1. 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

2. CONTENTS Objective Personal Data Chief Complaint History
Definition of SAH
Pathophysiology
Sign & symptom
Assessment
-Parameter
-Laboratory investigation
-Radiology investigation
Management
-Medical management
-Surgical management
Nursing Care
Health education
Summary

3. Objective

4. 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

5. Personal Data
Name: Mr. L Medical Registration Number: Age: 49 yrs old Sex: Male Occupation: Mechanic Date Of Admission: 15/01/2013 Diagnosis: Subarachnoid haemorrhage

6. 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.

7. Family request to transferred to NORMAH to have further treatment and management.
Patient was transferred by helicopter on 1.30 a.m.
Admitted to ICU for further treatment and management.

8. History Medical history: Unknown medical problem Surgical history: NIL
Social history:
Married with 3 children
Alcoholic- since patient was 14 years old.
Non-smoker

9. Subarachnoid space

10. Subarachnoid space

11. What is aneurysm?
A balloon-like bulge or weakening of an artery wall that ruptures, releasing blood into the subarachnoid space around the brain.

12. 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.
A ruptured aneurysm releases blood into the subarachnoid space (left).

13. 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.

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

15. Pathophysiology

16. Not known medical illness Aneurysms typically form in the bifurcations of the large vessels that make up the circle of Willis.

17. Aneurysm leaking Leading to blood extravasation into the subarachnoid space.

18. Subarachnoid hemorrhage Query rogressive decrease in cerebral blood flow occurs, result from a sudden massive increase in intracranial pressure (ICP)

19. Comatose state

20. Signs & symptoms of SAH General Signs & Symptoms from MSN book
The 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

21. Assessment Vital signs: On admission- 15/1/13, B/P: 220/90mmHg
PR: 85 bpm
RR: 15 bpm
Temp. : 37.5°C
SPO₂: 100% ventilated with 40% O₂
An invasive line was inserted
Arterial line
Central Venous Catheter (CVC)
Intracranial Pressure (ICP) mmHg
Cerebral Perfusion Pressure (CPP)- 75mmHg

22. Vital signs during hospitalization in ICU (16/1/13-24/1/13): (Ranging)
B/P: / 60-80mmHg
PR: bpm
RR: bpm
Temp.: 37.5°C- 39.4°C
SPO₂: 96%-100% ventilated with 40% O₂
On – 130/50 (IV Noradrenaline was given as per Dr. order)
*Off on

23. 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.

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

25. All invasive line and ventilator was off on 22/1/13
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 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

26. Diagnostic Procedure
Lab test
Radiological

27. Laboratory Test 1.Heamatology Date HB T.Red Cell PCV MCV MCH
T.White Cell
12.7 [13-18]g/dl
0.38 [ ]L/L
69 [76-96]fl
23 [27-33]pg
19.8x10[4-11]
9.7 [13-18]g/dl
0.31 [ ]L/L
72 [76-96] fl
23 [27-33] pg
11.2x10^9/L [4-11]
10.4 [13-18]g/dl
0.32 [ ]L/L
23 [27-33] pg

28. Laboratory Test 1.Heamatology Date HB T.Red Cell PCV MCV MCH
T.White Cell
0641HR
10.4 [13-18]g/dl
0.32 [ ]L/L
68 [76-96] fl
23 [27-33] pg HR
9.6 [13-18]g/dl
0.32 [ ]L/L

29. Laboratory Investigation 2.Biochesmistry

30. Renal Function Test Objectives : To evaluate how well the kidney are working. Types of test carried out :-
Date
Types
Result
Remarks
0310HR
Potassium
Chloride
Bicarbonate
3.4 mmol/L [ ]
96 mmol/L [97-110]
21 mmol/L [22-29]
Low
1045HR
3.3 mmol/L[ ]
1533HR
3.3 [ ]mmol/L
111 [97-110]mmol/L
High

31. Liver Function Test Objectives : To detect inflammation and damage to the liver and to evaluate how well liver working. Types of test carried out :-
Date
Types
Result
Remarks
0310HR
Total Bilirubin
Globulin
GGT
21 umol/L [3-20]
25 g/L [28-36]
85 U/L [11-50]
High
Low
0745HR
Alkaline Phosphate
58 g/L [66-87]
24 g/L [28-36] 56 U/L [11-50]
1045HR
25 g/L [28-36] 85 U/L [11-50]
1533HR
24 g/L [28-36]
56 U/L [11-50]

32. Lipid Profile Objectives : to evaluate the abnormalities in lipid level in the blood. Types of test carried out :-
Date
Types
Result
Remarks
0745HR
HDL Cholesterol
1.7 mmol/L [ ]
High

33. Laboratory Investigation 3.Microbiology

34. 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 : 15/1/13 Specimen : Blood Test Ordered : Urin , spuctum,CSF Result : No growth after 48hour Date: 18/1/13 (repeat) Specimen: Sputum Test Ordered : Blood ,urine , CSF Result : Klebsiella pneumoniae ( Tazocin ) Date : 23/1/13 (repeat) Specimen : Sputum taken at ETT Result : Acinetobacter baumannii

35. Radiological investigation
CXR
MSCT
Cerebral angiogram

36. Chest X-Ray Objective: Used to screen ,diagnose and evaluate changes in respiratory system.
Date: 15/1/13 Result: -Left mid zone consolidation. (alveoli stick to each other)

37. Multislice Computed Tomography Scan Objective: To visualize the heart anatomy, coronary circulation and great blood vessel.
Date : 15/1/13 Result :- -Right frontal bleed with massive subarachnoid extension. Date: 16/1/13 Result:- -No hydrocephalus or increase in bleeding noted. -The brain does not show any mass effect.

38. Operation: Cerebral Angiogram
Date:
Definition 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- ? ACAA
Conclusion:-
-Anterior communicating artery aneurysm.(ACAA)

39. Medical Management
G:\ICU CASE STUDY - medical.docx

40. Surgical Management Tracheostomy & clipping of the aneurysm

41. Operation : Tracheostomy
Date :19/1/13
Definition 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.

42. Operation:Left Craniotomy & Clipping of aneurysm
Date: 21/1/13
Definition 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.

43. 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.

44. Nursing Care…

45. NURSING
PROBLEM
GOAL
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.

46. 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
( )
Subjective data:
-NIL
Patient will not develop increased in intracranial pressure.
1.Monitor for trend of ICP hourly
2.Elevate bed degree
1.To prevent increased in ICP
2. To reduce the pressure to the brain

47. 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 .

48. 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 having
Repeat sputum
Culture
and sensitivity
23.1.show
The result is
Acinetobacter
baumanii

49. 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.
To detect any skin break down.
To prevent the redness of the skin and maintain the good blood circulation in their body.

50. 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.

51. Health Education

52. Care of patient with Tracheostomy
Wash your hand before touching the trachy to prevent infection

53. Care of patient with Tracheostomy
Makesure the trachy is attach to the correct position.

54. Care of patient with Tracheostomy
Observed for redness at the trachy site

55. Care of patient with Tracheostomy
Advised patient to cough out to remove the mucus that can block the airway

56. 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

57. Summary
Patient was admitted to ICU on January Patient condition was stable during hospitalization in ICU. Tracheotomy had been done on 19, January, 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

58. The End…