KING GEORGE’S MEDICAL UNIVERSITY

K.G.M.U COLLEGE OF NURSING

SUBJECT - MEDICAL SURGICAL NURSING

CASE STUDY- SUBDURAL HEMATOMA

SUBMITTED TO: SUBMITTED BY:

Mr. SUBIN S.
ASSISTANT PROFESSOR M.Sc. NURSING 1st YEAR
K.G.M.U COLLEGE OF NURSING

DATE OF
SUBMISSION-
NURSING HISTORY

1. IDENTIFICATION DATA

Patient Profile:

Name : Mrs. Narayani

Age : 56 years
Sex : Female
Unit/Ward : Neurosurgery Ward
Bed No. : 17
Address : Baliya, U.P.
Medical Diagnosis : Subdural
Hematoma

Name of Surgery : Burr Hole

Date of Admission : / /202
3

2. SOCIO ECONOMIC DATA

 Religion : Hindu
 Marital status : Married
 Education : No formal education
 Occupation : Housewife

3. HEALTH HISTORY

 Presenting Complaints:

Patient came to the hospital with family members with the complaints of headache,
vomiting and altered sensorium
 Present Illness:
Patient is having headache, vomiting and altered sensorium from 5 days and had taken
treatment from family doctor.
 Past Medical illness: Patient have no significant past medical history
 Past Surgical History: Patient have no significant past surgical history.
 Dietary pattern: non-Vegetarian.

 Habits: Patient is not having any habit of smoking, tobacco chewing or alcoholism.

 Allergic history – Patient does not have any known allergic history.
PHYSICAL EXAMINATION

General health status:

 Level of consciousness- conscious

 Height- 5.4 inch

 Weight- 72 kg

 Appearance – Ectomorphic
HEAD TO TOE ASSESSMENT

General Appearance:

 Observations – Patient is with altered sensorium

 Color –Pale
 Skin – Patient skin is dry, redness is present due to rashes, skin is warm to touch, no
edema present.
VITAL SIGNS

Vitals signs Patient value Normal value Remarks

Temperature 98.5 o F 95- 99o F Normal

Pulse 88 beats/min 60-80 beats/min Normal

Respiration 25 breaths/min 20-24 breath/min Low

Blood pressure 132/80 mm Hg 120/80 mm Hg Normal

HEAD AND FACE

 Symmetry : Symmetrical
 Shape : Round
 Color : Wheatish
 Pain : Pt. is having headache due to surgical procedure
 Tenderness : Asent
 Lesion : Absent
 Edema : Absent
Scalp –
 Color : Pale
 Texture : Dehydrated
 Scales : Absent
 Lumps : Non palpable
 Lesions : no lesion
 Inflammation : present due to surgical procedure

Hair –

 Color- black

Face –

 Shape : Round
 Color : Wheatish
 Movement : Normal
 Expression : Anxious
 Pigmentation : No pigmentation
 Tics : Absent
 Tremors : Absent
 Scars : Absent
EYES

 Acuity : Normal
 Visual loss : no vision loss
 Glasses : absent
 Diplopia : absent
 Photophobia : absent
 Pain burning :
absent Eyelids –

 Color : normal color

 Ptosis : absent
 Edema : absent
 Sty : absent

Extra ocular movement –

 Position and alignment of eyes: symmetrical

  Strabismus : absent
 Nystagmus :
absent Conjunctiva –

 Color : pale
 Discharge :
absent Pupils –

 Size : 2mm
 Shape : round
 Equality : equal
 Reaction to light : reactive to light
EARS

Acuity--

 Hearing loss : no hearing loss, able to hear properly

 Hearing Aid : absent
 Pain : absent
 Tinnitus : absent
External ear –

 Lobe : round in shape

 Auricle : normal, no lesions present
 Ear Canal : wax
present Inner ear –

 Vertigo : absent

NOSE

 Smell : yes
 Symmetry : symmetrical
 Flaring : absent
 Sneezing : no sneezing
 Deformities : no deformity
 NG Tube : absent
MOUTH AND THROAT

 Odor : no halitosis present

 Pain : no pain
 ability to speak : clear
 chew : patient can chew
 swallow : no
problem Lips –

 Color : dark
 Symmetry : symmetrical
 Hydration : dry lips
 Lesions : absent
 Blister : absent
 Swelling : absent
 Numbness :
absent Gums –

 Color : pale
 Edema : no pitting edema
 Bleeding :
absent Teeth –

 Missing : No missing teeth

 Caries : dental carries absent
 Sensitivity to heat and cold:
absent Tongue –

 Symmetry : symmetrical
 Color : pale
 Hydration : dry
 Protrusion : absent
 Ulcers : absent
 Swelling : absent
Throat –

 Gag reflex : present

 Soreness : non sensitive
 Cough : dry present
 Sputum : not present
 Hemoptysis : absent
NECK

 Symmetry : symmetrical
 Movement : active flexion, extension, and rotation
 Range of motion : normal range of motion
 Masses : absent
 Scars : absent
 Pain : present
 Stiffness :
absent Trachea –

 Deviation : no deviation

present Thyroid –

 Size : normal
 Symmetry : symmetrical
 Tenderness : not present
 Enlargement : no enlargement present
 Nodules : non palpable
 Scares : absent
Vessel’s (carotid, jugular) –

 Quality strength and symmetry of pulsation bruits: normal

 Venous distention : no venous
distention Lymph nodes -

 Shape : not palpable

 Mobility : not palpable
 Tenderness : absent
 Enlargement : absent
CHEST

 Size : normal
 Shape : normal
 Symmetry : symmetrical
 Deformities : not present
 Pain : no pain
 Tenderness : absent
Skin –

 Color : pale
 Rashes : present
 Scars : absent
 Turgor : poor
 Temperature : normal
 Edema : not present
Breast –

 Symmetry : symmetrical
 Color : normal
 Size : normal
 Shape : normal, no deformity
 Inflammation : no inflammation present
 Scars : not present
 Masses : not present
 Pain : no pain
Axillae –

 Nodes : not palpable

 Enlargement : absent
 Tenderness : absent
 Rash : absent
 Inflammation : absent

LUNGS -

 Breathing pattern : impaired

 Rate : 24 breath/min
  Use of accessory muscles : present
 Sound : wheezing
 Quality : wheezing
HEART

Cardiac patterns –
 Rate : 69 beats/min
 Rhythm : normal
 Regularity : regular
 skipped or extra beats : no skipped or missed beats present
 Implanted pacemaker : absent
ABDOMEN

 Size : normal
 Color : pale
 Symmetry : symmetrical
 Muscles tone : decreased
 Turgor : poor
 scars : absent
 umbilicus : normal, no redness or inflammation present
 distention : absent
 Sound : normal
 Liver border : not palpable
KIDNEY--

Urinary output

 Amount : 700 ml
 Color : yellow
 Odor : pungent
 Frequency : 6 time/day
 Hematuria : absent
 Nocturia : absent
 Oliguria : not significant
RECTUM

 Hemorrhoid : no hemorrhoids are present

 Rashes : no rashes present
  Pain : absent
 Itching : absent
 Burning sensation : absent
BACK –

 Scars : absent
 Edema : absent
 Spinal abnormalities : absent
 Pain : absent
 Tenderness : absent

EXTREMITIES

Upper extremities

 Symmetry : symmetrical
 Joint : mobile
 Muscles ; movement and strength are good
 Edema : not present
 Other symptoms : no other
symptoms Lower extremities

 Symmetry : symmetrical
 Joint : immobile due to presence of edema
 Muscles : strength is good
 Edema : edema is not present
 Other symptoms : rashes and dryness is present

NEUROLOGICAL EXAMINATION

 Orientation : patient is oriented toward and staffs

 Reflexes : reflexes are normal
 Movements : movement is normal but lower extremities are having edema
MEDICATION CHART
Drug Name Pharmacological Name Dose/Route Frequency
Inj. Pan 40 Pantoprazole 40 mg 24 hourly
Inj. Crezone Ceftriaxone 2 gm 12 hourly
Inj. Acivir Acyclovir 500 mg 8 hourly
Inj. Levipril Levetiracetam 500 mg 12 hourly
Inj. Sumol Paracetamol 100 cc 8 hourly
Inj. Dexa Dexamethasone 8 mg 8 hourly
Inj. Lacialac Lacilactone 20 mg 12 hourly

INVESTIGATIONS
HEMATOLOGY:
Sr. no Investigations Patient values Normal values Remark
1 Hb 9.7 gm/dl 13-17 gm/dl Low
2 TLC 7700cells/mm3 4000-11000 cells/mm3 Normal
3 Neutrophils 62% 40-80 % Normal
4 Lymphocytes 34% 20-40 % Normal
5 Eosinophil 03% 1-6 % Normal
6 Monocytes 01% 1.0-5.0 % Normal
7 Basophils 00% 0.0-2.0 % Normal
8 Platelets 1.80 1.5-4.5 Normal
9 Total RBC 5.26 million cells 3.8-4.8 million cells High
10 MCV 78.5 fL 80-100 fL Low
11 MCH 26 pg 27-32 pg Low
12 MCHC 33.1 g/dl 32-35 g/dl Normal
13 HCT 41.3 % 36-46 % Normal
BIOCHEMISTRY:
Sr. no Investigations Patient values Normal values Remark
1 Serum sodium 134.5 mg/dl 133-143 mg/dl Normal
2 Serum potassium 4.96 mg/dl 3.5-5.6 mg/dl Normal
3 Serum alkaline phosphate 167 IU/l 90-300 IU/l Normal
4 AST 37.9IU/L 15-42 IU/L Normal
5 ALT 17.2 IU/L 15-42 IU/L Normal
6 Serum bilirubin 0.36 mmol/l 3-20 mmol/l Normal

7 SGOT 66 IU/l 0-70 IU/l Low

8 Total albumin 32 g/l 35-55 g/l Normal
9 A\G ratio 2:1 2:1 High
10 Serum creatinine 1.8 mg/dl 0.6-1.2 mg/dl Normal
11 Urea 2.5-7.8 mg/dl 2.5-7.8 mg/dl Normal
 SUBDURAL HEMATOMA

INTRODUCTION

A subdural hematoma is a type of bleed inside your head. It's a type of bleed that
occurs within your skull but outside the actual brain tissue. The brain has three
membrane layers or coverings (called meninges) that lie between the bony skull and
your brain tissue. The purpose of the meninges is to cover and protect the brain.

A subdural hemorrhage is more frequently venous in origin and is caused by the rupture
of small vessels that bridge the subdural space.

TYPES

1. Acute subdural hematoma- This is the most dangerous type of subdural hematoma.
Symptoms are severe and appear right after a head injury, often within minutes to
hours. Pressure on the brain increases quickly as the blood pools. If not diagnosed
and treated quickly, you could lose consciousness, become paralyzed or even die.

2. Sub-acute subdural hematoma- Symptoms usually appear hours to days or even

weeks after the head injury. A subacute subdural hematoma can occur with a
concussion.

3. Chronic subdural hematoma- This type of hematoma is more common in older

people. Bleeding occurs slowly and symptoms may not appear for weeks or months.
Even minor head injuries can cause chronic subdural hematomas. Due to the delay in
developing symptoms, an older person may not even recall how their head injury
happened. Also, the changes can be so subtle and occur so slowly that symptoms
may not be noticed by the older person or their friends or family.

ETIOLOGY

BOOK PICTURE IN PATIENT

Non-Modifiable
 Advanced age (older than 55
Age (56 years)
years)
 Gender (Male)
 Race (African American)
BOOK PICTURE PATIENT
Modifiable
 Hypertension
 Atrial fibrillation
 Hyperlipidemia
 Obesity Obesity
 Smoking
 Diabetes
 Road traffic accidents
 Asymptomatic carotid stenosis and
valvular heart disease (e.g.
endocarditis, prosthetic heart
valves)
 Peritoneal disease

PATHOPHYSIOLOGY:
CLINICAL MANIFESTATIONS

IN BOOK IN PATIENT

Numbness or Weakness of the face.

Without adequate perfusion, oxygen is
also low, and facial tissues could not
function properly without them.

Change in mental status. Altered sensorium

Trouble speaking or understanding Trouble speaking or understanding

speech. speech.

Visual Disturbances Visual Disturbances

Loss of peripheral vision

Hemiparesis

Hemiplegia

Ataxia

Dysarthria Dysphagia

Paresthesia

Expressive aphasia, Receptive aphasia,

Global aphasia

Motor loss

Communication loss
Dysarthria
Dysphasia
Apraxia

Perceptual Disturbance and Sensory Disturbed sensory function

Loss
DIAGNOSTIC EVALUATION

IN BOOK IN PATIENT
Neurologic Examination Neurological Examination

CT Scan CT Scan

PET Scan PET Scan

MRI

Cerebral Angiography Cerebral Angiography

Lumbar Puncture

Transcranial Doppler Ultrasonography

EEG

Skull X-Ray

ECG and Echocardiography ECG and Echocardiography

Laboratory studies to rule out Laboratory studies to rule out

systemic causes: CBC, platelet and systemic causes: CBC, platelet and
clotting studies, VDRL/RPR, ESR, clotting studies, VDRL/RPR, ESR,
Serum Blood tests Serum Blood tests
MANAGEMENT

BOOK PICTURE IN PATIENT

Medical Management
Pantoprazole 40 mg
1. Recombinant tissue plasminogen activator
Ceftriaxone 2 gm
2. Anticoagulants: warfarin sodium (Coumadin), low- Acyclovir 500 mg
molecular-weight heparin (Lovenox) Levetiracetam 500 mg
3. Antiplatelet agents: aspirin (ASA), dipyridamole Paracetamol 100 cc
(Persantine), ticlopidine (Ticlid) Dexamethasone 8 mg
4. Antifibrinolytics: aminocaproic acid (Amicar)
5. Peripheral vasodilators: cyclandelate
(Cyclospasmol), papaverine (Pavabid),
isoxsuprine (Vasodilan)
6. Neuroprotective agents: calcium channel
blockers, excitatory amino acid inhibitors,
gangliosides
7. Phenytoin (Dilantin), phenobarbital

Endotracheal Tube
Hemodynamic Monitoring Hemodynamic Monitoring
Neurologic Assessment Neurologic Assessment
Surgical Management
Surgical management may include prevention and
relief from increased ICP.

 Carotid endarterectomy

 Hemicraniectomy

 Burr hole Burr Hole

Nursing Management
Nursing Assessment
o Change in level of consciousness or
responsiveness. Patient is showing altered
level of consciousness,
o Presence or absence of voluntary or drowsiness, and irritability.
involuntary movements of extremities.
o Stiffness or flaccidity of the neck.
 o Eye opening, comparative size of pupils, and
pupillary reaction to light. Monitored vital signs and
neurological status
o Colour of the face and extremities;
temperature and moisture of the skin.
o Ability to speak. Observed for any signs of
increased intracranial
o Presence of bleeding. pressure.
o Maintenance of blood pressure.
Nursing Care Planning & Goals
Assessed for nuchal rigidity,
o Improve mobility.
twitching, increased
o Avoidance of shoulder pain. restlessness, and irritability.
o Achievement of self-care.
o Relief of sensory and perceptual deprivation. Maintained head or neck in
o Prevention of aspiration. midline position, provide
small pillow for support.
o Continence of bowel and bladder.
o Improved thought processes. During reposition, avoided
bending of the knee and
o Achieving a form of communication.
pushing heels against the
o Maintaining skin integrity. mattress.
o Restore family functioning.
o Improve sexual function. Provided comfort measures
Nursing Intervention and decreased external
o Preparing for Ambulation stimuli such as quiet
environment, soft voice, and
o Enhancing Self Care gentle touch.
o Managing Sensory Perceptual Difficulties
o Assisting with Nutrition
o Attaining Bowel and Bladder Control Elevated the head of the bed
o Improving Thought Processes 30°and avoid neck flexion
and hip flexion.
o Improving Communication
o Maintaining Skin Integrity
o Improving Family Coping
o Improving Family Coping
o Helping the Patient Cope with Sexual
Dysfunction
NUTRITIONAL MANAGEMENT

 Eat little or no meats, dairy and processed foods, which are high in saturated fat.

 If you are overweight, adopt a healthy weight-reduction diet plan and stick to it.
Obesity places a strain on the cardiovascular system.

 Make sure that your diet is well balanced and contains plenty of fiber. Fibre from
cereal, vegetables, and fruits is the most beneficial. Eat more organically
produced grains, legumes, fruits, vegetables and seeds.

 Eat plenty of fresh fruits and vegetables. Emphasize foods that are rich in the
antioxidant substances (beta-carotene, vitamins C and E, and selenium) that fight
free radicals. Enjoy fruits, tomatoes, carrots, sweet potatoes, dark leafy greens,
alfalfa sprouts, and whole-grain products.

 Avoid stimulants such as coffee and black tea that contain caffeine.
 Drink at least eight 8-ounce glasses of water every day.
NURSING THEORY APPLICATION

 Nightingale's theory can be applied in order to help control the severity of fungal
growth and decrease the risk of secondary infections (Howett, Connor, &
Downes. 2010).

 Florence Nightingale (12 May 1820 - 13 August 1910) was a nurse who
contributed in developing and shaping the modern nursing practice and has set
examples for nurses which are standards for today's profession.

Early Life

Florence Nightingale vas born on May 12,1820, in Nightingale, Italy.

She was the younger of two children.

Her British family belonged to elite social circles.

Her father, William Shore Nightingale, a wealthy landowner who had inherited two
estates one at Lea Hurst. Derbyshire. and the other in Hampshire, Embley Park when
Nightingale was 5 years old.

Education Florence Nightingale was raised on the family estate at Lea Hurst where her
father provided her with a classical education, including studies in German, French and
Italian.

As for being home schooled by her parents and tutors, Nightingale gained excellence in
Mathematics from a very young age, Nightingale was active in philanthropy,
ministering to the ill and poor people in the village neighboring her family's estate. At
seventeen, she made the decision to dedicate her life to medical care for the sick
resulting in a lifetime commitment to speak out, educate, overhaul and sanitize the
appalling health care conditions in England.

Despite the objections of her parents, Nightingale enrolled as a nursing student in 1844
at the Lutheran Hospital of Pastor Fliedner in Kaiserswerth, Germany.

Works

In 1860, her best authored works was published, "Notes on Nursing," outlining
principles of nursing. It is still in print today with translation in many foreign
languages. In all, she
had published some 200 books, reports and pamphlets. Using the money she got from
the British government, she funded the establishment of St. Thomas' Hospital, and
within it, the Nightingale Training.

Crimean War

The Crimean War began and soon reports in the newspapers were describing the
desperate lack of proper medical facilities for wounded British soldiers at the front.
Sidney Herbert, the war minister, already knew Nightingale, and asked her to oversee a
team of nurses in the military hospitals in Turkey. In 1854

She led an expedition of 38 women to take over the management of the barrack
hospital at Scutari where she observed the disastrous sanitary conditions.

School for Nurses

She defines Florence Nightingale's Environmental Theory defined Nursing as "the act
of utilizing the environment of the patient to assist him in his recovery."

In the 1870s, Nightingale mentored Linda Richards, "America's first trained nurse",
and enabled her to return to the USA with adequate training and knowledge to establish
high- quality nursing schools.

Awards

England has given Florence Nightingale numerous awards and honors.

Nightingale became known as "The Lady with the Lamp." The Queen rewarded

Nightingale's work by presenting her with an engraved brooch that came to be known
as the "Nightingale Jewel" and by granting her a prize of $250.000 from the British
government.

In 1883, Nightingale was awarded the Royal Red Cross by Queen Victoria. In 1904,
she was appointed a Lady of Grace of the Order of St John.

In 1907, she became the first woman to be awarded the Order of Merit. In the
following year she was given the Honorary Freedom of the City of London.

Death Despite being known as the heroine of the Crimean War, Florence Nightingale
felt ill in August 1910. She seemed to recover and was reportedly in good spirits,
however, she developed an array of troubling symptoms a week later, on the evening of
Friday, August 12, 1910.She died unexpectedly at 2 pm the following day, Saturday,
August 13, at her home in London. She left a large body of work, including several
hundred note.

MAJOR CONCEPTS OF NIGHTINGALE 'S ENVIRONMENT THEORY

Nursing: Nursing is basically the modification of patient environment to provide him

comfort during disease period. Florence nightingale describes "I use the word nursing
for want of a better. It has been limited to signify little more than the administration of
medicines and the application of poultices"

Nursing aids in the ability of a person to maintain health and to heal, by managing the
environment

Health: Health is a dynamic process according to nightingale "Health is not only to be

well, but to be able to use well every power we have"

Nightingale relates the health with 6 essential elements in order to secure an

individual's health. "HLs includes fresh air, pure water, well organized drainage,
cleanliness as well as proper light.

SUB CONCEPTS OF NIGHTINGALE THEORY

• Ventilation and warming.

• Variety.
• Light.
• Chattering hopes and advices.
• Noise.
• Taking food-What food?
• Cleanliness of rooms.
• Petty management
• Health of houses.
• Observation of the sick.
• Bed and bedding.
• Personal cleanliness.
 Assessment
Patient (Mrs. Narayani) is having headache vomiting and altered sensorium from 5 days
Nursing Diagnosis
Impaired sleeping pattern related to change in the environmental condition, light and
noise as evidenced by verbalization.
Planning/Implementation
• Assess the sleeping pattern, bed time, and duration of sleep.
Note the physical and psychological circumstances that hinder the sleeping pattern.
• Observe and evaluate the timing and effect of medication that can affect the sleep
• Reduction of light and noise at the time of sleep.
Evaluation
Criteria for evaluation: Sleeping pattern of patient is improved

NEEDS OF THE PATIENT

 Physical need:
o Improve cerebral tissue perfusion
o Pain reduction
o Nutritional status maintenance
 Emotional needs
o Anxiety
o Orientation and support
o Decreased self esteem
o Knowledge deficit
 NURSING DIAGNOSIS
 Ineffective cerebral tissue perfusion related to increased intracranial pressure
cerebral edema as evidenced by drowsiness and delirium.
 Disturbed sensory perception related to altered sensory reception, transmission,
and/or integration altered level of consciousness.
 Impaired physical mobility related to loss of balance and coordination as evidenced
by limited ROM.
 Ineffective coping related to situational crisis; vulnerability related to inability
to cope/difficulty asking for help.
 Risk for Injury related to Internal factor of altered neurologic regulatory function.
 Interrupted family processes related to catastrophic illness and caregiving burdens.
 Sexual dysfunction related to neurologic deficits or fear of failure.
 Deficient knowledge related to lack of information as evidenced by frequent
asking question.
 Self-Care Deficit related to Pain/discomfort as evidenced by Impaired ability to
perform ADL.