic headache, non
 TOA: 2:00 pm conversant
 DOA: October 17, 2019
 INITIAL DIAGNOSIS: TP
Patient Health History
 3 mths pta, head trauma in his temporal area. Patient
had hematoma to the area of the trauma hence sought
consult at Balaoan hospital. Pain relievers were
prescribed.
 4 wks pta, experienced headache which was
intermittent associated with body weakness. Took pain
reliever which provided comfort.
 1 wk pta, persistence of the intermittent
headache,condition worsened and suddenly became
non-conversant. rushed to Balaoan hospital. Condition
deteriorated hence was referred to ITRMC after 2 days.
PAST HEALTH HISTORY
 Patient has no known allergies in foods, drugs,
animals, insect bites, bee stings etc.
 No history of communicable illnesses, injuries, and
accidents, blood transfusions, and surgical
procedures.
 The patient’s mother claimed that he suffered from
chicken pox when he was 12 years old. Underwent
childhood immunizations
SOCIAL HISTORY OF THE PATIENT

 Patient Derek is unemployed. He usually does some

errands for his family. He is fond of his pigeon and
rabbit pets. He only reached 3rd year high school, for a
reason that he got bullied at school because of his
height. During his high school days, he was short
according to his mother. And he never let her mother
knew that he got bullied at school that made him quit
studying.
Course of Confinement
 October 17, 2019 2:00pm
 Admitted under service 2 in Medical ward 2
 BP: 110/90mmHg, heart rate of 67 bpm, respiratory
rate of 14 bpm, temprerature of 36.5°C and oxygen
saturation of 94%.
 diet via NGT at 1,500 kcal/day (CHON-100g/day;
CHO-135g/day; Fat-65g/day) in 5 divided doses
 PNSS 1L x 12hrs
 Laboratory examinations.
 ceftriaxone 2g for 24 hours
 7:10pm
 Transferred at Internal Medicine ward
 BP: 120/70, heart rate: 76bpm, RR: 23 bpm, Temp:
36.5°C SPO: 98%. GCS of 11 (E4V2M5).
 October 18, 2019 - Burrhole
October 24, 2019 7-3 shift
 IVF of PNSS 1L x10 hours. With an indwelling
catheter, fed through his intact NGT. Oral care was
given . At 9:am the regulation changed to KVO.
Medication administered.
 BP: 120/80 mmHg; CR: 88 bpm; RR: 20 bpm; Temp.:
36.7°C. GCS 14 (E4V4M6).
 October 25, 2019 7-3 shift
 IVF of PNSS at 800cc level. With indwelling catheter,
 later ordered for bladder training by clipping/unclipping
method ever 2 hours by 15 minutes.
 Oral care was given. Patient was fed through his intact
NGT. Endorsed at Medical ward 1 at 2:00pm with Vital
signs of BP: 120/80mmHg, CR: 92, RR: 20bpm, temp:
36.8°C and oxygen saturation of 96%. GCS 14
(E4V4M6).
13 Areas of Assessment
 PSYCHOSOCIAL STATUS
 40 year old male. PTA, he is unemployed and usually
stays with his family and spends his time mostly by
doing house hold chores. Fond of his animal pets.
 Mental and Emotional Status
Responses to verbal stimuli as evidenced by blinking
his eyes and responses through sound if you call his
namePatient is confused, can still recognize his
significant others, and does craves for food he
remembers.
 Environmental Status
PTA, he can do his usual activities at home. In their house, there is
adequate space and cleaned regularly. Their house is a concrete two
story that is near the highway and the usual transportation used is
jeep and tricycle. They have a traditional way of comfort room. Patient
is in the acute stroke unit together with his mother (sometimes
substituted by his aunt).
Sensory Status
Visual Status
 dilated pupils which is black in color and has sluggish reaction to light. He have
some discharges around the lacrimal area.
Auditory Status
 Not to able repeat words whispered from a distance of two feet (voice whisper
test). With some dust accumulation on firm cartilage.
Olfactory Status
 Had difficulty upon discriminating different odors by letting him determine the
smell of a cologne, alcohol and vinegar. Has an intact NGT.
Gustatory Status
 Foul breath during hospitalization. The lips appear red-brownish
and dry. The dorsum of the tongue is dark pink and dry but the
anterior part has a thick white coating. The buccal mucosa
appears dry and rough. Has dark reddish gums. Doesn’t have
dentures. Dry lips and some lesions.
Tactile Status
 The skin color of his body is brown. There is no presence
of dryness with minimum perspiration. The skin turgor is 2-3
seconds.
Motor Status
2/5 2/5
3/5 3/5
 Patient has muscle weakness. Cannot lift both arms but can
only move them while on the base of the bed. He can slightly
move both of his legs.
Nutritional Status
 PTA, usually eats 3 meals with snacks a day. Height 5’7” and
weighs 76 kilograms. Body Mass Index is 26.2 which is
overweight.
 Ordered to consume 1900 kcal per day in 6 equal feeding to
gain his ideal body weight of 63 kilograms
 Respiratory Status
 The respiratory rate of the patient is ranging from 19-21 bpm. The
environment and position of the patient may alter his breathing
pattern. During the day of assessment he nebulises every 8 hours.
Temperature Status
 36.5 – 37.3 degree Celcius. The patient perspires when the hospital
environment is warm.
Integumentary Status
 Dandruff is present. Incision at his left temporal area of his head
covered with wound dressing. During the 2nd day of assessment the
dressing was out of place/detached.
Comfort and Rest Status
 Derek usually has a number of sleep of 6 hours, slept at 10 pm and
awakes at 4:00 am, as verbalized by his mother.
 During hospitalization, the patient was unable to sleep well (3 hours)
because of the noisy environment and thirst.
 Ineffective cerebral tissue perfusion related to
interruption of blood flow secondary to hemorrhage
as evidenced by GCS of 14
 Impaired swallowing related to muscle paralysis and
perceptual impairment as evidenced by NGT.
 Impaired physical mobility related to neuromuscular
involvement as evidenced by muscle strength of 2/5
 Impaired verbal communication related to
neuromuscular impairment as evidenced by inability
to modulate speech.
 Risk for impaired skin integrity related to physical
mobility secondary to CVA
 Risk for Infection
 SAH CS\NCP tissue perf.docx
 SAH CS\ncp swallow.docx
 SAH CS\ncp physical.docx
 SAH CS\ncp verbal.docx
 SAH CS\ncp skin.docx
 Drug study

 SAH CS\Drug study.docx

REFERENCES:
 https://www.emedicinehealth.com/anatomy_of_the_central_nervous_syste
m/article_em.htm#brain_and_cerebrum_location
 https://mayfieldclinic.com/pe-sah.htm
 https://bio.libretexts.org/Bookshelves/Introductory_and_General_Biology/Bo
ok%3A_Biology_(Kimball)/Unit_15%3A_The_Anatomy_and_Physiology_of
_Animals/15.03%3A_Circulatory_Systems/15.3A%3A_Anatomy_of_Human
_Circulatory_System
 MS Greenberg. Handbook of Neurosurgery. Seventh Edition. New York:
Thieme Medical Publishers; 2010.
 Davis’s drug guide for nurses ELEVENTH EDITION
 https://www.drugbank.ca/drugs/
 Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 10th Edition
 Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 12th Edition
 Medical-Surgical Nursing made Incredibly Easy Lippincott 3rd Edition