Nursing care of the patient with SAH reflects the complicated and life-threatening nature of this condition. The nurse makes the critical difference in continuously assessing for changes in neurological status, identifying and reporting changes immediately so that appropriate treatment may be given, and in preventing lethal complications. Accurate documentation and complete sharing of information during intershift report are essential to identify subtle changes in neurological function that may signal the development of potentially life-threatening complications. The nurse's baseline neurological assessment should include the following observations regarding level of consciousness, mental status, speech, motor function, and pupil reactivity:
Ongoing monitoring of neurological status should focus on changes from one assessment to the next. General conversation with the patient during routine care can provide valuable clues to changing mental status. The nurse has a critical role in preventing rebleeding due to constipation and in protecting the patient from the hazards of immobility. If the patient becomes constipated and performs a Valsalva maneuver to empty the bowel, he/she greatly increases rebleeding risk. From the time of admission, patients with a SAH are at high risk for constipation due to bed rest, immobility, and the use of codeine to control headache. A common side effect of codeine is a decrease in peristalsis. A bowel program that includes stool softeners and fluids should be implemented on admission to decrease the risk of constipation that will likely occur at the peak time for rebleeding. Immobility also increases the patient's risk of developing deep vein thrombosis and pulmonary emboli. Elastic hose and sequential compression boots should be applied immediately and used until the patient is able to be mobile after surgical repair of the aneurysm. The nurse should assess the patient regularly for signs of deep vein thrombosis.
Seizure precautions should also be implemented, including ensuring available suction and having a padded bite stick and oral airway at the bedside. Side rails should be kept up at all times and padded to prevent injury should the patient have a seizure. If the patient is confused, a restraining type vest or jacket is more appropriate than wrist or ankle restraints. When extremities are restrained, the patient has a tendency to pull against them. It is likely that reaction to extremity restraints will result in a Valsalva maneuver that increases intracranial pressure. The nurse should also assist the patient with deep breathing and turning exercises to prevent the pulmonary complications of immobility.