Assessment

HISTORY. Ask if the patient has had a sudden brief loss of consciousness followed by a severe headache; this sign has been reported by 45% of patients who survive SAH. Many also report a severe headache associated with exertion but no loss of consciousness. Establish any recent history of vomiting, stiff neck, photophobia, seizure, or partial paralysis. Establish any history of cerebral aneurysms.

PHYSICAL EXAMINATION. Observe the patient for signs and symptoms of cranial nerve deficits, especially cranial nerves III, IV, and VI. Meningeal irritation may lead to nausea, vomiting, stiff neck, pain in the neck and back, and possible blurred vision or photophobia. Examine for symptoms of stroke syndrome, such as hemiparesis, hemiplegia, aphasia, and cognitive deficits. Cerebral edema, increased ICPs, and seizures may also occur. Assess the vital signs for bradycardia, hypertension, and a widened pulse pressure. Other symptoms may result from pituitary dysfunction, caused by irritation or edema, leading to diabetes insipidus (excessive urinary output, hypernatremia) or hyponatremia.

SAHs are graded as follows: Grade I: Mild headache with or without meningeal irritation; Grade II: Severe headache and a nonfocal examination, with or without mydriasis; Grade III: Mild alteration in neurological examination, including mental status; Grade IV: Obviously depressed level of consciousness or focal deficit; Grade V: Patient either posturing or comatose.

PSYCHOSOCIAL. Provide emotional support for the patient and family. Encourage the patient to verbalize his or her fears of death, disability, dependency, and becoming a burden. Answer the patient's and family's questions, and involve both the patient and the family or the significant others in all aspects of planning care. If necessary, make home health referrals before the patient's discharge.

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