case study for nursing students

1. A Case Study Presentation
on
Subarachnoid
Hemorrhage
Presented by:
Asma Alzahrani
Asma Alshehri
Nada Atallah
Layla Ali Akam
Rawan Almarwani
Shrog Mfleh Alblwi
Jawaher Alharbi
Norah Ahmed
Khlood alatwi

2. Why we choose this
case ?

3. General Objectives:
The primary concern of this Case Study Presentation is to
further enhance the understanding of Subarachnoid
Hemorrhage in congruence with the learned concepts of the
Nursing students.

4. • Specific Objectives:
This case presentation seeks to provide different information about the
disease being considered with the ff. specific objectives:
Give a brief introduction about Subarachnoid Hemorrhage together with
the clinical manifestations.
Present the clients demographic and health history.
Present the abnormal results of the physical assessment and compare it
to the normal.
Present the different laboratory test and results done to the clients with
its interpretation.
5. Discuss the normal Anatomy and Physiology of Central Nervous
System.
6. Explain the Pathophysiology of Subarachnoid Hemorrhage.
7. Discuss the drug study.
8. Present a Nursing Care Plan.
9. Show a Discharge Planning that the client may use upon discharge
to the hospital.

5. I. Introduction
Statistics ( incidence and prevalence)
II. Patient/Case Presentation
a. Assessment
b. Demographics
c. Lifestyle
d. Family history
e. Medical History:
III. Anatomy and Physiology
IV. Medical Management l Interventions
a. Medications
b. Medical interventions
c. Diagnostic and laboratory tests
V. Nursing Interventions
V. Conclusion & Recommendation
VI. References
Outline:

6. A subarachnoid hemorrhage is an uncommon type of
stroke caused by bleeding on the surface of the brain.
It is a very serious condition and can be fatal
SAH : fourth most frequent cerebrovascular disorder-
following athero-thrombosis, embolism and primary
intra-cerebral hemorrhage.
CAUSE: Excluding head trauma, the most common
cause of SAH is rupture of vascular aneurysm.
introduction:

8. Subarachnoid Hemorrhage:
Bleeding in the area between the brain and
the thin tissues that cover the brain.
This area is called the subarachnoid space
Definition:

9. •The doctors have confirmed that the main caused
by the presence stretch in one of the main arteries
feeding the brain, and that in 90% of cases as there
are up to 5% of normal people are predisposed to
occurrence of this expansion, and there are 10
people out of every 100 thousand people each
year enter the stage It is called infiltration bloody
phase, which precedes the bleeding or explosion,
and the best treatment of these cases before
entering into this phase where increasing the
chances of successful surgical treatment to 99% if
caught early.
10-12% die before receiving medical attention.
Incidence and Prevalence

10. Many risk factors have been implicated in the pathogenesis of
aneurysmal SAH. They include:
arterial hypertension
atherosclerosis
alcohol use
smoking
race
gender
age
analgesic use
body mass index
drug abuse
oral contraceptive
use
size of unruptured aneurysm
collagen vascular disease

11. and other genetic factors:
a. the incidence of aneurysmal SAH increases with age
reaching a peak in the sixth decade of life.
b. sex: in adults, woman are affected more than men by a
ratio of 3 : 2
c. aneurysmal SAH is rare in children and boys are affected
more than girls by a ratio of 3 : 1
d. race: African-Americans are at a higher risk than white
Americans
e. the critical size of aneurysms determining the risk of
rupture is reported to be between 5 and 7 mm .
f. 11% of patients with either a ruptured or unruptured
aneurysm had a family history of cerebrovascular
disease(compared with 4% of matched controls)

12. Subarachnoid hemorrhage can be caused by:
•Bleeding from (AVM)
•Bleeding disorder
•Bleeding from a
•Head injury
•Unknown cause (idiopathic)
•Use of blood thinners
Subarachnoid hemorrhage caused by injury is often
seen in the elderly who have fallen and hit their head.
Among the young, the most common injury leading to
subarachnoid hemorrhage is motor vehicle crashes.
Causes:

13. in other blood vessels
An aneurysm is an abnormal widening or ballooning of a
portion of an artery due to weakness in the wall of the
blood vessel
•Fibromuscular dysplasia (FMD) and other connective
tissue disorders
•High blood pressure
•History of
Polycystic kidney disease is a kidney disorder passed
down through families in which many cysts form in the
kidneys, causing them to become enlarged.
•Smoking
•A strong family history of aneurysms may also increase
your risk.
Risks Include:

14. Internal carotid artery
Posterior
communicating artery
aneurysm

15. subarachnoid hemorrhage (SAH) is classified
according to 5 grades, as follows
• Grade I: Mild headache with or without meningeal irritation
• Grade II: Severe headache and a nonfocal examination, with or
without mydriasis
• Grade III: Mild alteration in neurologic examination, including mental
status
• Grade IV: Obviously depressed level of consciousness or focal deficit
• Grade V: Patient either posturing or comatose

16. The main symptom is a severe headache that starts
suddenly (often called thunderclap headache). It is
often worse near the back of the head. Many
persons often describe it as the "worst headache ever"
and unlike any other type of headache pain. The
headache may start after a popping or snapping
feeling in the head.
Other symptoms:
and alertness
Eye discomfort in bright
Mood and personality changes, including
and irritability
(especially
Nausea and vomiting
Symptoms:

17. Symptoms continuation…
•Numbness in part of the body
•Stiff neck

20. The goals of treatment are to:
•Save life
•Repair the cause of bleeding
•Relieve symptoms
•Prevent complications such as permanent
brain damage (stroke)
treatment

21. •How well a patient with subarachnoid hemorrhage
does depends on a number of different factors,
including:
•Location and amount of bleeding
•Complications
•Older age and more severe symptoms can lead to
a poorer outcome.
•People can recover completely after treatment.
But some people die even with treatment.
Prognosis:

22. Possible Complications

29. PATHOPHYSIOLOGY
Modifiable Risk Factors
>HPN
>Smoking
>excessive intake of foods
high in fats and
cholesterol
Non-modifiable Risk Factors>
Advanced Age
>Gender
>Heredity
Triggering Factors
>Sudden extreme emotion
Arterio venous malformation
Cerebral aneurysm rupture
Bleeding into the brain tissue and
subarachnoid space

30. Blood Clots in the Subarachnoid
Space
Brain Compression
Blood supply interruption
Tissue Necrosis
Neuronal Death
Increase Intracranial
Pressure
T
total Paralysis
Regional Paralysis
Epileptic Seizure : increase
intraocular pressure=
blindness
Death
Coma

32. Name: S.M
Date of birth: December 14, 1984
Age: 31 years
Gender: Female
Marital status : Married
Admission Date: 25/02/2015
Diagnosis: Subarachnoid hemorrhage
Chief complaint: Headache, hypertension and
projectile vomiting.

34. GENERAL APPEARANCE:
alert of patient is reduce or
low ,uncooperative

35. 1-skull
2-scalp
3-eyes
4-nose
5-throat
6-skin
7-neck region
8-lungs
12-upper and lower extremities
11-abdomen
10-breast
9-heart

36. AnalysisActual findingTechnique usedBody parts
NormalThe skull is normocephalic and
symmetrical to the body with
prominences in frontal and
occipital area ,symmetrical in
all place.
Inspection,
palpation
1-Skull
NormalWhite ,no mass, lumps, scar
,and lesions no area of
tenderness is observed .
Inspection2-Scalp

37. AnalysisActual findingTechnique usedBody parts
Not normal
indicates
Low level of
conscious
Dilated pupils and no reaction to
light , she have some discharges
around the lacrimal area .
Inspection3- Eyes
NormalMidline symmetrical and patent , no
discharge.
Inspection4-Nose

38. AnalysisActual findingTechnique usedBody parts
NormalOral cavity and pharynx
normal. No inflammation,
swelling, exudate, or lesions.
Teeth and gingiva in good
general condition.
Inspection5- Throat
Normalnormal color, texture and
turgor
with no lesions or eruptions.
Generally uniform skin
temperature.
Inspection ,
palpation
6- Skin

39. AnalysisActual findingTechnique usedBody parts
NormalSymmetrical and straight
,no palpable lumps, and
supple, trachea is on
midline of neck , and spaces
are equal onboth sides.
Inspection ,
palpation
7-Neck region
NormalClear to auscultation and
percussion without rhonchi,
wheezing or diminished
breath sounds.
Auscultation ,
percussion
8-Lungs

40. AnalysisActual findingTechnique usedBody parts
NormalNormal S1 and S2. No S3, S4
or murmurs. Rhythm is
regular. There is no
peripheral edema, cyanosis
or pallor. Extremities are
warm and well perfused.
Auscultation9-Heart
NormalNo tenderness,
Masses,
Nodules and discharge.
Inspection ,
Palpation
10-Breast

41. AnalysisActual findingTechnique
used
Body parts
NormalPositive bowel sounds. Soft, no
distended, non tender. No
guarding or
rebound. No masses, uniform
color ,rounded symmetrical
Inspection ,
Auscultation,
Percussion,
Palpation
11-Abdomen
NormalBoth feet reveals all toes to be
normal in size and symmetry, normal
range of motion, normal sensation
with distal capillary filling of less
than 2 seconds without tenderness,
swelling, discoloration, nodules,
both ankles, knees, legs, and hips
reveals normal range of motion,
normal sensation without
tenderness, swelling, discoloration,
crepitus, weakness or deformity.
Inspection12-Upper and
lower
extremities

42. Normal Values:Result:
132-146mmol/L124(Sodium: (1
3.6-5.0mmol/L4.2Potassium :
98-107mmol/L92(Chloride:(2
22-29mmol/L25Enzymatic
bicarbonate:
Hyponatremia
Hypochloremia
1
2

43. Normal Values:Result:
4.0-11.0 10^3/Ml14.51(WBC (1
3.8-4.8 10^6/Ml4.40RBC
12.0-16.0g/dl12.9Hemoglobin
36.0-45.0%37.5HCT
82.7-89.485.2MCV
31.5-34.5g/dl34.4MCHC
leukocytosis 1

44. Normal Values:Result :
0.74-0.99mmol/L0.79Magnesium
0.81-1.58mmol/L1.01Phosphate
2.12-2.52mmol/L2.33Calcium
Miscellaneous Chemistry

45. Normal Values:Result:
2.5-6.4mmol/L1.66Urea nitrogen
53-155mmol/L37Creatinine
Renal Function Test

47. •Grade I or II SAH:
•In patients with a suspected grade I or II
subarachnoid hemorrhage (SAH), emergency
department (ED) care essentially is limited to
diagnosis and supportive therapy.
•Early identification of sentinel headaches is
key to reduced mortality and morbidity rates.
Use sedation judiciously.
•Secure intravenous access, and closely
monitor the patient's neurologic status

48. • Grade III, IV, or V SAH:
• In patients with a grade III, IV, or V subarachnoid hemorrhage (SAH) (ie,
altered neurologic examination), ED care is more extensive.
• Address the patient's airway, breathing, and circulatory status (ABCs). In
addition, reliable neurologic examinations before and after initial
treatment are critically important to optimizing management and to
deciding on the appropriate neurosurgical intervention.
• Intubation
• Endotracheal (ET) intubation of obtunded patients protects them from
aspiration caused by depressed airway protective reflexes. Also intubate
to hyperventilate patients with signs of herniation.
• Precautions
• Avoid excessive or inadequate hyperventilation. Target the partial
pressure of carbon dioxide (pCO2) at 30-35 mm Hg to reduce elevated
ICP. Excessive hyperventilation may be harmful to areas of vasospasm.
• Avoid excessive sedation. It makes serial neurologic exams more difficult
and has been reported to increase ICP directly. However, avoid any
increase in ICP due to excessive agitation from pain and discomfort.

49. •Neurosurgery to

52. •If no aneurysm is found, the person should be
closely watched by a health care team and may
need more imaging tests
•Treatment for coma or decreased alertness
includes:
•Draining tube placed in the brain to relieve
pressure
•Life support
•Methods to protect the airway
•Special positioning

53. •A person who is conscious may need to be
on strict bed rest. The person will be told to
avoid activities that can increase pressure
inside the head, including:
•Bending over
•Straining
•Suddenly changing position

54. •Treatment may also include:
•Medicines given through an IV line to
control blood pressure
•Nimodipine to prevent artery spasms
•Painkillers and anti-anxiety medications to
relieve headache and reduce pressure in the
skull
•Phenytoin or other medications to prevent
or treat seizures
•Stool softeners or laxatives to prevent
straining during bowel movements

55. Adjunctive Therapies and Measures
•Keep the patient's core body temperature at 37.2°C
•Consider antiemetics for nausea or vomiting.
•Elevate the head of the bed 30° to facilitate
intracranial venous drainage. Emergent ventricular
drainage by the neurosurgeon may be necessary.
•Maintain the patient's serum glucose level at 80-120
mg/dL; use sliding or continuous infusion of insulin if
necessary.
•Fluids and hydration
•Do not over hydrate patients because of the risks of
hydrocephalus.
•Patients with subarachnoid hemorrhage (SAH) may
also have hyponatremia from cerebral salt wasting.

59. In our case :
•Investigation :
•CBC analysis
•Urine analysis
•Pt ,PTT
•Diagnostic procedures :
•ECG
•CT brain
•MRI
• chest x ray

60. Special order :
•Elevate the head of the bed 30° .
•Normal saline 70ml hour
•Regular soft diet
•Keep oxygen saturation between 95 to 98 % .

61. DRUG STUDY

62. NURSING RESPONSIBILITIESSIDE EFFECTSINDICATIONS/
CONTRAINDICATION
DOSAGE/
ROUTE/
FREQUENCY
DRUG NAME
Do not exceed 4gm/24hr. in adults
Do not take for 10 days for pain in adults,
or more than 3 days for fever in adults.
Extended-Release tablets are not to be
chewed.
Monitor CBC, liver and renal functions.
Assess for fecal occult blood and nephritis.
Avoid using OTC drugs with
Acetaminophen.
Take with food or milk to minimize GI
upset.
Report N&V. cyanosis, shortness of breath
and abdominal pain as these are signs of
toxicity.
Report paleness, weakness and heart beat
skips
Report abdominal pain, jaundice, dark
urine, itchiness or clay-colored stools.
Phenacetin may cause urine to become
dark brown or wine-colored.
Report pain that persists for more than 3-5
days
Avoid alcohol.
This drug is not for regular use with any
form of liver disease.
Minimal GI upset.
Methemoglobinemia
Hemolytic Anemia
Neutropenia
Thrombocytopenia
Pancytopenia
Leukopenia
Urticaria
CNS stimulation
Hypoglycemic coma
Jaundice
Glissitis
Drowsiness
Liver Damage
.
-INDICATIONS
Analgesic-antipyretic in
patients with aspirin
allergy, hemostatic
disturbances, bleeding
diatheses
CONTRAINDICATION
Renal Insufficiency
Anemia
Special Concerns:
Liver toxicity (hepatocyte
necrosis)
ROUTE
IV
DOSAGE
60mg
FREQUENC
Y
Q6h
GENERIC
NAME:
Paracetamol
BRAND
NAME
Acetaminophen
CLASSIFICATION
Analgesics
(nonopioid) -
Muscle
Relaxants -Anti-
pyretic

63. NURSING RESPONSIBILITIESSIDE EFFECTSINDICATIONS/
CONTRAINDICATION
DOSAGE/
ROUTE/
FREQUENCY
DRUG NAME
Assess patient for pain and
limitation of movement; note
type, location, and intensity
prior to and at the peak
following administration.
Administer after meals or with
food or an antacid to minimize
gastric irritation.
Instruct patient to take with a
full glass of water and to remain
in an upright position for 15-30
min after administration.
Teach patient to report blurred
vision, ringing of ears that may
indicate toxicity.
Advise patient to report change
in urine pattern, edema,
increased pain in joints, fever,
blood in urine that may indicate
nephrotoxicity
Gastrointestinal -
Abdominal discomfort,
heartburn, abdominal
cramps, nausea,
vomiting and diarrhea.
Central Nervous
System - Headache,
dizziness and
drowsiness.
Genitourinary - Blood
in urine, decrease in
urination and kidney
failure.
-INDICATIONS
prescribed for painful
Relieve pain after
surgical intervention
inflammatory conditions
CONTRAINDIC
ATION to patients with
gastrointestinal bleeding,
ulcer, severe kidney, liver
disease, bleeding
disorders, and
hypersensitivity
ROUTE
IV
DOSAGE
40MG
FREQUENCY
OD
GENERIC
NAME:
Nimesulide
BRAND
NAME
Nexen
CLASSIFICATION
Analgesic, antipyretic
Non steroidal Anti-
Inflammatory Agents
NSAID

64. NURSING RESPONSIBILITIESSIDE EFFECTSINDICATIONS/
CONTRAINDICATION
DOSAGE/
ROUTE/
FREQUENCY
DRUG NAME
Assess condition before therapy and
reassess regularly thereafter to monitor
drug’s effectiveness>
Monitor pt for any adverse GI
reactions,nausea,vomiting,diarrhea,>
Assess for adverse reactions>
for pt. with hepatic encephalopathy
:regularly assess mental condition>
monitor I & O>
monitor for Inc.glucose level in diabetic
pts
Abdominal
discomfort
associated with
Flatulence and
intestinal cramps.
Nausea,vomiting,
diarrhea on
prolonged use.
-INDICATIONS
Prevention and
treatment of portal-
systemic encephalopathy
(PSE), including stages of
hepatic precoma and
coma
CONTRAINDIC
ATION to
Patients who require a
low galactose diet
ROUTE
Po
DOSAGE
15 ML
FREQUENCY
OD
GENERIC
NAME:
Lactulose
BRAND
NAME
Cephulac
CLASSIFICATION
hyperosmotic
laxative

65. Nursing managment

66. evaluationinterventionpalnningNursing diagnosisscientific
explanation
assessment
Evaluate
patient
pain scale if
it is
reduced or
not.
-Assess for signs and
symptoms of headache
(statements of same,
restlessness, irritability,
grimacing, rubbing head,
avoidance of bright lights and
noises, reluctance to move)
Rational:to assess whether the
client felt the pain of acute or
chronic
-Assess patient's perception
of the severity of the
headache using a pain
intensity rating scale.
Rational:It is important to
help patients express as
factually as possible
- Assess the patient's pain
pattern
(e.g. location, quality, onset,
duration, precipitating factors,
aggravating factors, alleviating
factors).
Rational:Different etiologic
factors respond better to
different therapies
after 3hrs of
nursing
intervention
the patient
will reduce
of pain as
evidenced
by:
1.
verbalization
of the same
2. relaxed
facial
expression
and body
positioning
Acute pain related
to stretching or
compression of
cerebral vessels
and tissue
associated with
increased
intracranial
pressure
leakage of blood
from an aneurysm
in the brain
accumulation of
blood between the
arachnoid and pia
mater
elevation of the
pressure in the
cranium
Subjective:I have a
severe headache”
as verbalized by
patient
Objective:
Behavior: showing
symptoms pain.
Changes in the
ability to perform
daily activities.
pain scale:5of 10 .

67. intervention
-Assess the degree of making a false step in person from the patient, such
as isolating themselves,Note the influence of pain such as: loss of interest
in life, decreased activity, weight loss
Position patient in semi fowler position.
Rational:Pain that has been chronic and long-standing may have
devastating emotional effects on the patient and these emotional
complications may make effective treatment of the pain more difficult.
-Encourage patient to rest in bed.
Rational:to reduce the intensity of pain.
-Provide quite and calm environment.
-Teach relaxation and deep breathing techniques
Rational:to reduce tension and create a feeling more comfortable.
-Give the hot moist compress / dry on the head, neck, arms as needed.
Rational:Hot moist compresses have a penetrating effect. The warmth
rushes blood to the affected area to promote healing
Massage the head / neck / arm if the patient can tolerate the touch.
Rational:to decreases muscle tension and can promote comfort
-Use the techniques of therapeutic touch, visualization, and stress
reduction and relaxation techniques to another.
Rational:Techniques used to bring about a state of physical and mental
awareness and tranquility. The goal of these techniques is to reduce
tensions, subsequently reducing pain.
-Instruct the patient to use a positive statement "I am cured, I'm relaxing, I
love this life“, Instruct the patient to be aware of the external-internal
dialogue and say "stop" or "delay" if it comes up negative thoughts.
Collaboration for providing analgesic as doctor order..
Rational:The use of a mental picture or an imagined event that involves
use of the five senses to distract oneself from painful stimuli.

68. evaluati
on
interventionpalnningNursing
diagnosis
scientific
explanation
assessment
After 2
hr
Cerebral
function
improve
d;
neurolog
ical
deficits
stabilized
.
Assess factors related to
individual situation for decreased
cerebral perfusion and potential
for increased ICP.
Rationale: Assessment will
determine and influence the
choice of interventions.
Deterioration in neurological
signs or failure to improve after
initial insult may reflect
decreased intracranial adaptive
capacity requiring patient to be
transferred to critical area for
monitoring of ICP, other
therapies.
After 2 hr patient
will able to
Maintain improved
level of
consciousness,
cognition, and
sensory function.
Ineffective
Cerebral
Tissue
Perfusion
related to
hemorrhage
the inadequacy of
blood flow
through the
cerebral
vasculature to
maintain brain
function
Subjective:
“Why am I here,
what happened to
me "as verbalized
by patient
Objective:
-Altered level of
consciousness;
-Changes in
sensory responses

69. intervention
-Closely assess and monitor neurological status frequently and compare with baseline.
Rationale: Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in
determining location, extent, and progression of damage. May also reveal presence of TIA, which may warn of
impending thrombotic CVA.
-Evaluate pupils, noting size, shape, equality, light reactivity.
Rationale: Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining
whether the brain stem is intact. Pupil size and equality is determined
-Document changes in vision: reports of blurred vision, alterations in visual field, depth perception.
Rationale: Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice
of interventions.
Assess higher functions, including speech, if patient is alert.
Rationale: Changes in cognition and speech content are an indicator of location and degree of cerebral
involvement and may indicate deterioration or increased ICP.
-Position with head slightly elevated and in neutral position.
Rationale: Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.
Maintain bedrest, provide quiet and relaxing environment, restrict visitors and activities. Cluster nursing
interventions and provide rest periods between care activities. Limit duration of procedures.
Rationale Continuous stimulation or activity can increase intracranial pressure (ICP). Absolute rest and quiet may
be needed to prevent rebleeding in the case of hemorrhage
Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity
Rationale: Indicative of meningeal irritation, especially in hemorrhage disorders. Seizures may reflect increased
ICP or cerebral injury, requiring further evaluation and intervention.
Administer supplemental oxygen as indicated.
Rationale: Reduces hypoxemia. Hypoxemia can cause cerebral vasodilation and increase pressure or edema
formation.

70. evaluatio
n
interventionPlanningNursing interventionassessment
After 1
hour
Patient
was able
acceptan
ce of self
in
situation
and
awarenes
s of own
coping
abilities
Assess extent of altered perception
and related degree of disability.
Determine Functional Independence
Measure score.
Rationale: Determination of
individual factors aids in developing
plan of care/choice of interventions
and discharge expectations.
Determine outside stressors: family,
work, future healthcare needs.
Rationale: Helps identify specific
needs, provides opportunity to offer
information and begin problem-
solving. Consideration of social
factors, in addition to functional
status, is important in determining
appropriate discharge destination.
After 1 hour
Patient Verbalize
acceptance of self in
situation and Verbalize
awareness of own
coping abilities.
Ineffective Coping
related to vulnerability,
cognitive perceptual
changes.
Subjective:
Inability to make
decisions
Objective:
Inability to
cope/difficulty asking
for help

71. evaluationinterventionplanningNursing interventionassessment
Encourage patient to express feelings,
including hostility or anger, denial ,
depression, sense of disconnectedness
Rationale: Demonstrates acceptance
of patient in recognizing and beginning to
deal with these feelings.
Identify previous methods of dealing with
life problems. Determine presence of
support systems.
Rationale: Provides opportunity to use
behaviors previously effective, build on past
successes, and mobilize resources.
Monitor for sleep disturbance, increased
difficulty concentrating, statements of
inability to cope, lethargy, withdrawal.
Rationale: May indicate onset of depression,
which may require further evaluation and
intervention

72. evaluationinterventionplanningNursing interventionassessment
.
Refer for
neuropsychological
evaluation and/or
counseling if indicated.
Rationale: May
facilitate adaptation to
role changes that are
necessary for a sense
of feeling/being a
productive person.

73. Discharge Plan
• Activity
 You will need to have someone with you for the next several days to
watch for worsening of symptoms (see below) and to allow you to rest.
 Start with light activity around the house for the first 3 days you are
home.
 Gradually increase your activity starting with short walks 1-2 times
per day.
 Avoid contact sports, skating, bike riding, or other such activities for 6
weeks.
Encourage pt to do passive range of motion
• Nutrition :
Instruct the relative to feed pt on time with proper food low in Na
Low in cholesterol low in fat and give citrus fruits ,moderate in fluid
intake and increase fiber diet to improve health.
 Ffollow the diet prescribed by the doctor.

74. Medications
 Take your medications as prescribed and
gradually decrease pain medications as your pain
improves.
Instruct pt and their relative to follow medication
regimen
Educate and instruct the patient and her family to
monitor BP and PR before giving medication
Follow-up
Follow up with your primary care physician for all
medical issues.

75. Call your doctor or return to the emergency room if
you experience any of the following symptoms:
. • Clear or bloody drainage from your nose or ears
• Worsening headache
• Changes in vision or differently sized pupils
• Seizure activity or jerking / twitching of the face, arms, or legs
• Sleepiness or difficulty waking up
• Memory loss
• Irritability
• Nausea or vomiting that won’t stop
• Confusion or difficulty talking
• A fever above 100 degrees F
• Arm, leg, or facial weakness
• Difficulty walking, loss of balance, and dizziness
• Stiff neck

76. • Subarachnoid hemorrhage (SAH) is a pathologic condition
that exists when blood enters the subarachnoid space
• The most common cause of SAH is trauma
• The most common cause of spontaneous SAH is an
aneurysmal bleed (65-80%)
• •Sudden explosive headache may be the only symptom in a
third of patients.
•Of patients who present with a sudden explosive headache
as the only symptoms, around 10% have SAH

77. References:
• Naggara ON, White PM, Guilbert F, et al. Endovascular
treatment of intracranial unruptured aneurysms: systematic
review and meta-analysis of the literature on safety and
efficacy. Radiology. 2010;256:887-897.
• Reinhardt MR. Subarachnoid hemorrhoid. J Emerg Nurs.
2010;36:327-329.
• Tateshima S, Duckwiler G. Vascular diseases of the nervous
system: intracranial aneurysms and subarachnoid
hemorrhage. In: Daroff RB, Fenichel GM, Jankovic J,
Mazziotta JC. Bradley’s Neurology in Clinical Practice. 6th ed.
Philadelphia, PA: Elsevier Saunders; 2012:chap 51C.
• Zivin J. Hemorrhagic cerebrovascular disease. In: Goldman L,
Schafer AI, eds. Goldman's Cecil Medicine. 24th ed.
Philadelphia, PA: Elsevier Saunders; 2011:chap 415.
• http://www.strokecenter.org/professionals/brain-
anatomy/blood-vessels-of-the-brain/

78. THANK
YOU