Far Eastern University

Institute of Nursing
Nicanor Reyes St., Manila

Nursing Care Management 103B

Related Learning Experience

Subarachnoid Hemorrhage

Submitted by:
BSN 105
Group 19B

CUNANAN, Tristan John V.

Submitted to:

Ma’am Corazon Santos, RN

Clinical Instructor

October 12, 2010

Subarachnoid Hemorrhage
- Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space,
between the arachnoid and the pia mater. Traumatic (SAH) develops from
 traumatic brain injury and usually considered a separate disorder known as
traumatic brain injury. Spontaneous SAH is seen with intracranial aneurysms and
arteriovenous malformations. Other causes include brain tumors, blood
dyscrasias, and anticoagulant therapy.

Etiology
- Spontaneous SAH occurs when an abnormal artery or vein ruptures and blood
spills into the subarachnoid space ventricles. In adults, aneurysms are the most
common cause of SAH. Aneurysmal hemorrhage may occur at any age but is
most common from age 40 to 65. Less common causes are mycotic aneurysms,
arteriovenous malformations, and bleeding disorders.

Aneurysms
- An intracranial aneurysm is a weakness in the tunica media, the middle layer of
the blood vessel. The most common type of intracranial aneurysm is the saccular
or the berry aneurysm. The muscular walls of the artery weaken and lead to
formation of a sac-like or berry-like structure.

Pathophysiology
- As an aneurysm develops, it often forms a neck with a dome. The arterial internal
elastic lamina disappears at the base of the neck. The media thins, and connective
tissue replaces smooth muscle cells. At the site of the rupture (most often the
dome), the wall thins, and the tear that allows bleeding is often no more than
0.5mm long. It is not possible to predict which aneurysms are likely to rupture.
Blood byproducts from the SAH contribute to serious delayed effects. The most
serious is vasospasm, defined as the constriction or narrowing of the cerebral
vessels. In general vasospasm causes ischemia and infarction and is the major
cause of delayed morbidity or death following SAH.

Clinical Manifestations
- Symptoms are found usually after SAH occurs. They may also occur without
bleeding by placing pressure on the adjacent structures. The classic presentation
is sudden onset of the “worst headache of my life” accompanied by vomiting and
generalized seizures may occur.
- The client’s level of consciousness may be altered becoming confused and
lethargic gradually progressing to comatose within hours. Manifestations of
meningeal irritation is also present (nuchal rigidity, bradzinsky’s sign, pain,
photophobia, back pain)
- Depending on the size and location of the aneurysm and the SAH focal clinical
manifestations may be noted (e.g. motor or sensory deficits, speech and cranial
nerve deficits) Retinal hemorrhages may be present. Various grading scales are
used Hunt-Hess scale and the Fisher scale.
- Manifestations of vasospasms appear 4 – 14 days after the hemorrhage, most
frequently at about 7 days. The severity, duration, and distribution of vasospasm
determine whether ischemia progresses to infarction.
Diagnosis
 - Diagnosis of SAH is usually based on history and physical examination. In about
80%-90% of affected clients, enough blood is present to e visualized on a non-
contrast CT scan. If the scan fails to establish the diagnosis a lumbar puncture
may be performed to look for the presence of subarachnoid blood. Lumbar
puncture is contraindicated when ICP is elevated.

Management
- The client with SAH resulting from an intracranial aneurysm is a medical
emergency and requires multi-disciplinary treatment in an intensive care unit.
Definitive treatment is often instituted within 24 hours of onset of manifestations.
Recovery is variable; one third of SAH survivors may succumb to the disease and
another one third may have permanent sequelae.
- Goals of treatment:
1. Prevent re-bleeding
- Rebleeding is prevented by the neurosurgeon or interventional radiologist
securing the aneurysm. The nurse must keep the client quiet and comfortable.
The nurse does neurologic assessments for the first 24-72 hours and notes
anything that suggests changes in the level of consciousness.
2. Maintaining cerebral perfusion pressure
- Medical and nursing management focuses on maintaining blood pressure
to facilitate CPP. Once the aneurysm is secure the blood pressure must be
maintained at a level high enough to provide adequate cerebral perfusion.
3. Controlling intracranial pressure
- The onset of lethargy or restlessness may be the first clinical manifestation
of increased intracranial pressure which is why it is necessary to provide
measures to prevent an increase in ICP
4. Minimizing effects of vasospasm
- To prevent vasospasm, liberal isotonic fluids are used. If needed, volume
expansion is added to promote cerebral perfusion. If vasospasm occurs,
induced hypertension and hypervolemia are used with the major goal of
increasing cerebral blood flow and cerebral perfusion.
5. Managing hydrocephalus
6. Managing cardiac dysrhythmias
-cardiac and respiratory function is also closely monitored because it provides
a direct role in providing adequate cerebral perfusion pressure

Nursing Goals: Surgical Management:

1. Limitation of activity 1. Aneurysm Clipping
2. Seizure control 2. Endovascular Therapy and Embolization
3. Blood pressure management