For a patient with subarachnoid hemorrhage who is restless, agitated, and has a severe headache, which of the following changes—decreased systolic blood pressure (mean arterial pressure still within target), slight increase in restlessness without change in agitation, persistent headache with pain score 9/10, or unresponsiveness to physical stimuli with sluggish pupillary response—requires an immediate call to the provider?

Immediate Provider Notification Required

Unresponsiveness to physical stimuli with sluggish pupillary response requires immediate notification of the provider, as this represents acute neurological deterioration indicating potential catastrophic complications such as rebleeding, herniation, or hydrocephalus. 1

Critical Neurological Deterioration

The combination of unresponsiveness and sluggish pupillary response represents a dramatic change in level of consciousness that demands emergent intervention:

• Any change in level of consciousness, onset of irritability, confusion, headache, or pupillary reactivity requires immediate notification of the physician team in patients with subarachnoid hemorrhage 1

• Hemorrhagic transformation or rebleeding should be suspected if there is a change in level of consciousness, elevation of blood pressure, deterioration in motor examination, onset of new headache, or nausea and vomiting 1

• Unresponsiveness with sluggish pupils indicates potential herniation, increased intracranial pressure, or rebleeding—all life-threatening emergencies requiring immediate imaging and possible surgical intervention 1, 2

Why Other Options Do Not Require Immediate Notification

Decreased SBP with MAP in Target Range

• Blood pressure management focuses on maintaining mean arterial pressure within ordered parameters to balance rebleeding risk and cerebral perfusion 1, 3
• If MAP remains within the therapeutic target (typically >90 mmHg), systolic blood pressure variations alone do not constitute an emergency 4, 5

Slight Increase in Restlessness Without Change in Agitation

• Restlessness and agitation are baseline symptoms in this patient and require monitoring with validated scales like RASS or SAS, but minor fluctuations without other concerning signs do not require emergent notification 1
• This represents expected variability rather than acute deterioration 1

Continuing Headache with Pain 9/10 vs 10/10

• Severe headache is the hallmark presenting symptom of subarachnoid hemorrhage, present in 74% of patients 1
• A one-point reduction in pain score (10/10 to 9/10) represents minimal change and does not indicate acute deterioration 1, 6
• New or worsening headache would be concerning, but persistent severe headache at similar intensity is expected 1

Clinical Pitfall to Avoid

The most critical error in subarachnoid hemorrhage management is failure to recognize acute neurological deterioration, which may indicate rebleeding (occurring in 20-30% of patients), hydrocephalus, or herniation—all requiring immediate intervention 1, 7, 8. Nurses in intensive care units are best positioned to recognize neurological decline and provide rapid intervention, as these complications can occur quickly and without warning 9.