Nonaneurysmal Subarachnoid Hemorrhage: A Review of Clinical Course and Outcome in Two Hemorrhage Patterns

Linda L. Herrmann; Joseph M. Zabramski


J Neurosci Nurs. 2007;39(6):135-142. 

In This Article

Nursing Interventions

Nursing interventions include the initial admission of the patient to the unit, physical examination, administration and titration of medications according to prescribed parameters, and assessment of hemodynamic status to achieve and maintain goals as outlined by the neurosurgical service.

Ongoing collaboration with the neurosurgical team (attending physician, residents, nurse practitioners) fosters communication regarding test results, the patient's response to treatment modalities, and plans for repeat testing (CT scans, angiograms). Nurses should also review the patient's medications. Initial medications include nimodipine; antihypertensive medication may be initiated to maintain SBP goal of less than 140 mm Hg until aneurysmal rupture has been excluded. After ASAH is excluded, a patient's SBP parameters are relaxed, allowing the patient's SBP to return to baseline. Patients with persistently elevated SBP of greater than 160 mmHg are usually started on low-dose oral antihypertensive medications before hospital discharge. These medications can be gently titrated by the primary care provider toward a goal SBP of 120–140 mm Hg. In patients with hypotension (SBP less than 110 mm Hg), pressors such as IV phenylephrine may be initiated to maintain an SBP greater than 110 mm Hg. The use of antiepileptic drugs (AEDs) in this population depends on the presence or potential risk of seizure activity; this decision is at the discretion of the attending neurosurgeon or neurosurgical team.

Other issues to be addressed by nurses are the patient's diet and activity status and the assessment and management of pain. These patients rarely require surgical intervention, with the exception of a few who may require placement of an EVD. Therefore, patients with an appropriate level of consciousness and adequate swallow function typically begin taking a diet shortly after admission. Early mobilization is beneficial from a pulmonary and psychological standpoint, as well as in reducing the incidence of deep vein thrombosis (DVT). Initiation of subcutaneous enoxaparin or heparin for DVT prophylaxis in patients on prolonged bed rest is left to the discretion of the attending neurosurgeon. Physical and occupational therapy may be initiated at the discretion of the nurses and neurosurgical team.

Analgesics, prescribed upon admission, usually include IV morphine sulfate at 1–2 mg per hour for mild pain, 3–4 mg per hour for moderate pain, and 5–6 mg per hour for severe pain. In addition, patients may take oral narcotic analgesics (e.g., one or two tablets of hydrocodone 5 mg/acetaminophen 325 mg every 4–6 hours as needed). The 0–10 Numeric Pain Intensity Scale (Agency for Health Care Policy and Research, 1992), a standardized pain assessment tool, is helpful in evaluation of adequate analgesia. Nonpharmacologic interventions include the use of ice packs, warm compresses, and relaxation techniques.

Additional pertinent patient care issues reviewed with the neurosurgical team are the results of trans-cranial Doppler (TCD) studies and cerebrospinal fluid (CSF) studies in patients with an EVD, as well as the need for repeat cerebral angiography and frequency of follow-up CT imaging. Finally, one of the most important nursing interventions is regular communication with the patient and family regarding the plan of care, patient and family education, patient progress, upcoming tests, symptom relief, and discharge planning.