1. Running head: ACUTE SUBDURAL HEMATOMA 1
Living with an Acute Subdural Hematoma
Karla Ruiz
California Baptist University
Author Note
This paper is presented to Professor Robertson in partial fulfillment for the requirements
of Adult Health II, NUR 440 B on February 4th, 2016.

2. ACUTE SUBDURAL HEMATOMA 2
Living with an Acute Subdural Hematoma
There is an endless amount of contractible diseases in the world, everyday that we wake
up, we must thank the Lord to be alive. A new diagnosis, no matter how mild or severe, requires
a life style change. An illness can be sudden in onset or be slow to progress. Some can impact
your life drastically while others will linger in the background. The experience that an individual
has while overcoming a disease relies on their spiritual strength, and on the support they receive
from those around them. In some cases, the person fights hard for their life throughout the entire
disease process, and does not make it. The beginning of life and death, starts and ends with our
Creator. An acute subdural hematoma injury can happen anywhere and at anytime, possibly
changing your life forever, including those around you.
Pathophysiology and Clinical Manifestations
A subdural hematoma can happen to anyone, of any age, gender, and ethnicity. Subdural
hematoma is a type of brain injury (Hinkle & Cheever, 2010). According to Morton and
Fontaine (2012) a subdural hematoma is defined as an accumulation of blood below the dura and
above the arachnoid layer covering the brain. Subdural hematoma can be separated into three
categories, which is based on the time from injury to the onset of symptoms: acute, subacute, and
chronic (Morton & Fontaine, 2012). According to Hinkle & Cheever (2010) and acute subdural
hematoma is associated with “major head injury involving contusion or laceration” (p.1999).
Acute subdural hematomas are rapid to progress, and therefor have a high mortality rate, related
to edema and increased ICP (Hinkle & Cheever, 2010). Patients with an acute subdural
hematoma will manifest symptoms within 24 to 48 hours after insult, depending on rate and
amount of blood accumulation (Morton & Fontaine, 2012). Symptoms of this disease process
include headache, focal neurological deficit, unilateral pupillary abnormalities, and a decreasing

3. ACUTE SUBDURAL HEMATOMA 3
level on consciousness (Morton & Fontaine, 2012). The correct diagnostic tests and medication
regimen must be implemented in order to have a positive patient outcome.
Diagnostic Studies and Medication
The management of an acute subdural hematoma includes complexity of care. According
to Hinkle and Cheever (2010) assessment and diagnosis of the extent of injury are accomplished
by the initial physical and neurological examination. CT and MRI scans “are the main
neuroimaging diagnostic tools and are useful in evaluating the brain structure (Hinkle &
Cheever, 2010, p.2000). These diagnostic tests will give healthcare providers a direction for care.
Hinkle and Cheever (2010) also inform that as the damaged brain swells with edema or as blood
collects within the brain, and increased intracranial pressure (ICP) occurs. According to Hinkle
and Cheever (2010) the high mortality rate of acute subdural hematoma has been associated with
uncontrolled ICP; therefor it must be monitored closely. If ICP is increased, adequate
oxygenation must be provided, head of the bed must be elevated, and normal blood volume must
be maintained (Hinkle & Cheever, 2010). In conjunction with treating ICP, treatment also
includes “ventilatory support, seizure prevention, fluid and electrolyte maintenance, nutritional
support and management of pain and anxiety” (Hinkle & Cheever, 2010, p.2001). Hinkle and
Cheever (2010) inform that brain damage can produce metabolic and hormonal dysfunctions.
Head injuries have been linked to sodium imbalances (Hinkle & Cheever, 2010). Hinkle &
Cheever (2010) state that hyponatremia is common after head injury due to shifts in extracellular
fluid, electrolytes, and volume. Hypernatremia may also occur as a result of sodium retention.
Due to electrolyte imbalance, lethargy, confusion, and seizures may occur (Hinkle & Cheever,
2010). Hinkle and Cheever inform us, that when a patient has sustained a severe head injury that
is incompatible with life, the patient could be a potential organ donor. There are three cardinal

4. ACUTE SUBDURAL HEMATOMA 4
signs of brain death on examination are coma, absence of brain stem reflexes, and apnea (Hinkle
& Cheever, 2010). Strict medication regimens are also included as supportive measures.
In order to address this complex, medications must address the multiple clinical
manifestations and progression. Hinkle and Cheever (2010) tell us that due to the fact that
seizures can occur after a head injury, and can cause” secondary brain damage from hypoxia,
antiseizure agents may be administered”, if a patient becomes distressed, sedatives may be given
to increase sedation without interrupting cerebral blood flow or ICP, and decreasing oxygen
demand (p.2001). Medications such as Phenytoin, Lorazepam, Propofol, and Furosemide may be
given to patients with acute subdural hematoma. Phenytoin (Dilantin) is an anticonvulsant used
to treat and prevent tonic/clonic seizures (“Nursing Central”, 2012). Nursing Central (2012)
informs that patients on oral phenytoin, are usually started with a loading dose of 15-20 mg/kg as
extended capsules in 3 divided doses given every 2-4 hours; maintenance dose is 5-6 mg/kg/day
given in 1-3 doses, the usual dose ranges between 200-1200 mg/day. Lorazepm (Ativan) is an
antianxiety agent with sedative properties. Nursing Central (2012) informs that lorazepam will
decrease anxiety and increase sedation. Both of these therapeutic actions will aid a patient with
an acute subdural hematoma by relaxing them, which in turn will not increase ICP, and will
decrease their oxygen demand. Lorazepam can be given by mouth, intramuscularly, and
sublingual. Usually 1-3 mg is given by mouth, 2-3 times a day (“Nursing Central”, 2012).
According to Hinkle and Cheever (2010), propofol, intravenously, is the sedative-hynotic agent
of choice because it is an ultra-short acting drug, with rapid onset. It has the major advantage of
“being titratable to its desired clinical effect but still provides the opportunity for an accurate
neurologic assessment” (p.2001). Nursing Central (2012) describes propofol (Diprivan) as a
general anesthetic, which can be used in the intensive care unit as sedation for patients that are

5. ACUTE SUBDURAL HEMATOMA 5
intubated. Patients on propofol, intravenously, for sedation are given 5mcg/kg/min for a
minimum of five minutes. Additional increments of 5-10 mcg/kg/min over 5-10 minutes may be
given until desired response is obtained, dose should be reassessed every 24 hours (“Nursing
Central”, 2012). Lastly, a diuretic such as furosemide (Lasix) assists in managing intracranial
hypertension (“Nursing Central”, 2012). Furosemide is a loop-diuretic, which means it increases
renal excretion of water, sodium, potassium, magnesium, chloride, and calcium; it does not spare
any electrolytes (“Nursing Central”, 2012). Nursing Central (2012) informs that furosemide is
given by mouth when used to treat hypertension. A patient is usually given 40 mg twice daily
initially; the dose is then adjusted depending on patient’s response (“Nursing Central”, 2012).
The nurse’s role in caring for this patient must include prioritizing based on assessment data
collected.
Nursing Diagnosis and Interventions
Nursing diagnosis aid the nurse in prioritizing care for the patient, including realistic
goals and specific interventions to meet those goals. The priority nursing diagnosis that would
take president in a patient with an acute subdural hematoma would be: Impaired gas exchange
related to brain injury. Sparks and Taylor’s (2011) suggest assessing and recording pulmonary
status every four hours or more frequently if patient’s condition is unstable. The rational for this
is because poor pulmonary status may result in hypoxemia. Also, place the patient in a position
that best facilitates chest expansion, in order to enhance gas exchange (Sparks & Taylor’s, 2011).
A second nursing diagnosis for this patient would be: Risk for ineffective cerebral tissue
perfusion related to increased ICP and possible seizures (Sparks & Taylor’s, 2011). Nursing
interventions for this patient will include maintaining adequate oxygenation to ensure cerebral
perfusion (Sparks & Taylor’s, 2011). Educating at-risk patients of the signs of decreased cerebral

6. ACUTE SUBDURAL HEMATOMA 6
perfusion about the importance of timely medical interventions for positive symptoms. This is
important because a change in mental status is a sensitive indicator for decreased cerebral
perfusion (Sparks & Taylor’s, 2011). A psychosocial diagnosis appropriate for a patient with an
acute subdural hematoma would be: Ineffective coping related to head trauma (Hinkle &
Cheever, 2010). A person with an acute subdural hematoma, for the most part, experiences
mental changes beyond what they can comfortably handle. Nursing interventions that would help
a patient in this situation would be to arrange to encourage expression of feelings, and accept
what the patient says. Try to identify factors that exacerbate patient’s inability to cope, such as
fear of loss of health or job. By listening to the patient, it helps to express emotions, grasp
situation, and cope effectively (Sparks & Taylor’s, 2011). In conjunction to listening to the
patient, the nurse should also encourage patient to make decisions and perform activities to
reinforce coping behaviors (Sparks & Taylor’s, 2011).
Personal Reflection
This diagnosis, even though acute, would change my life and my point of view.
Understanding the complex disease process of an acute subdural hematoma, and its severity, I
would be anxious and worried of the known. I would still be able to go to clinical and finish the
semester, if I had no complications. If my health deteriorated and I had increased ICP, I would
have to take at least a semester off to recover. My family and friends would be worried and
anxious to not know what the next step would be. My biblical worldview would help me cope
with the entire situation. My initial reaction would be to be upset, but reminding myself that God
has a purpose for everything will help me accept it. 1 Chronicles 16:11 says “Look to the Lord
and His strength, seek His face always”, this verse reminds me that He is my strength through all
I encounter. I should always strengthen myself through Him. Parse’s (1995) Human Becoming

7. ACUTE SUBDURAL HEMATOMA 7
theory is made up of three assumptions of man. The one assumption that best relates with my
current situation is transcendence. Transcendence tells us that the human is cotranscending
multidimensionally with emerging possibles at all times (Parse, 1995). During this stage in my
life, I have had to transcend and shift. I was living my life being a healthy nursing student,
thinking of graduation in December, never fathoming the idea that my fate could change in an
instant. About a month ago, I had a close friends tell me about his cousin who suffered a brain
injury and went in to get it checked and he had a subdural hematoma. He mentioned that the
medical personnel made the whole situation seem minor and routine. They decided that the best
choice for his cousin would be to surgically remove the hematoma and he passed away in the
operating room. The whole family was in shock because they did not understand the severity of
the situation and the possible outcomes of the complications. This story reminds me that God is
always in control, in all aspects of life. This 19 year-old boy went to the hospital because he got
hit in the head, and 4 days after being admitted he was deceased. When I was assigned this
disease, I spoke to my friend, his cousin, and explained my assignment. He asked me if I could
educate him on the topic, and I did. I believe God had me exactly where he wanted, I was able to
give this boy closure, and help him understand what his cousin went through.
A subdural hematoma can happen to anyone, of any age, gender, and ethnicity. In an
acute subdural hematoma, there is an accumulation of blood below the dura and above the
arachnoid layer covering the brain. The correct diagnostic tests and medication regimen must be
implemented in order to have a positive patient outcome. A CT scan and MRI are the main
neuroimaging diagnostic tools used. A patient with acute subdural hematoma would be taking
medications such as Phenytoin, Lorazepam, Propofol, and Furosemide, a strict medication
regimen is part of supportive measures. The nurse’s role in caring for this patient must include

8. ACUTE SUBDURAL HEMATOMA 8
prioritizing based on assessment data collected. Throughout the entire disease process of these
patients, we must remind ourselves that this is exactly where Gods wants us, and He wouldn’t
put us through something if He knew we couldn’t handle it. We must be grateful for everyday we
are spared.

9. ACUTE SUBDURAL HEMATOMA 9
References
Hinkle, J. & Cheever, K. (2010). Brunner and Suddarth’s textbook of medical- surgical
nursing (13th ed.). New York, NY: Lippincott.
Morton, P. G. & Fontaine, D. K., (2012) Critical Care Nursing: A Holistic Approach (10th ed.).
Philadelphia, PA: Lippincott Williams & Wilkins.
Nursing Central (2012) http://nursing.unboundmedicine.com/nursingcentral/ub/
Parse, R. (1995). Illuminations: The human becoming theory in practice and research. New
York: National League for Nursing Press.
Sparks, R. & Taylor, C. (2014). Sparks and Taylor's nursing diagnosis reference manual (9th
ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.