Care Plan - Subdural Hematoma

[Daytonite, BSN, RN]

As a student you must understand that doing a care plan also involves learning about the patient's underlying disease process. This is why I have listed a number of weblinks toward the end of this post for you to explore on subdural hematomas, head injuries, alcoholism and malnutrition. I am not meaning to be mean to you, but I can't believe that your patient doesn't have any abnormal symptoms. What I can believe is that you are just not recognizing them. This may, perhaps, be because you are not familiar with what to look for. Is the subdural hematoma a result of a fall or some kind of head trauma? This is a very common thing with alcoholics. Long term alcoholics often have underlying liver problems which usually means they have some kind of coagulopathy going on which makes the likelihood of hemorrhaging anywhere in the body very easy to occur. Add all that up and alcoholism + a fall = the likelihood of a subdural hematoma. The alcoholism is also going to link you (for your care map) to his low body weight and malnutrition.

I worked on a neuro unit when I first graduated from nursing school and saw all kinds of head trauma. There are always symptoms although they may be very subtle. Did you read the chart? What did the doctor's progress notes and the history and physical have to say? This information can be used in determining his signs and symptoms and in writing your care plan.

A subdural hematoma usually occurs slowly and results from venous bleeding as a result of tearing of the vein(s). Long term alcoholism also contributes to liver problems (coagulopathy) that result in easy bleeding with any trauma. (Do you see these linkages that I'm giving you that you need for your concept map?) You need to make these pathophysiological connections in doing this care plan. A subdural hematoma is the result of an increase in the intracranial pressure in the brain. Increased intracranial pressure obstructs the absorption of cerebrospinal fluid (CSF) and affects the function of the nerve cells which can lead to brainstem compression and death. The signs and symptoms of intracellular pressure include (you will find others in the weblinks I listed for you):

• slurred speech
• dilated, nonreactive pupils, often ipsilateral (on the same side) to the location of the hematoma
• changes in motor function from weakness to hemiplegia with positive Bablinski's reflex (dorsiflexion of the ankle and great toes with fanning of the other toes), decorticate (flexion of one or both arms and stiff extension of the legs) or decerebrate (stiff extension of one or both arms and/or legs) posturing, flaccidity (no motor response at all in any extremity) and seizures
• hemiparesis (one-sided paralysis) contralateral (on the opposite side) to the hematoma
• balance problems and impaired gait (if the patient is able to ambulate)
• dizziness
• declining levels of consciousness from restlessness to confusion to coma
  • alert wakefulness
  • restlessness
  • drowsiness
  • confusion
  • delirium
  • stupor
  • coma
• various levels of dementia is usually a specific finding in patients with subdural hematomas
• headache
• abnormal respirations
• a rise in blood pressure with widening pulse pressure
• slowing of the pulse
• an elevated temperature
• vomiting
• CSF drainage from the ears or nose

Any of these signs will lead you to nursing diagnoses of

• Acute Pain
• Ineffective Tissue Perfusion: Cerebral
• Decreased Intracranial Adaptive Capacity (use this only if the patient is in ICU and ICP pressures are being measured)
• Risk for Infection
• Risk for Injury

What might be the reasons for the patient's low weight? What does the chart say? Is he eating? Is there an underlying GI problem? Is he so involved with his alcoholism that he focuses on his drinking rather than eating (this is a common problem in long term, diehard alcoholics)?

A big part of doing a care plan is your assessment which includes investigating as much of the patient's background information as you can get your hands on. You have to always be asking yourself "why" questions and seeking to know the underlying pathophysiology of the medical conditions the patient has.

Please go over the signs and symptoms of subdural hematoma and head injury that are listed in these articles and think about what you saw in your patient. Did you miss something when you were observing and assessing your patient? Assessment, when you are new at it, is a difficult skill to learn. We learn from the errors and omissions we make.

Here is a guideline for assessing a patient's mental status:

Sensorium, Mental Grasp and Capacity:

Consciousness: Alert, Clouded, Fluctuating, Stuporous

Orientation: Normal, Mild, Moderate, Severe, Disorientation to (time, place, person, situation)

Memory: Intact, Mild, Moderate, Severe, Memory Deficits (Immediate, Recent, Remote)

Digit Span: Forward (good, poor), Backward (good, poor)Disorders of: Counting, Calculation, Reading, Writing, Attention, Concentration, Comprehension

General Knowledge: Good, Poor, Consistent with education, Inconsistent with education, Personalized, Superficial, Pseudoabstraction

Intelligence: Normal, Below Normal, Above Normal

Insight: Good, Fair, Poor, None

Judgment: Good, Fair, Poor, None

Emotional State/Reaction:

Affect: Unremarkable, Indifferent, Fearful, Angry, Euphoric, Anxious, Sad

Range: Normal, Labile, Constricted

Depth: Normal, Shallow, Increased

Vegetative Symptoms of Depression: Depressed mood, Loss of interest of pleasure, Appetite Disturbance, Sleep Disturbance, Psychomotor Agitation or Retardation, Fatigue of Loss of energy, Decreased concentration, Feelings of worthlessness or guilt, Diurnal mood variation

Suicidal/Homicidal: Denies, Ideation, Plan, Attempt

General Attitude and Behavior:

Behavior: Cooperative, Passive, Domineering, Withdrawn, Restless, Dramatic, Hostile, Intimidating, Suspicious, Uncooperative, Other __________

Appearance: Unkempt, Disheveled, Clean, Neat, Unusual

Attire: Appropriate, Seductive, Loud, Meticulous, Untidy, Atypical

Facial Expression: Unremarkable, Sad, Angry, Perplexed, Fearful, Elated, Immobile, Grimacing, Atypical

Gait: Normal, Parkinsonian, Ataxic, Shuffling, Unusual, Other__________

Motor Activity: Unremarkable, Agitated, Hypoactive, Tremor, Tic, Hyperactive, Pacing, Handwringing, Mannerisms

Stream of Mental Activity:

Productivity: Spontaneous, Verbose, Pressured, Slow, Soft, Mute, Atypical

Progression: Logical, Association, Loose Association

Circumstantiality: Perseveration, Halting, Incoherent, Fragmented, Tangential, Flight of Ideas, Ruminations, Confabulation, Neologism

Language: Normal, Childlike, Peculiar, Stilted

Mental Trend and Thought Content:

Perception: Unremarkable, Depersonalization, Derealization, Dissociation

Hallucinations: Auditory, Visual, Tactile, Olfactory, Gustatory

Cognitive Style: Obsessive, Self Deprecatory, Intellectualized, Autistic, Global (Histrionic), Other__________

Cognitive Content: Obsessions, Phobias, Compulsive Rituals, Religiosity, Ideas of Reference, Bizarre Ideas, Self Depreciations, Delusions, Nihilistic, Somatic, Grandiose, Paranoid, Guilt

[Nurse.SK]

Thanks... that really helped me..

I'm currently a student nurse..working on my assignment ?

Thanks again

[Gemlin]

Wow - this is amazing - I'm helping to write an information pack for my ward as a first year student and you have given me more places to go look for information that my ward did with this article.

I have also just been given an assignment brief similar to the student you replied to - it was very limited in patient details, so statement of doctors reports or findings etc. so I feel more confident in arguing the point in my assignment!

Thanks for being so open with information! ?