Subdural Hemorrhage Nursing Diagnosis: A Comprehensive Guide

Understanding Subdural Hemorrhage

A subdural hemorrhage (SDH), also known as a subdural hematoma, is a critical condition characterized by the accumulation of blood in the subdural space. This space is located between the dura mater and the arachnoid mater, two of the protective layers surrounding the brain (meninges). The meninges are vital for shielding the delicate brain tissue from injury, comprising the pia mater (innermost layer), arachnoid mater (middle layer), and dura mater (outermost and toughest layer) (Kondamudi & Pierre, 2021). Subdural hemorrhage typically arises when blood vessels, often bridging veins, tear due to trauma, leading to blood pooling beneath the dura mater.

Types of Subdural Hemorrhage

Subdural hemorrhages are classified based on the time frame from injury to symptom onset:

Acute SDH: Manifests rapidly, from minutes to hours after a head injury. This type is particularly dangerous due to its swift progression and potential for rapid neurological decline.
Subacute SDH: Develops more gradually, over days to weeks following the initial trauma. Symptoms may emerge less acutely compared to acute SDH.
Chronic SDH: Predominantly observed in older adults, especially those over 65. Chronic SDH develops slowly, with symptoms potentially appearing weeks or even months after a minor head injury, which may even be forgotten.

Common Causes of Subdural Hemorrhage

The primary cause of subdural hemorrhage is head trauma. This trauma can result from various incidents, including:

Falls: Especially prevalent in older adults and young children, falls are a significant cause of head injuries leading to SDH.
Motor Vehicle Accidents: Car crashes and other vehicle accidents are major causes of traumatic brain injuries and SDH across all age groups.
Sports-Related Injuries: Contact sports and activities with a risk of head impact can lead to subdural hemorrhages in athletes.
Assaults: Physical violence and abuse are also recognized causes of head trauma and subsequent SDH.

High-Risk Populations for Subdural Hemorrhage

Certain groups are at an increased risk of developing subdural hemorrhages:

Elderly Individuals: Brain shrinkage associated with aging creates more space within the skull, stretching bridging veins. This makes these veins more vulnerable to tearing even with minor head trauma.
Athletes in Contact Sports: Repetitive or forceful head impacts in sports increase the risk of SDH.
Individuals on Anticoagulants: Medications that thin the blood (like warfarin or aspirin) impair the body’s clotting ability. This means bleeding may be more extensive and prolonged after a head injury, increasing SDH risk.
Individuals with Bleeding Disorders: Conditions like hemophilia, which affect blood clotting, predispose individuals to more severe and prolonged bleeding, elevating the risk of subdural hemorrhage.
Chronic Alcohol Abuse: Long-term alcohol abuse can lead to coagulopathy and increased risk of falls, both contributing to a higher likelihood of SDH.

Prevalence of Subdural Hemorrhage

Subdural hematomas are not uncommon following head injuries. Studies indicate that up to 25% of individuals who experience head trauma will develop a subdural hematoma (Cleveland Clinic, 2024). This highlights the importance of recognizing risk factors and symptoms, and prompt medical evaluation after head injury.

Diagnosing Subdural Hemorrhage

Diagnosis begins with a comprehensive physical and neurological examination. Crucially, a detailed patient history is taken, focusing on:

History of head injury (even seemingly minor ones)
Current medications, especially anticoagulants
Pre-existing medical conditions
Lifestyle factors, including alcohol consumption

Neurological assessments are essential and may include:

Vital signs monitoring, particularly blood pressure
Balance and coordination tests
Vision and eye movement checks
Cognitive and mental status evaluation

Imaging Modalities

Definitive diagnosis relies on neuroimaging:

Computed Tomography (CT) Scan: CT scans are the primary and often first-line imaging choice for rapid assessment of head injuries. They effectively visualize subdural hemorrhages as areas of increased density within the subdural space.
Magnetic Resonance Imaging (MRI) Scan: MRI provides more detailed images of brain tissue and can be particularly useful in diagnosing subacute and chronic SDHs, and in differentiating SDH from other conditions. Magnetic Resonance Imaging

Recognizing Subdural Hemorrhage Symptoms

Symptoms of subdural hemorrhage can vary widely, depending on the size and rate of bleeding, and the type of SDH (acute, subacute, chronic). Symptoms may appear immediately after injury or develop gradually over time. Key symptoms include:

Altered Mental Status: This is a critical sign, ranging from mild confusion and drowsiness to significant changes in alertness, responsiveness, and even coma.
Persistent Headache: Often described as severe and worsening, headaches are a common symptom, especially in subacute and chronic SDH.
Weakness on One Side of the Body (Hemiparesis): SDH can compress brain areas controlling motor function, leading to weakness or paralysis on one side of the body.
Seizures: Increased intracranial pressure and brain irritation from the hemorrhage can trigger seizures.
Memory Loss: Cognitive impairment, including memory problems, is frequently observed.
Personality Changes: Subtle to significant alterations in personality and behavior can occur, particularly with chronic SDH.
Confusion: Disorientation and difficulty thinking clearly are common, especially in older adults.
Slurred Speech: Difficulty articulating words can indicate neurological dysfunction.
Vision Changes: Blurred vision, double vision, or other visual disturbances may occur.
Dizziness and Balance Issues: Impaired balance and dizziness can result from pressure on brain structures.
Nausea and Vomiting: Increased intracranial pressure can trigger nausea and vomiting.

Subdural Hemorrhage Management

Treatment strategies for subdural hemorrhage are determined by the hematoma size, symptom severity, and patient’s overall clinical condition.

Large or Symptomatic SDH:
- Intubation and Airway Management: In cases of decreased consciousness, securing the airway and providing mechanical ventilation may be necessary.
- Surgical Intervention: Prompt surgery is often required. Surgical options include:
  - Craniotomy: Involves creating a larger opening in the skull to remove the hematoma and address the bleeding source.
  - Burr Hole Drainage: A less invasive procedure where small holes are drilled in the skull to drain the hematoma.
Small, Asymptomatic SDH:
- Observation: Close monitoring of symptoms and neurological status may be sufficient for small SDHs without significant symptoms.
- Vital Signs Monitoring: Regular monitoring of vital signs to detect any changes.
- Bed Rest: Restricting activity to minimize further injury.
- Vitamin K Therapy: May be administered to patients on anticoagulants to help reverse blood thinning effects.
- Medications: Corticosteroids or other medications to reduce brain swelling and intracranial pressure.

Adult Subdural Hemorrhage Nursing Care Plan and Nursing Diagnosis

Nursing care is paramount in managing patients with subdural hemorrhage. A comprehensive nursing care plan focuses on neurological assessment, symptom management, and preventing complications. Key nursing diagnoses related to subdural hemorrhage include:

Nursing Assessment

Nurses play a crucial role in the continuous assessment of patients with SDH. Key assessment parameters include:

Neurological Status: Frequent and detailed neurological assessments are vital, monitoring for changes in:
- Level of consciousness (LOC) using tools like the Glasgow Coma Scale (GCS)
- Pupillary response (size, equality, reactivity to light)
- Motor function (strength, movement in all extremities)
- Sensory function
- Cranial nerve function
Headache: Assess the presence, severity, location, and characteristics of headache.
Vital Signs: Monitor blood pressure, heart rate, respiratory rate, and temperature regularly.
Symptoms of Increased Intracranial Pressure (ICP): Observe for signs such as:
- Decreased LOC
- Headache
- Vomiting (especially projectile)
- Pupillary changes
- Bradycardia
- Hypertension
- Irregular respirations (Cushing’s triad – a late sign)
Communication Abilities: Assess for slurred speech, confusion, or other communication difficulties.
Pain Levels: Evaluate pain using appropriate pain scales.

Common Nursing Diagnoses for Subdural Hemorrhage

Based on the assessment findings, common nursing diagnoses for patients with subdural hemorrhage include:

Ineffective Cerebral Tissue Perfusion related to hemorrhage, as evidenced by altered level of consciousness, memory loss, slurred speech, and vision changes. This is a primary nursing diagnosis, focusing on the compromised blood flow to the brain due to the hematoma.
- Nursing Interventions:
  - Frequent Neurological Assessments: Monitor LOC, GCS, pupillary reactions, motor and sensory function at least every 1-2 hours, or more frequently as needed.
  - Vital Signs Monitoring: Closely monitor blood pressure to maintain cerebral perfusion pressure (CPP) as ordered by physician. Avoid hypotension and hypertension.
  - Positioning: Maintain head of bed elevation at 30-45 degrees (if not contraindicated) to promote venous drainage and reduce ICP.
  - Oxygenation: Ensure adequate oxygenation to support cerebral blood flow. Monitor oxygen saturation and administer supplemental oxygen as ordered.
  - Fluid Management: Administer intravenous fluids as prescribed, carefully monitoring intake and output to maintain euvolemia and avoid fluid overload, which can worsen cerebral edema.
  - ICP Monitoring (if indicated): For severe cases, ICP monitoring may be implemented. Manage ICP based on physician orders and protocols.
Impaired Verbal Communication related to neuromuscular impairment, as evidenced by slurred speech, confusion, and altered level of consciousness. This diagnosis addresses communication difficulties resulting from neurological deficits.
- Nursing Interventions:
  - Use Simple and Direct Language: Communicate using clear, concise language and simple sentences.
  - Yes/No Questions: Utilize yes/no questions to facilitate communication for patients with expressive aphasia or confusion.
  - Communication Aids: Provide alternative communication methods such as writing materials, picture boards, or communication devices.
  - Allow Adequate Time: Give the patient sufficient time to respond. Avoid rushing or interrupting.
  - Repeat and Rephrase: If the patient does not understand, repeat or rephrase statements.
  - Nonverbal Communication: Pay attention to nonverbal cues and use nonverbal communication (gestures, facial expressions) to support understanding.
Acute Pain related to trauma or headache, as evidenced by verbalization of pain, facial expressions of pain, irritability, anxiety, and restlessness. Pain management is crucial for patient comfort and recovery.
- Nursing Interventions:
  - Pain Assessment: Regularly assess pain using a pain scale (e.g., numerical rating scale, visual analog scale) to quantify pain intensity.
  - Administer Analgesics: Provide pain medication as ordered by the physician. Monitor effectiveness and side effects of analgesics.
  - Non-Pharmacological Pain Relief: Implement non-pharmacological measures to complement pain medication, such as:
    - Quiet and dark environment
    - Cool compresses to the forehead
    - Relaxation techniques (if appropriate for patient’s LOC)
    - Repositioning for comfort

Expected Outcomes

The expected outcomes of nursing interventions for subdural hemorrhage aim to improve the patient’s neurological status and overall well-being:

Improved level of consciousness and cognitive function.
Reduction or resolution of the subdural hematoma (demonstrated by repeat imaging).
Improved or stabilized vision.
Enhanced strength, balance, and mobility.
Effective pain management.
Restoration of adequate cerebral tissue perfusion.
Improved communication abilities.

Patient and Caregiver Education

Patient and caregiver education is a vital component of discharge planning and ongoing care. Education should include:

Condition and Treatment: Provide clear and understandable information about subdural hemorrhage, the treatment received, and the expected recovery process.
Prevention Strategies: Educate on measures to prevent future head injuries, such as:
- Fall prevention strategies (home safety modifications, assistive devices for mobility, etc.)
- Head protection (helmets during sports, seatbelt use in vehicles)
Wound Care: If surgery was performed, provide detailed instructions on wound care, signs of infection, and when to seek medical attention.
Medication Adherence: Ensure understanding of prescribed medications, including dosage, frequency, purpose, and potential side effects.
Warning Signs: Educate on symptoms that warrant immediate medical attention:
- Persistent or worsening headache
- Increased confusion or drowsiness
- Seizure activity
- Signs of wound infection (if surgical)
- Visual disturbances
- New weakness or numbness
Follow-up Care: Emphasize the importance of follow-up appointments with healthcare providers for neurological assessments and monitoring recovery.

By providing comprehensive nursing care and education, nurses play a critical role in optimizing outcomes for patients recovering from subdural hemorrhage.

References

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

Kondamudi, N. P., & Pierre, L. J. (2021). Subdural hematoma. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537304/