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OBJECTIVES
GENERAL
The primary concern of this case study is to further enhance the understanding of
subarachnoid hemorrhage in congruence with the learned concepts.
SPECIFIC
This case study seeks to provide different information about the disease being considered
with the following specific objectives:
1. Give a brief introduction about subarachnoid hemorrhage together with a clinical manifes
tation.
2. Present the clients demographic and health history.
3. Present the abnormal result of the physical assessment and compare it to the normal.
4. Present the different laboratory test and result 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.
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INTRODUCTION
Subarachnoid Hemorrhage (SAH) is bleeding into the area between the arachnoid
membrane and the pia matter surrounding the brain. SAH may occur as a result of a head injury
for spontaneous cases included high blood pressure, smoking, family history, alcoholism and
cocaine use. Generally, the diagnosis can be determining by a CT scan of the head if done
within six hours. Occasionally a lumbar puncture is also required. After confirmation further
tests are usually done to determine the underlying cause.
SAH occurs in about one percent in 10,000 people per year. And it so happens that the
patient handled in the ICU was diagnosed with the same diagnosis, hence the reason for the
case study.
The doctors have confirmed that the main caused is by the presence of stretch in one
of the main arteries feeding the brain, and that 90% of cases as there are up to 5% of normal
people are predisposed to occurrence of this expansion and there are 10 transition 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 the medical attention.
Females are more commonly affected than males. While it becomes more common
with age, about 50% of people present under 55 years old. It is a form of stroke and
compromises about 5% of all strokes. The classic symptom of SAH is thunder clop headache
a headache described as like being kicked in the head or the worst ever developing over
seconds to minutes. About 1/3 of people have no symptoms apart from the characteristic
headache, and about 1 in 10 people who seek medical care with this symptom are later
diagnosed with SAH. Vomiting may be present and 1 in 14 have seizures, confusion, decreased
level of consciousness or coma may be present, as may neck stiffness and other signs of
meningitis.
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Most cases of SAH are due to trauma. In 85% of cases, the cause rupture of a cerebral
aneurysm a weakness in the wall of one of the arteries in the brain that becomes enlarged
while most cases are due to bleeding from small aneurysms, larger aneurysms (which are less
common) are most likely to rupture.
The initial steps for evaluating a person with a physical examination. The diagnosis
cannot, however, be made on clinical grounds alone and in general medical imaging and
possibly a lumbar puncture is required to confirm or exclude bleeding.
Subarachnoid Hemorrhage is classified according to 5 grades as follow:
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 on focal deficit.
Grade V: Patient either posturing or comatose.
This cases study is focused on a patient diagnosed with subarachnoid hemorrhage
secondary to ruptured aneurysm.
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CHIEF COMPLAINT
Headache
PATIENTS PROFILE
Name: A.A. G
Age: 65 years old
Gender: Female
Birthdate: May 10, 1952
Nationality: Filipino
Place of Birth: Cavite
Civil Status: Married
Address: Dasmarinas
Religion: Roman Catholic
Admission Date and Time: August 31, 2017 04:50PM
Attending Physician: Dr. Medardo Joseph E. Millares
Admitting Diagnosis: Subarachnoid Hemorrhage probably secondary to ruptured
aneurysm, mild cerebral edema, UTI
Final Diagnosis: Subarachnoid Hemorrhage secondary to ruptured aneurysm
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Nursing History
Gordons Functional Pattern of Assessment
HISTORY OF PRESENT ILLNESS
was washing clothes when she suddenly experienced headache. Throbbing in character
radiating to the right shoulder and upper back. Patient had one episode of vomiting
approximately one table spoon in amount. Patient was rushed to Emilio Aguinaldo Hospital in
Dasmarias for management. From then, the patient had another episodes of vomiting filing
half of the kidney basin. Relative claimed that the patient was drowsy and groggy during that
time.
One day prior to consultation, patient was diagnosed to have aneurysm and was
advised to see a neurosurgeon. Transferred of hospital followed for management patients was
drowsy, afebrile. (+) pain at upper back and right shoulder, but no headache.
help medical center. She was then seen and examined by the attending physician, hence
admission.
The only past medical history of the patient that the relative could remember was
that she was admitted twice before at the EAC Hospital for cesarean delivery of her third child.
She also underwent bilateral cataract removal last 2015 on the same institution.
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According to the relative, patient AAG used to value health more than anything
else. She was very compliant with the medications for her hypertension. The patient relative
claimed that the patient believed that the most important thing in the world is life, that is why
she makes sure all the time that her children receives quality medical assistance whenever in
need.
The relative stated that patient loves to drink coffee every morning, she added that
patient AAG also carbonated beverages occasionally. The patient eats 4 times daily and she
preferred eating fatty foods, fresh vegetables and fish. Her family was the ability to provide
her nutritional needs. She has known allergies to shrimp and some medications such as
ELIMINATION PATTERN
Patient AAGs relative mentioned that the patient has no problems when it comes to
elimination. During confinement, patient was in indwelling foley catheter with light yellow
urine and inadequate in amount. The only accumulated urine was less than 20 cc every hour
The relative stated that patient AAG used to be active, She usually walks going to the
market. She also capable of doing the activities of daily living. During confinement patient
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Before hospitalization, the relative mentioned that the patient AAG do not have
difficulty of sleeping. She normally sleeps at 9:00 pm and wakes up at 5:00 am routinely.
Patients relative is claiming that she was a college graduate. She was used to work in
a Municipal hall. Due to her age, she was having difficulty seeing for objects without lenses.
During confinement patient was unresponsive. She was unconscious with a GCS of 3/15.
Patients relative refused to say anything with regards to patients sexual life, but
FAMILY GENOGRAM
FATHER MOTHER
HYPERTENSION HYPERTENSION
BRONCHIAL ASTHMA
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Upon admission, patient was admitted under neurosurgery service. Patient was on NGT
feeding 1,000 kcal in 6 equal feedings with oxygen via nasal cannula at 1 LPM. Diagnostics
ordered were CBC, FBS, cranial CT scan, lipid profile, HBA1C, CBG, SGPT, PT, PTT, UA,
and Ct angiogram. Patient was given mannitol 100cc IU every 6 hours. Citicholine 1gm IV
vitamin B complex IV, OD, Piracitam IV, lactulose 30 cc ODHS, tramadol 2.5 mg IV every 8
minodipine 50 mg every 12 hours. Patient was scheduled for clipping of aneurysm the next
day and was put on NPO for 8 hours PTOR, hooked PNSS 1L to run for 8 hours. Patient was
referred to internal medicine for CP clearance and co management. Patient was seen by
neurologist and was advised to continue present management. Patient was seen by cardiologist.
12 lead ECG and repeat creatinine was done. Patient was seen by attending physician.
On the first day of hospitalization patient was seen by anesthesiologist. Patient was
cleared by a neurologist and was ordered to have CBG every 4 hours. Patient has undergone
clipping of aneurysm and craniotomy in which the patient has tolerated the procedure.
Mannitol was increased to 200cc IV every 4 hours and was maintained on positive fluid
On the second day of hospitalization, patient was GCS 9/15 (E3V1M5) and present
management was continued to KCL drip was started; 10 meqs KCl in 100 cc, PNSS to run for
1 hour x 3 cycles. Patient was for repeat plain cranial CT scan and for CBC, PT and PTT, CT
scan results revealed cerebral edema and was advised for hemicraniotomy.
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On the third day of hospitalization patient was for hemicraniotomy and 1 whole blood
PRBC was prepared. Vitamin K and trenaxemic acid was also started. Hemicraniotomy was
done with the patient tolerating the procedure and was subjected to mechanical ventilator.
Patient was also given pain medication. IVF was shifted to NaCl 2L to 40 meqs KCL to run
On the fourth day of hospitalization, patient was GCS 7. Patient was for bedsore
precaution and for regular suctioning. Patient was referred to pulmonologist for co-
On the fifth day of hospitalization, patient was for UA and CXR. Patient was given
ordered to be done every 12 hours and for ETA GS. Patients JP drain was removed. Patients
CBG was discontinued. KCL tablets were increased to 2 tablets TID for 6 doses and for transfer
On the sixth day of hospitalization, patient was GCS 6 (E1V1M4) correct mechanical
ventilation setting were continued. Kalium was discontinued and IVF was shifted to D5W 1L
to run for 12 hours. Patient was later given paracetamol 500 mg IV every 4 hours RTC for
On the seventh day of hospitalization, patient was still GCS 6. Present management
was continued. Later patient become GCS 3 (E1V1M1). A family conference was held. The
condition of the patient was explained to the relative and supportive care was continued.
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On the eight day of hospitalization present management was continued and was
suggested for plain cranial CT scan. Patient was still GCS 3. Early tracheostomy was deferred
and feeding was administered through feeding bag. Patient was given PNSS 500cc fast drip,
atropine ampule IV and norepinephrine drip 16 mg + PNSS to complete 100 cc x 0.2 meql
kg to titrate accordingly maintaining MAP 890 mmhg. FiO2 was decreased. Monoperem
was increased to 2g IV every 8 hours, suggested to shift citicholine to oral 500 mg BID.
Cerebrolysin to add vancomycin 1g IV every 12 hours, repeat creatinine and decrease mannitol
On the ninth day of hospitalization, patient was still GCS 3 present management was
continued. On the tenth day of hospitalization, present management was continued. DNR
waver was signed on the eleventh day, present management was continued and DNR consent
was noted. Daily wound care was done and continued present management. Supportive care
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PHYSICAL EXAMINATION
VITAL SIGNS during the assessment September 15, 2017 at 12:00 PM
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GENERAL APPEARANCE
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dysfunction of vasomotor
centers in the brain stem.
Reference:
http://stroke.ahajournals.org
/content/strokeaha/33/5/
1225.full.pdf
Skin lesions Inspection Presence of lateral No lesion Patient undergone
clean surgical clipping of aneurysm at
wound with the the right internal carotid
length of artery and insertion of
approximately 3 ventriculostomy tube on
cm on the left side September 01, 2017.
of the neck
Temperature Palpation Cold and clammy Warm to Temperature changes are
common in patients in a
touch neurosurgical intensive
care unit. Fever is
frequent among severe
cases and hypothermia is
used after cardiac arrest
and is currently tested in
clinical trials to lower
ICP
Reference:
Stretti & Gotti 2014 Bramed
Central 2014
Skin Turgor Palpation Good skin turgor Good skin Edema after SAH may
turgor reflect diffuse ischemic
injury due to transient
ictal cerebral circulatory
arrest, diffuse
inflammatory or
neurotoxic effects of
blood and its degradation
products on brain tissue,
or abnormal
autoregulation due to
microvascular damage or
dysfunction of vasomotor
centers in the brain stem.
Reference:
http://stroke.ahajournals.org
/content/strokeaha/33/5/
1225.full.pdf
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NAILS
HEAD
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EYES
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EARS
AREA TECHNIQUE ACTUAL NORMAL ANALYSIS
ASSESSED USED FINDINGS FINDINGS
Pinna Inspection Uniform in color, Uniform in color, Normal
symmetrical symmetrical
Ear canal Inspection Presence of Presence of Normal
cerumen/earwax cerumen/earwax
Hearing Inspection No Response Responds when Patients is
acuity when called called unconscious with
GCS of 3/15
(E1V1M1)
NOSE
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NECK
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ABDOMEN
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DIAGNOSITICS/LABORATORY EXAMINATIONS
BRAIN CT SCAN
September 8, 2017
Clinical Data: Diagnose case of aneurysm at the right internal carotid artery, s/p clipping
(09/01/2017)
Comparison: Previous CT scan dated (08/31/17)
Technique: Multiplanar CT scan of the brain without IV contrast
Findings:
Follow up since 8/31/2017 shows craniectomy defect in the right frontal bone. Underlying
minimal extra-axial blood collection is appreciated measuring 0.7 cm in thickness. Soft
tissue swelling in the right frontal area with a drainage tube in place. Metallic density is
now seen along the area of the right sylvian fissure representing the surgical clip.
There is still subarachnoid hemorrhage now seen in the area of the surgical clip, right
sylvian fissure, suprasellar and right cerebro-pontine angle cisterns, left frontal and both
parietal cortical sulci. These show interval increase since the previous study.
Intraventricular hemorrhage is now appreciated within the ventricular system. The left
lateral ventricle is mildly dilated. Ventriculostomy tube is noted coursing through the right
frontal lobe with the tip at the atrium of the left lateral ventricle.
Midline shift at about 0.6 cm to the left is noted.
Wedge shaped hypodensities are now appreciated in the right frontal and right temporal
lobes. There is decrease in attenuation of the subcortal layer of the right parietal lobe.
Minimal pneumocephalus in the right prepontine cistem.
Impression:
s/p clipping of aneurysm, craniectomy and ventriculostomy tube insertion
subarachnoid hemorrhage, showing interval increase
mild hydrocephalus (non-communicating)
midline shift to the left
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Red Blood Cell 3.71 4.50-5.50 x 10^12/L Patient with SAH commonly
(L) develops anemia and requires
blood transfusion.
Reference:
(Gresenbaum & Ruskin, 2015)
Hematocrit 0.38 0.37-0.47 L Normal
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URINALYSIS
September 5, 2017
PROTHROMBIN TIME
September 2, 2017
TEST RESULT NORMAL VALUES ANALYSIS
45 seconds
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IMMUNOLOGY SECTION
September 5, 2017
HBA1C 5.40% (NV: 4.3 6.4)
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CLINICAL FINDINGS
HEMATOLOGY SECTION
DIGESTIVE SYSTEM
INTEGUMENTARY SYSTEM
Skin Lesions Presence of surgical wound on the left side of the neck
Temperature Cold and clammy
Nail bed bluish
CARDIOVASCULAR
RESPIRATORY
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The Hindbrain
The hindbrain is the structure that connects the spinal cord to the brain.
The medulla is located directly above the spinal cord and controls many vital autonomic
functions such as heart rate, breathing, and blood pressure
The pons connects the medulla in the cerebellum and helps coordinate movement on
each side of the body
The reticular formation is a neural network located in the medulla that helps control
functions such as sleep and attention
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The Midbrain
It controls many important functions such as the visual and auditory systems as well as
eye movement. Portions of the midbrain called the red nucleus and the substantia nigra are
involved in the control of the body movement.
The Cerebellum
Sometimes referred to as the little Brain, it lies on top of the pons, behind the brain
stem. The cerebellum is comprised of small lobes and receives information from the balance
system of the inner ear, sensory nerves and the auditory and visual systems. It involves in the
coordination or motor movements as well as the basic parts of the memory and learning.
The Thalamus
Located above the brainstem, the thalamus processes and relays movement and sensory
information. It is essentially a relay station, taking in sensory information and then passing it
on the cerebral cortex, the cerebral cortex also sends information to the thalamus to other
systems.
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The Hypothalamus
The hypothalamus is a small area in the center of the brain that has many jobs. Its
underneath the thalamus and above the pituitary gland. It plays an important role in hormone
production and helps to stimulate many important processes in the body. the hypothalamus
acts as the connector between the endocrine and nervous systems. It plays a part in many
essential functions of the body such as:
Body temperature
Blood pressure and heart rate
Production of digestive juices
Balancing bodily fluids
Appetite and Weight control
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The Meninges
The meninges refer to the membranous coverings of the brain and spinal cord. There
are three layers of meninges, known as the dura mater, arachnoid mater and pia mater.
These coverings have two major functions:
Provide a supportive framework for the cerebral and cranial vasculature.
Acting with cerebrospinal fluid to protect the CNS from mechanical damage.
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Arachnoid Mater
It is interposed between the two other meninges, the more superficial and much thicker
dura mater and the deeper pia mater, from which it is separated by the subarachnoid space. The
delicate arachnoid layer is attached to the inside of the dura and surrounds the brain and spinal
cord. The arachnoid mater is one of the three meninges, the protective membranes that cover
the brain and spinal cord. The arachnoid mater is a derivative of the Neural crest mesectoderm
in the embryo.
Pia Mater
It is often referred to as simply the pia, is the delicate innermost layer of the meninges,
the membranes surrounding the brain and spinal cord. Pia mater is medieval Latin meaning
"tender mother. The other two meningeal membranes are the dura mater and the arachnoid
mater. Both the pia and arachnoid mater are derivatives of the neural crest while the dura is
derived from embryonic mesoderm. Pia mater is a thin fibrous tissue that is impermeable to
fluid. This allows the pia mater to enclose cerebrospinal fluid. By containing this fluid, the pia
mater works with the other meningeal layers to protect and cushion the brain. The pia mater
allows blood vessels to pass through and nourish the brain. The perivascular space created
between blood vessels and pia mater functions as a lymphatic system for the brain. When the
pia mater becomes irritated and inflamed the result is meningitis
It is the movement of blood through the network of cerebral arteries and veins
supplying the brain. The rate of the cerebral blood flow in the adult is typically 750 milliliters
per minute, representing 15% of the cardiac output. The arteries deliver oxygenated blood,
glucose and other nutrients to the brain, and the veins carry deoxygenated blood back to the
heart, removing carbon dioxide, lactic acid, and other metabolic products.
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Blood supply
Cortical areas and their arterial blood supply
Blood supply to the brain is normally divided into anterior and posterior segments,
relating to the different arteries that supply the brain. The two main pairs of arteries are the
Internal carotid arteries (supply the anterior brain) and vertebral arteries (supplying the
brainstem and posterior brain).
The anterior and posterior cerebral circulations are interconnected via bilateral
posterior communicating arteries. They are part of the Circle of Willis, which provides backup
circulation to the brain. In case one of the supply arteries is occluded, the Circle of Willis
provides interconnections between the anterior and the posterior cerebral circulation along the
floor of the cerebral vault, providing blood to tissues that would otherwise become ischemic.
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Vertebral arteries: These smaller arteries branch from the subclavian arteries which primarily
supply the shoulders, lateral chest and arms. Within the cranium the two vertebral arteries fuse
into the basilar artery.
Posterior inferior cerebellar artery (PICA)
Basilar artery: Supplies the midbrain, cerebellum, and usually branches into the
posterior cerebral artery
Anterior inferior cerebellar artery (AICA)
Pontine branches
Superior cerebellar artery (SCA)
Posterior cerebral artery (PCA)
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