Subdural Hematoma Nursing Diagnosis: Comprehensive Guide for Healthcare Professionals

Etiology and Epidemiology of Subdural Hematoma

A subdural hematoma (SDH) is characterized by the accumulation of blood in the subdural space, located beneath the dura mater and outside the brain parenchyma (Stat Pearls, 2023). The meninges—comprising the pia mater, arachnoid mater, and dura mater—act as protective layers for the brain (Kondamudi & Pierre, 2021). SDH occurs when bridging veins between the brain surface and the dural sinuses rupture, leading to blood collection in the subdural space. This condition can elevate intracranial pressure and cause significant neurological deficits.

Types of Subdural Hematoma

Subdural hematomas are classified based on their time of onset following the initiating event:

Acute Subdural Hematoma: Develops rapidly, within minutes to hours after a traumatic injury. Acute SDH is often associated with significant neurological symptoms and carries a high risk of mortality.
Subacute Subdural Hematoma: Evolves over a period of days to weeks post-injury. Symptoms may be less immediate than in acute SDH but still require prompt medical attention.
Chronic Subdural Hematoma: Typically seen in older adults and develops slowly over weeks to months. The initial trauma might be minor or even forgotten. Chronic SDH can present with subtle and gradually worsening symptoms, often mimicking dementia or other neurological conditions.

Common Causes of Subdural Hematoma

The primary cause of subdural hematoma is head trauma. Common incidents leading to SDH include:

Motor Vehicle Accidents: High-impact collisions can result in significant head trauma.
Falls: Particularly in older adults and young children, falls are a frequent cause of head injuries.
Sports-Related Injuries: Contact sports and activities with a risk of head impact can lead to SDH.
Assaults and Physical Abuse: Direct blows to the head can cause vascular damage and subdural bleeding.

Populations at Increased Risk

Certain populations are more susceptible to developing subdural hematomas:

Elderly Individuals: Age-related brain atrophy increases the space between the brain and the dura, stretching bridging veins and making them more vulnerable to tearing even with minor trauma.
Athletes in Contact Sports: Repetitive or high-impact head trauma increases the risk.
Patients on Anticoagulants: Medications that thin the blood impair the clotting process, increasing the risk of bleeding and hematoma formation even from minor injuries.
Individuals with Bleeding Disorders: Conditions like hemophilia predispose individuals to prolonged and severe bleeding.
Chronic Alcohol Abuse: Alcohol abuse can lead to coagulopathies and increased risk of falls, both contributing to SDH development.

Prevalence of Subdural Hematoma

Subdural hematomas are a relatively common consequence of head injury. Studies indicate that up to 25% of patients with head trauma will develop a subdural hematoma (Cleveland Clinic, 2024). The incidence is higher in elderly populations due to increased risk factors like falls and anticoagulant use.

Diagnosis of Subdural Hematoma

Diagnosing a subdural hematoma involves a comprehensive approach:

Clinical Evaluation: A thorough neurological examination is crucial, assessing the patient’s level of consciousness, pupillary responses, motor strength, and sensory function. Detailed history taking includes inquiries about head injuries, medications (especially anticoagulants), pre-existing conditions, and lifestyle factors.
Neurological Assessment: This may include:
- Blood Pressure Monitoring: To assess hemodynamic stability.
- Balance and Coordination Tests: To evaluate neurological function.
- Vision and Oculomotor Tests: To check for cranial nerve deficits.

Recognizing Subdural Hematoma Symptoms

Symptoms of a subdural hematoma can vary widely depending on the size and location of the hematoma, as well as the rate of bleeding. Symptoms may appear immediately after injury or develop gradually over time. Common signs and symptoms include:

Changes in Mental Status: Confusion, drowsiness, lethargy, or difficulty concentrating are common.
Headache: Persistent or worsening headache, which may be more pronounced in acute SDH.
Weakness: Hemiparesis or weakness on one side of the body can occur due to pressure on motor pathways.
Seizures: Increased intracranial pressure can trigger seizures.
Memory Loss and Cognitive Impairment: Especially prominent in chronic SDH, mimicking dementia.
Personality Changes: Irritability, apathy, or altered behavior can be observed.
Speech Disturbances: Slurred speech or difficulty finding words.
Visual Disturbances: Blurred vision, double vision, or visual field deficits.
Nausea and Vomiting: Signs of increased intracranial pressure.
Dizziness and Balance Issues: Impaired coordination and gait.

Diagnostic Imaging for Subdural Hematoma

Imaging studies are essential for confirming the diagnosis of subdural hematoma and determining its characteristics:

Computed Tomography (CT) Scan: CT scans are the primary imaging modality for acute evaluation due to their speed and sensitivity in detecting acute hemorrhage. SDH typically appears as a crescent-shaped hyperdense (bright) collection of blood along the inner table of the skull.
Magnetic Resonance Imaging (MRI) Scan: MRI is more sensitive for detecting subacute and chronic subdural hematomas and can provide more detailed information about the age of the hematoma and underlying brain tissue.

Management and Treatment Strategies

Management of subdural hematoma depends on the hematoma size, patient’s neurological status, and presence of symptoms. Treatment approaches range from conservative management to surgical intervention:

Conservative Management: For small, asymptomatic subdural hematomas, observation may be appropriate. This involves:
- Close Monitoring: Regular neurological assessments to detect any deterioration.
- Vital Signs Monitoring: Frequent monitoring of blood pressure, heart rate, and respiratory rate.
- Bed Rest: To minimize risk of further injury.
- Vitamin K Administration: In patients on anticoagulants, Vitamin K may be given to reverse anticoagulation.
- Medications: Corticosteroids or osmotic diuretics may be used to reduce brain swelling and intracranial pressure.
Surgical Intervention: Larger hematomas, those causing significant mass effect, or those associated with neurological deterioration often require surgical evacuation. Surgical procedures include:
- Burr Hole Craniostomy: Small holes are drilled into the skull to drain the hematoma. This is often used for chronic subdural hematomas.
- Craniotomy: A larger section of the skull is removed to allow for direct visualization and removal of the hematoma. This is typically performed for acute subdural hematomas or when burr holes are insufficient.
- Intubation and Airway Management: In severe cases with altered consciousness, intubation and mechanical ventilation may be necessary to secure the airway and ensure adequate oxygenation.

Adult Subdural Hematoma Nursing Care Plan: Focusing on Nursing Diagnoses

Nursing care for patients with subdural hematoma is crucial and focuses on continuous neurological assessment, managing symptoms, preventing complications, and providing patient and family education. Key aspects of the nursing care plan revolve around addressing specific nursing diagnoses.

Nursing Assessment for Subdural Hematoma

A comprehensive nursing assessment is the cornerstone of effective care. Key assessment parameters include:

Neurological Status: Regularly assess level of consciousness using the Glasgow Coma Scale (GCS), pupillary response, motor and sensory function, and cranial nerve function.
Headache: Evaluate the intensity, location, and characteristics of headache.
Mental Status: Assess for confusion, disorientation, memory deficits, and personality changes.
Vital Signs: Monitor blood pressure, heart rate, respiratory rate, and temperature. Changes can indicate increasing intracranial pressure or systemic complications.
Symptoms: Assess for nausea, vomiting, visual disturbances, speech difficulties, weakness, dizziness, and balance problems.
History: Gather information about the mechanism of injury, onset and progression of symptoms, medical history, and current medications.

Common Nursing Diagnoses Related to Subdural Hematoma

Based on the assessment findings, several nursing diagnoses may be applicable in patients with subdural hematoma. Prioritizing these diagnoses guides the nursing care plan.

Ineffective Cerebral Tissue Perfusion: Related to intracranial hemorrhage and increased intracranial pressure, as evidenced by altered level of consciousness, changes in vital signs, neurological deficits (weakness, speech changes, vision changes), and cognitive impairment. This is a primary nursing diagnosis due to the direct threat to brain function.
- Nursing Interventions:
  - Neurological Monitoring: Continuously monitor neurological status, including GCS, pupillary reactions, and motor function, every 1-2 hours or more frequently as needed.
  - Vital Signs Monitoring: Monitor blood pressure, heart rate, and respiratory rate closely. Report any signs of Cushing’s triad (hypertension, bradycardia, and irregular respirations), which indicate increased ICP.
  - Positioning: Elevate the head of the bed to 30-45 degrees to promote venous drainage and reduce ICP, unless contraindicated.
  - Maintain Normothermia: Manage fever aggressively as hyperthermia can increase cerebral metabolic demands and worsen cerebral edema.
  - Fluid Management: Maintain fluid balance, avoiding both fluid overload and dehydration, as both can negatively impact cerebral perfusion.
  - Administer Medications: Administer medications as prescribed to reduce ICP (e.g., mannitol, hypertonic saline) and manage pain.
  - Seizure Precautions: Implement seizure precautions to prevent injury in case of seizure activity.
Impaired Verbal Communication: Related to neurological impairment secondary to subdural hematoma, evidenced by slurred speech, aphasia, dysarthria, confusion, and altered level of consciousness. Communication deficits can significantly impact patient care and require specific nursing strategies.
- Nursing Interventions:
  - Assess Communication Abilities: Determine the patient’s ability to understand and express themselves.
  - Use Simple Communication Techniques: Use clear, simple language, yes/no questions, and visual aids.
  - Provide Communication Aids: Utilize communication boards, picture cards, or electronic devices as appropriate.
  - Allow Adequate Time: Give the patient sufficient time to respond and avoid interrupting.
  - Collaborate with Speech Therapy: Consult with speech therapists for comprehensive communication assessment and strategies.
  - Nonverbal Communication: Pay attention to nonverbal cues and use touch and gestures to enhance communication.
Acute Pain: Related to head trauma, increased intracranial pressure, and possible surgical interventions, evidenced by patient verbalization of pain, facial grimacing, restlessness, irritability, and changes in vital signs. Pain management is essential for patient comfort and recovery.
- Nursing Interventions:
  - Pain Assessment: Regularly assess pain using a pain scale (e.g., numeric rating scale) and document pain characteristics.
  - Pharmacological Pain Management: Administer analgesic medications as ordered, considering the type and severity of pain. Opioids may be necessary for severe pain, while non-opioids may be sufficient for milder pain.
  - Non-Pharmacological Pain Management: Implement non-pharmacological measures such as positioning, quiet environment, cool compresses, and relaxation techniques.
  - Monitor for Side Effects: Monitor for side effects of pain medications, especially respiratory depression with opioids and gastrointestinal upset with NSAIDs.
  - Evaluate Pain Relief: Regularly evaluate the effectiveness of pain management interventions and adjust as needed.

Expected Outcomes for Subdural Hematoma Nursing Care

The expected outcomes for nursing care of patients with subdural hematoma are focused on neurological recovery, symptom management, and prevention of complications:

Improved Cerebral Tissue Perfusion: Evidenced by stable vital signs, improved level of consciousness, and resolution of neurological deficits.
Effective Communication: Patient able to communicate needs and understand instructions using appropriate methods.
Pain Control: Patient reports pain is managed to a tolerable level, with minimal discomfort.
Prevention of Complications: Patient remains free from secondary complications such as seizures, infection, and deep vein thrombosis.
Enhanced Patient and Family Knowledge: Patient and family demonstrate understanding of the condition, treatment plan, and follow-up care.

Patient and Caregiver Education

Education is a critical component of the nursing care plan. Key education points include:

Condition and Treatment: Explain subdural hematoma, its causes, treatment options, and expected recovery process in terms understandable to the patient and family.
Medication Management: Provide clear instructions on prescribed medications, including dosage, frequency, purpose, and potential side effects. Emphasize adherence to medication regimens, especially for anticoagulants or anti-seizure medications.
Wound Care: If surgery was performed, provide detailed instructions on wound care, signs of infection to watch for, and follow-up appointments.
Prevention Strategies: Educate on strategies to prevent future head injuries, such as fall prevention measures for older adults, use of helmets during sports and cycling, and safe driving practices.
Warning Signs: Instruct the patient and family to recognize and promptly report any worsening symptoms, such as persistent headaches, increased confusion, seizures, new weakness, visual disturbances, or signs of wound infection.
Follow-Up Care: Ensure the patient and family understand the importance of follow-up appointments with healthcare providers for neurological assessments, imaging studies, and rehabilitation if needed.

By focusing on these nursing diagnoses and interventions, healthcare professionals can provide comprehensive and effective care for patients with subdural hematoma, optimizing patient outcomes and promoting recovery.

References

Cleveland Clinic. (2024). Subdural hematoma. Retrieved from https://my.clevelandclinic.org/health/diseases/14507-subdural-hematoma

Kondamudi, N. P., & Pierre, L. J. (2021). Subdural hematoma. In StatPearls. StatPearls Publishing.

Stat Pearls. (2023). Subdural hematoma. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537304/