TITLE: “SUBARACHNOID HAEMORRHAGE”

Group Members: (1) STN Minsuin ak Akong (2) STN Siti Niza (3) STN Siatny ak Bujang (4) STN Sim Jia Ming (5) STN Priscilla Dayang Ngilo (6) STN Monica Eemas (7) STN Mistika Rinai Baru (8) STN Nelson Ujai ak Singgon

CONTENTS1. Objective2. Personal Data3. Chief Complaint4. History5. Definition of SAH6. Pathophysiology7. Sign & symptom8. Assessment

-Parameter-Laboratory investigation-Radiology investigation

9. Management-Medical management-Surgical management

10. Nursing Care11. Health education12. Summary

Objective

Objective …

• To improve knowledge on neurological topic• To improve understanding on pathophysiology

of SAH• To relate the indication of medication to

patient condition • To give opportunity to relate theory to

practice regarding nursing care of the patient

Personal DataName: Mr. LMedical Registration Number: 333273Age: 49 yrs oldSex: MaleOccupation: MechanicDate Of Admission: 15/01/2013Diagnosis: Subarachnoid haemorrhage

Chief Complaint- Patient having sudden onset of severe

headache in the afternoon followed by comatose state at 5.00p.m on 14/1/13.

- No history of fall and emotional disturbance.- Subsequently admitted to Sibu Hospital and

he was intubated and ventilated. - Doctor(Sibu Hospital) was queried patient has

aneurysm.

- Family request to transferred to NORMAH to have further treatment and management.

- Patient was transferred by helicopter on 15/01/2013 @ 1.30 a.m.

- Admitted to ICU for further treatment and management.

History• Medical history:- Unknown medical problem

• Surgical history:- NIL

• Social history:- Married with 3 children- Alcoholic- since patient was 14 years old.- Non-smoker

Subarachnoid space

Subarachnoid space

What is aneurysm?

– A balloon-like bulge or weakening of an artery wall that ruptures, releasing blood into the subarachnoid space around the brain.

A ruptured aneurysm releases blood into the subarachnoid space (left).

When red blood cells break down, toxins can cause the walls of

arteries nearby to contract and spasm. The larger the SAH, the higher the risk of vasospasm.

Subarachnoid haemorrhage• Subarachnoid

haemorrhage is bleeding into the subarachnoid space-the area between the arachnoid membrane and the pia mater surrounding the brain. This may occur spontaneously, usually from a ruptured cerebral aneurysm.

The difference between a normal brain and a brain that has SAH

Pathophysiology

Not known medical illness

Aneurysms typically form in the

bifurcations of the large vessels that

make up the circle of Willis.

Aneurysm leaking

Leading to blood extravasation into the subarachnoid

space.

Subarachnoid hemorrhage

Query rogressive decrease in cerebral blood flow occurs,

result from a sudden massive increase in

intracranial pressure (ICP)

Comatose state

Signs & symptoms of SAHGeneral Signs & Symptoms from MSN

bookThe signs & symptoms of the patient

•Sudden onset of a severe headache (often described as "the worst headache of my life")•Nausea and vomiting•Stiff neck•Sensitivity to light (photophobia)•Blurred or double vision•Loss of consciousness•Seizures •Numbness in part of the body

•Sudden onset of headache before admitted verbalized by wife. •Muscle aches especially neck pain and shoulder pain verbalize by wife.•Weakness at left limb•Comatose status

Assessment• Vital signs:- On admission- 15/1/13,B/P: 220/90mmHgPR: 85 bpmRR: 15 bpmTemp. : 37.5°CSPO₂: 100% ventilated with 40% O₂

- An invasive line was insertedArterial lineCentral Venous Catheter (CVC) Intracranial Pressure (ICP)- 16-20mmHgCerebral Perfusion Pressure (CPP)- 75mmHg

- Vital signs during hospitalization in ICU (16/1/13-24/1/13): (Ranging)

B/P: 150-160/ 60-80mmHgPR: 83- 90bpmRR: 16- 21bpmTemp.: 37.5°C- 39.4°CSPO₂: 96%-100% ventilated with 40% O₂

- On 15/1/13 @3p.m – 130/50 (IV Noradrenaline was given as per Dr. order)

*Off on 16/1/13 @9a.m

• GCS (Glasgow Coma Scale):- Patient’s GCS was at the range of 5/15 – 11/15

during hospitalization in ICU.- On the GCS motor assessment, patient’s Lt.

sided was totally not response to our pain stimulisation. However, his Rt. sided was slightly weak and move flexion when response to pain stimulisation.

- On the eye assessment, patient looked drowsy, only open eyes to call and not obey command.

• Both pupil size was at the range of 2-4mm and reactive to light.

- All invasive line and ventilator was off on 22/1/13. Parameter was stable.

- No more ICP and CPP monitoring.- Patient was transferred out to Serapi ward on

24/1/13 @9.45 a.m with tracheostomy insitu.- Vital signs was stable before transferred to

Serapi ward except patient was still having fever (37°C-38°C).

- On trachy ventilated with 1L of O₂

Diagnostic Procedure

• Lab test• Radiological

Date HB T.Red Cell PCV MCV MCH T.White Cell

15/1/13@0310HR

12.7 [13-18]g/dl

0.38 [.40-0.54]L/L

69 [76-96]fl

23 [27-33]pg

19.8x10[4-11]

16/1/13@0740HR

9.7 [13-18]g/dl

0.31 [.40-0.54]L/L

72 [76-96] fl

23 [27-33] pg

11.2x10^9/L [4-11]

18/1/13@1048HR

10.4 [13-18]g/dl

0.32 [.40-0.54]L/L

72 [76-96] fl

23 [27-33] pg

Laboratory Test1.Heamatology

Date HB T.Red Cell PCV MCV MCH T.White Cell

20/1/13 @ 0641HR

10.4 [13-18]g/dl

0.32 [.40-0.54]L/L

68 [76-96] fl

23 [27-33] pg

21/1/13 @ 1533HR

9.6 [13-18]g/dl

0.32 [.40-0.54]L/L

68 [76-96] fl

23 [27-33] pg

Laboratory Test1.Heamatology

Laboratory Investigation2.Biochesmistry

Renal Function TestObjectives : To evaluate how well the kidney are working.Types of test carried out :-

Date Types Result Remarks

15/1/13 @ 0310HR

PotassiumChlorideBicarbonate

3.4 mmol/L [3.5-5.1]96 mmol/L [97-110]21 mmol/L [22-29]

LowLowLow

20/1/13 @ 1045HR

Potassium 3.3 mmol/L[3.5-5.1] Low

21/1/13 @ 1533HR

PotassiumChloride

3.3 [3.5-5.1]mmol/L111 [97-110]mmol/L

LowHigh

Liver Function TestObjectives : To detect inflammation and damage to the liver and to evaluate how well liver working. Types of test carried out :-

Date Types Result Remarks

15/1/13 @ 0310HR Total BilirubinGlobulinGGT

21 umol/L [3-20]25 g/L [28-36]85 U/L [11-50]

HighLowHigh

16/1/13 @ 0745HR Alkaline PhosphateGlobulinGGT

58 g/L [66-87]24 g/L [28-36]56 U/L [11-50]

LowLowHigh

20/1/13 @ 1045HR

Total BilirubinGlobulinGGT

21 umol/L [3-20]25 g/L [28-36]85 U/L [11-50]

HighLowHigh

21/1/13 @ 1533HR

Alkaline PhosphateGlobulinGGT

58 g/L [66-87]24 g/L [28-36]56 U/L [11-50]

LowLowHigh

Lipid ProfileObjectives : to evaluate the abnormalities in lipid level in the blood. Types of test carried out :-

Date Types Result Remarks

16/1/13 @ 0745HR HDL Cholesterol 1.7 mmol/L [0.91-1.45]

High

Laboratory Investigation3.Microbiology

Culture and sensitivity(C&S)Objective :-A culture is done to find out what kind of organism (usually a bacteria) is causing an illness or infection.

-A sensitivity test checks to see what kind of medicine, such as an

antibiotic,will work best to treat the illness or infection.

Date : 15/1/13Specimen : Blood Test Ordered : Urin , spuctum,CSFResult : No growth after 48hourDate: 18/1/13 (repeat)Specimen: Sputum Test Ordered : Blood ,urine , CSFResult : Klebsiella pneumoniae ( Tazocin

)Date : 23/1/13 (repeat)Specimen : Sputum taken at ETTTest Ordered : Blood ,urine , CSFResult : Acinetobacter baumannii

• CXR• MSCT

• Cerebral angiogram

Radiological investigation

Chest X-RayObjective: Used to screen ,diagnose and evaluate changes in respiratory system.

Date: 15/1/13Result:-Left mid zone consolidation.(alveoli stick to each other)

Multislice Computed Tomography ScanObjective: To visualize the heart anatomy, coronary circulation and great blood vessel.

Date : 15/1/13Result :--Right frontal bleed with massive subarachnoid extension.Date: 16/1/13Result:--No hydrocephalus or increase in bleeding noted.-The brain does not show any mass effect.

Operation: Cerebral Angiogram

Date: 15/1/13@2.50pmDefinition of cerebral angio?Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms.Result Cerebral Angiogram:-Clinical problem- ? ACAAConclusion:--Anterior communicating artery aneurysm.(ACAA)

Medical Management

• G:\ICU CASE STUDY - medical.docx

Surgical ManagementTracheostomy &

clipping of the aneurysm

Operation : Tracheostomy

Date :19/1/13Definition of

Tracheostomy?-A tracheostomy is a surgical

procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube.

Operation:Left Craniotomy & Clipping of aneurysm

Date: 21/1/13Definition of craniotomy?A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been performed.

Definition of aneurysm clipping?

The goal of surgical clipping is to isolate an aneurysm from the normal circulation without blocking off any small perforating arteries nearby.

A small clip is placed across the base, or neck, of the aneurysm.

Blades of the clip remain tightly closed until pressure is applied to open the blades.

Nursing Care…

NURSING PROBLEM

GOAL NURSING INTERVENTION

RATIONALE EVALUATION

Ineffective airways clearance related to thick secretion secondary to inadequate coughing and decrease mobility.

Objective data:-patient having low SPO2 level

Subjective data: -patient frequently coughing

Patient able to maintain patent airways

1.Observe patient general status for rate and rhythm of respiration.

2.Elevate the head of bed 30°.

3.ETT Tube or Nasal Suction as needed.

4. Monitor SPO2 level

5.Report to Doctor if the colour of sputum change

1.To assess any difficulty in breathing.

2.For maximal thoracic expansion.

3. To clear the airway from excessive secretion.

4.As base line

5.For further management .

The airways are clear and patient are not having any difficulty in breathing.

NURSING PROBLEM

GOAL NURSING INTERVENTION

RATIONALE EVALUATION

Increase intracranial pressure (ICP)related to accumulation of blood in the cerebral tissue.

Objective data: -ICP probe was show high reading of ICP within ( 16-20 )

Subjective data:-NIL

Patient will not develop increased in intracranial pressure.

1.Monitor for trend of ICP hourly

2.Elevate bed 20-30 degree

1.To prevent increased in ICP

2. To reduce the pressure to the brain

NURSING PROBLEM

GOAL NURSING INTERVENTION

RATIONALE EVALUATION

Increase intracranial pressure (ICP)related to accumulation of blood in the cerebral tissue.

Patient will not develop increased in intracranial pressure.

3.Maintain cerebral protection as ordered example keep patient fully sedated.

4.Give medication as prescribe by Doctor such as Nimotop

5. Inform Doctor if ICP trend increased more than 15 mmHg

3. To reduce brain activity.

4.To prevent cerebral spasm

5.For immediately action and management

Increased intracranial pressure well be under control .

NURSING PROBLEM

GOAL NURSING INTERVENTION

RATIONALE EVALUATION

Infection related to invasive line. (Example:-CBD-central venous catheter -ICP probe-IV line )

Objective data:-temperature 38.9.-total white cell.-sputum culture and sensitivity show klebsiella pneumoniae.

Subjective data:-flushing on the face

Patient is free from infection as evidenced by negative culture and sensitivity result.

1.Observe the sign and symptom of infection :a)Body temperature >38°c.

2.Proper hand washing technique (5 moment).

3.Use aseptic technique when do procedure.

4.Give antibiotic as order and apply tepid sponging

1.As a baseline to see any changes of body temperature.

2.To prevent infection.

3.Maintain the hygiene and prevent infection.

4.To reduce the infection and temperature.

-patient still having high Temperature-patient havingRepeat sputumCulture and sensitivity23.1.showThe result isAcinetobacter baumanii

NURSING PROBLEM

GOAL NURSING INTERVENTION

RATIONALE EVALUATION

Risk of impaired of skin integrity related to prolong bed rest and immobility.

Objective data:-redness of the skin ,and itchy.

Subjective data:-patient look not comfortable

Patient will remain skin intact and without redness during hospitalization.

1.Assess skin condition.

2.Turning patient every 2hourly and avoid friction on the bed sheet during turning.

1. To detect any skin break down.

2. To prevent the redness of the skin and maintain the good blood circulation in their body.

NURSING PROBLEM

GOAL NURSING INTERVENTION

RATIONALE EVALUATION

Risk of impaired of skin integrity related to prolong bed rest and immobility.

Patient will remain intact and without redness during hospitalization.

3.Keep linen dry ,free of wrinkles.

4.Apply lotion in the dry skin.

3.To prevent the skin break down cause by the wet linen.

4.To moisture the skin.

Patient will not develop skin break down through out hospitalization.

Health Education

Care of patient with Tracheostomy

• Wash your hand before touching the trachy to prevent infection

Care of patient with Tracheostomy

• Makesure the trachy is attach to the correct position.

Care of patient with Tracheostomy

• Observed for redness at the trachy site

Care of patient with Tracheostomy

• Advised patient to cough out to remove the mucus that can block the airway

Care of patient with Nasogastric tube

• Advise patient relative during feeding time , patient should on Fowler’s position

• Advise patient relative to do not pulling out the tube

• secure the NG tube with micropore or plaster

Summary

• Patient was admitted to ICU on 15-24 January 2013. Patient condition was stable during hospitalization in ICU. Tracheotomy had been done on 19, January,2013 . Then patient go for craniotomy on 21,January ,2013 for clipping of aneurysm . On 24 January 2013 patient was transfer to Serapi ward for further treatment and been discharge on 13 .March .2013 .

The End…