What are the nursing management strategies for subarachnoid hemorrhage?

Nursing Management for Subarachnoid Hemorrhage

Implement evidence-based protocols with frequent neurological assessments using validated tools (GCS or NIHSS every 1-4 hours), continuous vital sign monitoring, mandatory dysphagia screening before oral intake, and early mobilization after aneurysm securing to reduce mortality and improve functional outcomes. 1

Core Nursing Interventions

Standardized Protocols and Order Sets

Use evidence-based protocols and order sets for all aSAH patients, as this approach reduces length of stay, decreases delayed cerebral ischemia (DCI) rates, and improves 90-day functional outcomes. 1 The QASC trial demonstrated a 16% absolute improvement in death and dependency at 90 days when nurses implemented standardized fever, glucose, and swallowing protocols. 1

Neurological Monitoring

Perform frequent neurological assessments using validated tools:

• Use Glasgow Coma Scale (GCS) or National Institutes of Health Stroke Scale (NIHSS) to monitor for DCI and secondary complications. 1
• Conduct assessments every 1-4 hours depending on patient severity and clinical stability. 1
• Monitor specifically for: changes in level of consciousness, pupil reactivity, motor strength, speech changes, and new focal deficits that may indicate vasospasm or DCI. 2, 3

Vital Sign Monitoring

Implement continuous or hourly vital sign monitoring to detect neurological changes and prevent secondary cerebral insults. 1 Focus on:

• Blood pressure control: Maintain euvolemia and avoid BP variability, as both hypertension (rebleeding risk) and hypotension (cerebral perfusion compromise) worsen outcomes. 1, 4
• Temperature management: Fever increases metabolic demand and worsens outcomes. 1
• Glucose control: Hyperglycemia contributes to secondary brain injury. 1

Dysphagia Screening

Implement a validated dysphagia screening protocol before any oral intake, as up to 65% of stroke patients develop neurogenic dysphagia, increasing pneumonia risk, length of stay, and 90-day mortality. 1

• Screen within 24 hours of admission using a validated tool. 1
• Nurse-initiated dysphagia screening significantly reduces pneumonia rates and mortality. 1
• Keep patients NPO until screening is completed and passed. 1

Prevention of Secondary Complications

Delayed Cerebral Ischemia (DCI) Prevention

Maintain euvolemia through goal-directed fluid management rather than prophylactic hypervolemia, which does not improve outcomes and may cause harm. 4, 5, 6

Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days:

• Start within 96 hours of hemorrhage onset. 4, 5, 7
• If patient cannot swallow, extract capsule contents using an 18-gauge needle and administer via nasogastric tube with 30 mL normal saline flush. 7
• Never administer nimodipine intravenously—this is a fatal error. 7
• Label syringes "Not for IV Use" to prevent administration errors. 7

Infection Prevention

Implement aggressive infection prevention strategies, as pneumonia and sepsis are prevalent complications that worsen outcomes. 1

• Maintain head of bed elevation 30-45 degrees to reduce aspiration risk. 2
• Provide meticulous oral care. 2
• Monitor for signs of systemic inflammatory response syndrome, though distinguishing infectious from noninfectious causes remains challenging. 1

Intracranial Pressure Management

Monitor for signs of elevated ICP and hydrocephalus:

• Maintain head of bed elevation 30 degrees. 2
• Ensure adequate oxygenation and ventilation. 2
• Monitor for signs requiring urgent external ventricular drainage: decreased level of consciousness, pupillary changes, Cushing's triad. 4, 5, 6

Venous Thromboembolism Prevention

Initiate VTE prophylaxis once the aneurysm is secured to prevent deep vein thrombosis and pulmonary embolism. 4, 2

Specialized Nursing Competencies

Stroke-certified nurses with specialized competencies positively affect outcomes, timeliness of care, and protocol adherence. 1 Critical care nurses are uniquely positioned to recognize neurological decline and provide rapid intervention, as they maintain continuous bedside presence. 3, 8

Early Mobilization

For patients with secured aneurysms, implement an early evidence-based mobility algorithm to improve discharge functional level and 12-month global outcomes. 1 This should be initiated as soon as medically stable and after aneurysm treatment.

Psychosocial Support

Provide emotional support, education, and counseling to patients and families throughout hospitalization. 2, 8

• Establish therapeutic relationships to alleviate anxiety. 2
• Educate about medication management, lifestyle modifications, and follow-up importance. 2
• Address family concerns and facilitate coping mechanisms. 2, 8

Environmental Management

Maintain a therapeutic milieu by minimizing stimulation:

• Reduce noise and light exposure. 8
• Cluster care activities to allow rest periods. 8
• Reorient and distract agitated patients rather than using restraints when possible. 8

Critical Pitfalls to Avoid

• Never administer nimodipine intravenously—this causes severe hypotension and can be fatal. 7
• Avoid prophylactic hypervolemia—it does not prevent DCI and increases complications. 4, 5, 6
• Do not give anything by mouth before dysphagia screening—aspiration pneumonia significantly worsens outcomes. 1
• Avoid phenytoin for seizure prophylaxis—it is associated with excess morbidity and mortality. 4
• Do not delay recognition of neurological deterioration—frequent assessments are the cornerstone of preventing poor outcomes. 1, 3