Craniotomy surgical case report

1 | C r a n i o t o m y

Introduction:

In the past, the earliest evidence of craniotomy is most likely found in the

procedure called trephination, which is basically an antiquated medical

intervention in which a hole is drilled or scraped into the human skull, exposing

the dura mater in order to treat health problems concerning intracranial diseases.

Cave painitings also indicate that people believed such practice would cure

epileptic seizures, migraines, and mental disorders. It was also suggested that it

was a primitive, if not the oldest, emergency surgery for head wounds.

In modern medicine, it is a treatment used for epidural and subdural

hematomas, and for surgical access for certain other neurosurgical procedures,

such as intracranial pressure monitoring. Modern surgeons generally use the

term craniotomy for this procedure. The removed piece of skull is typically

replaced as soon as possible. If the bone is not replaced, then the procedure is

considered a craniectomy.

Today, as contemporary era comes in, it has evolved to craniotomy per se,

or considering the word’s etymology, the surgical cutting of the cranium. A

craniotomy is a surgical operation in which part of the skull, called a bone flap, is

removed in order to access the brain. Craniotomies are often a critical operation

performed on patients suffering from brain lesions or traumatic brain injury (TBI),

and can also allow doctors to surgically implant deep brain stimulators for the

treatment of Parkinson's disease, epilepsy and cerebellar tremor. The procedure

is also widely used in neuroscience for extracellular recording, brain imaging, and

for neurological manipulations such as electrical stimulation and chemical

titration.

Because craniotomy is a procedure that is utilized for several conditions

and diseases, statistical information for the procedure itself is not available.

However, because craniotomy is most commonly performed to remove a brain

tumor, statistics concerning this condition are given. Approximately 90% of


primary brain cancers occur in adults, more commonly in males between 55 and

65 years of age. Tumors in children peak between the ages of three and 12.

Brain tumors are presently the most common cancer in children (four out of

100,000).

In a news article dated April 21, 2009, it was found out that a new type of

brain surgery actually allows patients to stay conscious so there will be foolproof

monitoring of speech and motor functions as doctors basically fiddle with a tumor

or two resting on principal tasks of their brain.

Another innovation to brain surgery published on an earlier date, April 8,

2009, tells us about a new approach to brain surgery leaving no mark behind.

Such feat of using the eyes as a gateway to the brain makes surgery less

invasive, ergo, less risky. This procedure is called eyelid craniotomy, where in an

incision will be made on the eyelid crease and there will be removal of a small

bone from the patient’s eye socket. A smaller incision is almost always correlated

to shorter hospital stay, faster recovery, and less pain. However, it is not for every

patient as it is only used for those with needing brain surgery toward the front of

the skull.

Implications of the above information is almost always suggestive that as

productive members of the society, nurses, or aspiring nurses to be more

specific, as the researchers are, should generally be equipped with pertinent

information and knowledge regarding such high-end surgical intervention to

relieve effects of tumors, bleeding aneurysms, and blood clots in the brain. They

should also be aware how the procedure is to be performed, so they can

anticipate what surgeons are to asked during the course of the surgery. They

must always be in-the-know so they can execute nursing responsibilities and

considerations appropriately for better patient outcome post-operatively.


Awake Craniotomy will be featured on Methodist

hospital webcast today

New brain surgery allows patients to stay conscious

By Lindsay Melvin (Contact), Memphis Commercial Appeal

Tuesday, April 21, 2009

Diagnosed with an aggressive cancer referred to even in medical publications as "The Terminator," Sheila

Mullins couldn't find a neurosurgeon who would go near her brain tumor.

"They said it would leave me paralyzed," said the Oakland resident, who

has stage four glioblastoma multiforme.

Scott Fowler/Special to The Commercial Appeal

UT neurosurgical chief resident Dr. Jay Weimar (left) and Dr. Allen K. Sills

perform an "Awake Craniotomy" at Methodist.STORY TOOLS

After months of her body being racked by seizures, she finally found a

doctor who could remove the tumor safely.

In May, while surgeons scraped her brain of cancerous cells, Mullins lay

on the operating table reciting the alphabet and wiggling her toes and

fingers.

The "Awake Craniotomy" allowed her to stay conscious during the surgery

so doctors could monitor her speech and other functions as they fiddled

with a tumor resting on key functions of her brain.

People can view the Awake Craniotomy performed on Mullins when Methodist University Hospital streams a

webcast of the procedure today.

Questions about the hourlong webcast will be answered live between 4 and 5 p.m.

The procedure has been in the spotlight recently since U.S. Sen. Ted Kennedy underwent an Awake

Craniotomy last year to remove a tumor.

Executing these awake surgeries for the last decade, Methodist is the only facility in the Mid-South qualified

to do the procedure.

The hope is that by educating the public that this procedure is painless and safer than brain surgery of the

past, Methodist hopes to expand its visibility to patients and referring doctors, hospital officials say.

"All of us fear the unknown, particularly when it comes to medical procedures," said Dr. Allen Sills, one of

two neurosurgeons featured in the webcast.

Very sick patients have refused brain surgery because they were too frightened, said the director of

Methodist Healthcare's Neuroscience Institute.

http://www.commercialappeal.com/staff/lindsay-melvin/

http://www.commercialappeal.com/staff/lindsay-melvin/contact/

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Sills is also associate professor of neurosurgery for the University of Tennessee Health Science Center.

"Everyone wants to know if they're going to hurt or be uncomfortable," he said. "This helps the patient to

know exactly what to expect."

-- Lindsay Melvin: 529-2445

A new approach to brain surgery that leaves no

scar behind.

Staff Writer

9:33 AM CDT, April 8, 2009

More than half a million people will have brain surgery this year.

Large scars and lenghty recoveries typically go along with the surgery.

Now Doctors are using the eyes as the gateway to the brain to make surgery less invasive.

Swelling aside, you'd never guess Mike Hogan had life-saving brain surgery just a few weeks ago.

"The doctor ordered a CAT scan. When they did the CAT scan, the aneurysm showed up."

Doctors determined the aneurysm was in danger of ruptureing.

Hogan's surgeons used a new and unusual technique to treat it.

Neurosurgeon Dr. Khaled Aziz "when we do the standard procedure we make an incision behind the hairline

-- from here, all the way to here."

Instead, surgeons fixed the aneurysm through a tiny hole in his eyelid.

During the eyelid Craniotomy a Neuro-Opthamologist marks the eyelid crease then makes an incision and

removes a

small piece of bone from the patient's eye socket.

Next a Neurosurgeon reaches the front of the brain, clips the blood vessel that feeds the aneurysm and then

puts the bone back in place.

Doctors say a smaller incision means a shorter hospital stay, faster recovery and less pain.

"In the long run, I think this it's more helpful for the patient outcome rather than standard surgical

approaches."

Mike has no scar, little pain, and more importantly more time to watch his grandchildren grow up.

"It's amazing what they can do."

Doctor Aziz says the eyelid approach is not for every patient.

It only works for patients who need brain surgery toward the front of the skull

Neurosurgeons also use the eyelid surgery to operate on certain brain tumors.

Copyright © 2009, WQAD-TV

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II. Anatomy and Physiology

The Nervous System

The nervous system is a network of specialized cells that communicate

information about an animals surroundings and its self, it processes this

information and causes reactions in other parts of the body. It is composed of

neurons and other specialized cells called glia, that aid in the function of the

neurons.

The nervous system is

divided broadly into two

categories; the peripheral nervous

system and the central nervous

system. Neurons generate and

conduct impulses between and

within the two systems. The

peripheral nervous system is

composed of sensory neurons

and the neurons that connect

them to the nerve cord, spinal

cord and brain, which make up the

central nervous system. In

response to stimuli, sensory

neurons generate and propagate

signals to the central nervous

system which then process and

conduct back signals to the

muscles and glands.

The neurons of the nervous

systems of animals are

interconnected in complex

arrangements and use electrochemical signals and neurotransmitters to transmit


impulses from one neuron to the next. The interaction of the different neurons

form neural circuits that regulate an organism’s perception of the world and what

is going on with its body, thus regulating its behavior. Nervous systems are found

in many multicellular animals but differ greatly in complexity between species

The central nervous system (CNS) is the largest part of the nervous

system, and includes the brain and spinal cord. The spinal cavity holds and

protects the spinal cord, while the head contains and protects the brain. The CNS

is covered by the meninges, a three layered protective coat. The brain is also

protected by the skull, and the spinal cord is also protected by the vertebrae.

Brain is a part of the Central Nervous System, it plays a central role in the

control of most bodily functions, including awareness, movements, sensations,

thoughts, speech, and memory. Some reflex movements can occur via spinal

cord pathways without the participation of brain structures.

The cerebrum is the largest part of the brain and controls voluntary

actions, speech, senses, thought, and memory.

The surface of the cerebral cortex has grooves or infoldings (called sulci), the

largest of which are termed fissures. Some fissures separate lobes.

The convolutions of the cortex give it a wormy appearance. Each convolution is

delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is

divided into two halves, known as the right and left hemispheres. A mass of

fibers called the corpus callosum links the hemispheres. The right hemisphere

controls voluntary limb movements on the left side of the body, and the left

hemisphere controls voluntary limb movements on the right side of the body.

Almost every person has one dominant hemisphere. Each hemisphere is divided

into four lobes, or areas, which are interconnected.

The frontal lobes are located in the front of the brain and are responsible

for voluntary movement and, via their connections with other lobes,

participate in the execution of sequential tasks; speech output;

organizational skills; and certain aspects of behavior, mood, and memory.


The parietal lobes are located behind the frontal lobes and in front of the

occipital lobes. They process sensory information such as temperature,

pain, taste, and touch. In addition, the processing includes information

about numbers, attentiveness to the position of one’s body parts, the

space around one’s body, and one's relationship to this space.

The temporal lobes are located on each side of the brain. They process

memory and auditory (hearing) information and speech and language

functions.

The occipital lobes are located at the back of the brain. They receive and

process visual information

The Cardiovascular System

The heart and circulatory system make up the cardiovascular system. The

heart works as a pump that pushes blood to the organs, tissues, and cells

of the body. Blood delivers oxygen and nutrients to every cell and

removes the carbon dioxide and waste products made by those cells.

Blood is carried from the heart to the rest of the body through a complex

network of arteries, arterioles, and capillaries. Blood is returned to the

heart through venules and veins.

The one-way circulatory system carries blood to all parts of the body. This

process of blood flow within the body is called circulation. Arteries carry

oxygen-rich blood away from the heart, and veins carry oxygen-poor blood

back to the heart. In pulmonary circulation, though, the roles are switched.

It is the pulmonary artery that brings oxygen-poor blood into the lungs and

the pulmonary vein that brings oxygen-rich blood back to the heart.

Twenty major arteries make a path through the tissues, where they branch

into smaller vessels called arterioles. Arterioles further branch into

capillaries, the true deliverers of oxygen and nutrients to the cells. Most

capillaries are thinner than a hair. In fact, many are so tiny, only one blood

cell can move through them at a time. Once the capillaries deliver oxygen

and nutrients and pick up carbon dioxide and other waste, they move the


blood back through wider vessels called venules. Venules eventually join

to form veins, which deliver the blood back to the heart to pick up oxygen.

Vasoconstriction or the spasm of smooth muscles around the blood

vessels causes and decrease in blood flow but an increase in pressure. In

vasodilation, the lumen of the blood vessel increase in diameter thereby

allowing increase in blood flow. There is no tension on the walls of the

vessels therefore, there is lower pressure.

Various external factors also cause changes in blood pressure and pulse

rate. An elevation or decline may be detrimental to health. Changes may

also be caused or aggravated by other disease conditions existing in other

parts of the body.

The blood is part of the circulatory system. Whole blood contains three

types of blood cells, including: red blood cells, white blood cells and

platelets.

These three types of blood cells are mostly manufactured in the bone

marrow of the vertebrae, ribs, pelvis, skull, and sternum. These cells travel

through the circulatory system suspended in a yellowish fluid called

plasma. Plasma is 90% water and contains nutrients, proteins, hormones,

and waste products. Whole blood is a mixture of blood cells and plasma.

Red blood cells (also called erythrocytes) are shaped like slightly

indented, flattened disks. Red blood cells contain an iron-rich protein

called hemoglobin. Blood gets its bright red color when hemoglobin in red

blood cells picks up oxygen in the lungs. As the blood travels through the

body, the hemoglobin releases oxygen to the tissues. The body contains

more red blood cells than any other type of cell, and each red blood cell

has a life span of about 4 months. Each day, the body produces new red

blood cells to replace those that die or are lost from the body.

White blood cells (also called leukocytes) are a key part of the body's

system for defending itself against infection. They can move in and out of

the bloodstream to reach affected tissues. The blood contains far fewer

white blood cells than red cells, although the body can increase production


of white blood cells to fight infection. There are several types of white

blood cells, and their life spans vary from a few days to months. New cells

are constantly being formed in the bone marrow.

Several different parts of blood are involved in fighting infection. White

blood cells called granulocytes and lymphocytes travel along the walls of

blood vessels. They fight bacteria and viruses and may also attempt to

destroy cells that have become infected or have changed into cancer

cells.

Certain types of white blood cells produce antibodies, special proteins that

recognize foreign materials and help the body destroy or neutralize them.

When a person has an infection, his or her white cell count often is higher

than when he or she is well because more white blood cells are being

produced or are entering the bloodstream to battle the infection. After the

body has been challenged by some infections, lymphocytes remember

how to make the specific antibodies that will quickly attack the same germ

if it enters the body again.

Platelets (also called thrombocytes) are tiny oval-shaped cells made in the

bone marrow. They help in the clotting process. When a blood vessel

breaks, platelets gather in the area and help seal off the leak. Platelets

survive only about 9 days in the bloodstream and are constantly being

replaced by new cells.

Blood also contains important proteins called clotting factors, which are

critical to the clotting process. Although platelets alone can plug small

blood vessel leaks and temporarily stop or slow bleeding, the action of

clotting factors is needed to produce a strong, stable clot.

Platelets and clotting factors work together to form solid lumps to seal

leaks, wounds, cuts, and scratches and to prevent bleeding inside and on

the surfaces of our bodies. The process of clotting is like a puzzle with

interlocking parts. When the last part is in place, the clot is formed.


When large blood vessels are cut the body may not be able to repair itself

through clotting alone. In these cases, dressings or stitches are used to

help control bleeding.

In addition to the cells and clotting factors, blood contains other important

substances, such as nutrients from the food that has been processed by

the digestive system. Blood also carries hormones released by the

endocrine glands and carries them to the body parts that need them.

Blood is essential for good health because the body depends on a steady

supply of fuel and oxygen to reach its billions of cells. Even the heart

couldn't survive without blood flowing through the vessels that bring

nourishment to its muscular walls. Blood also carries carbon dioxide and

other waste materials to the lungs, kidneys, and digestive system, from

where they are removed from the body.



III. Patient and his Illness

Pathophysiology of Hemmorhagic Cerebrovascular Accident with Subdural Hematoma formation

Defective clotting formation

Non-modifiable Factors - Age – 55 y/o and above- A family history of stroke, heart attack or TIA - Blacks- Familial history of fragile blood vessels- History of ischemic attacks- History of epileptic attack

Modifiable Factors - Alcohol use -

Thrombocytopenia- Obesity - Coagulopathy- Diabetes- Oral Contraceptives - Smoking - Hypertension - Diet pills- Stress- Head injury

CNS Depressio

n

Thrombus formation

↑ Viscosity of blood

BVConstriction

FattyDeposits↑ risk for

acquiring the same disease

↓ elasticity

of BV Sluggish blood flow

↑ blood vessel resistance

↓ organ

Vascular damage

Leak of blood to the meninges

↓ venous return

Mass formation

↑ ICP ↓ renal and GIT function

Pain, malaise

Impaired optic

function

↓ cerebral functioning

Lactic acid formationBrain compression

Brittleveins

Enlarged subdural space due to shrinking brain tissue

Impaired cardiovascular

function

Impaired respiratory

function

Apneustic Breathing

Bradycardia, ↑SBP,

widened pulse

pressure

Neurologic affectationHeadache, dizziness, behavioral changes

↓ ROM retinal changes

Bladder and bowel

incontinencehemiplegiaSlurred speech drowsiness syncope

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http://www.thirdage.com/healthgate/files/11647.html


b. Synthesis of the Disease

Subdural hematoma- The brain is

covered by a membrane (layer of tissue)

called the dura. If the veins located

below the dura (subdural area) leak

blood, then pressure in this area may

build up and injure the brain, this blood

then will collect into a mass called

hematoma. Hematoma may have

different classification depending on the

site of the hematoma. If the hematoma on

the subarachnoid area, it will be then

classified as a subarachnoid hematoma, more so, a hematoma found on

the subdural area is classified as subdural hematoma.

Hematoma is one of the deadliest reason of mortality related to

brain injury if it is not managed well; as the mass formed my the

hematoma will then compress the brain tissue altering the normal

perfusion of the brain tissue thus altering the sensorial and motor function

of the brain depending on the affected area, this will also be accompanied

by hypoxia, which will result to ischemic attack specifically Transient

Ischemic Attack (TIA) and when not managed will result to brain cell

atrophy, which will progress to Cerebrovascular Attack damaging the brain

cell later on cell death which will progress to brain death (Comatose state),

inhibition of the regulatory mechanism of the brain including respiration

and circulation resulting to death.

Most commonly, the major factors contributing to subdural

hematoma are of lifestyle practices and underlying conditions such as

alcoholism, cigarette smoking, and decreased integrity of the blood vessel,

hypertension, diabetes mellitus, arteriosclerosis, and thrombocytopenia.


This is most commonly accompanied by the following signs and

symptoms headache, contralateral weakness, seizure, sensorial

alteration, increased ICP, nausea, personality changes, confusion,

decreased LOC, impaired vision, eye droop, speech difficulties, numbness

of decreased sensation of a limb, and papillary dilatation.

Subdural Hematomas are managed with different treatment

modalities such as follows:

Goal is to reduce pressure on the brain

Circulation support (intravenous fluids and medications to

maintain blood pressure)

Respiratory support (oxygen and mechanical ventilation if

necessary)

Dexamethasone (a corticosteroid medication) may be used to

decrease the inflammation of the brain

Mannitol (a diuretic) may be used to decrease the swelling of

the brain

Dilantin (a seizure medication) may be used to prevent or

control Seizures

Reversal of blood thinning agents such as Coumadin or Heparin

Emergency Surgery may be needed to drain the hematoma

(blood clot), and relieve the pressure on the brain. The

hematoma is outside the brain, but still puts pressure on it.

Therefore, the surgery involves drilling small holes in the skull

and evacuating the blood. Occasionally, if the hematoma is very

large or has solidified, a large opening in skull may be needed (this is

called a craniotomy).

Cerebrovascular Accident (Stroke)- A Cerebrovascular accident

is the sudden disruption of O2 supply to the nerve cells, generally caused


by obstruction or rupture in one or more of the blood vessels that supply

the brain. There two main types of stroke:

Ischemic- is the most common type of stroke, 85% of

cerebrovascular cases are of the ischemic type. Ischemic type of

CVA has three main mechanism:

o Thrombosis- results from the blockage of a blood supply to

the brain tissue due to atherosclerosis.

o Emboli- embolic type of ischemic CVA is also a result of a

blockage of the blood supply to the brain tissues only it is

due to emboli.

o Systemic hypoperfusion- this is usually a result of decreased

cerebral blood flow owing to circulatory failure. Circulatory

failure results from too little blood, too low BP, or failure of

the heart to pump blood adequately. Hypoxia from any

cause can also produce this syndrome.

Transient ischemic attack (TIA) is one of the indicators of CVA; this

is a temporary neurologic deficit that resolves completely without

permanent damage, it usually occurs when the artery cannot

deliver enough blood to meet the brain’s O2 demand.

Hemorrhagic- this is due to neural tissue destruction because of

infiltration and accumulation of blood. Ischemia and infarction may

occur distal to the hemorrhage because of the interrupted blood

supply. Although hemorrhage is usually brought about by

hypertension or an aneurysm, this could be also because of

trauma. This is usually accompanied by increased Intracranial

Pressure (ICP) due to the mass effect brought about by the blood

leakage from either of the meninges.


Mostly, patient having a CVA does not get any clue that they are having a

stroke, but there are some manifestations that one must be alerted if he is

experiencing the following manifestations below as this could be an

indication of a stroke.

Trouble with walking. If you're having a stroke, you may stumble

or have sudden dizziness, loss of balance or loss of coordination.

Trouble with speaking. If you're having a stroke, you may slur

your speech or may not be able to come up with words to explain

what is happening (aphasia). Try to repeat a simple sentence. If

you can't, you may be having a stroke.

Paralysis or numbness on one side of the body. If you're

having a stroke, you may have sudden numbness, weakness or

paralysis on one side of the body. Try to raise both your arms over

your head at the same time. If one arm begins to fall, you may be

having a stroke.

Trouble with seeing. If you're having a stroke, you may suddenly

have blurred or blackened vision or may see double.

Headache. A sudden, severe "bolt out of the blue" headache or

an unusual headache, which may be accompanied by a stiff neck,

facial pain, pain between your eyes, vomiting or altered

consciousness, sometimes indicates you're having a stroke.

Many factors can increase your risk of a stroke. A number of these

factors can also increase your chances of having a heart attack. Stroke risk

factors include:

A family history of stroke, heart attack or TIA

Being age 55 or older

High blood pressure — a systolic blood pressure of 140

millimeters of mercury (mm Hg) or higher, or a diastolic pressure

of 90 mm Hg or higher


High cholesterol — a total cholesterol level of 200 milligrams per

deciliter (mg/dL), or 5.2 mmOl/L, or higher

Cigarette smoking

Diabetes

Obesity — a body mass index of 30 or higher

Cardiovascular disease, including heart failure, a heart defect,

heart infection, or abnormal heart rhythm

Previous stroke or TIA

Use of birth control pills or other hormone therapy

In relation with Mr. Enfarcion’s case, his CVA was initially brought

about by a hemorrhagic type of CVA due to a leak of venous blood from

the subdural meninges of the brain brought about by an increased

pressure on the blood vessels due to an increased vascular resistance

due to hypertension and viscosity of the blood related to his diabetes

mellitus. This resulted to a decreased volume of the circulating blood due

to a decreased venous return, and a depression of the brain due to the

mass formation. This resulted to neurologic deficits manifested by severe

headache, hemiparesis, decreased LOC, and dizziness.


IV. Clinical Intervention

1.1 Description of the prescribed surgical treatment

Craniotomy is any bony opening that is

cut into the skull. A section of skull, called

a bone flap, is removed to access the

brain underneath. There are many types

of craniotomies, which are named

according to the area of skull to be

removed (Fig. 1). Typically the bone flap

is replaced. If the bone flap is not

replaced, the procedure is called a craniectomy.

Who performs the procedure?

A craniotomy is performed by a neurosurgeon; some have additional training in

skull base surgery. A neurosurgeon may work with a team of head-and-neck,

otologic, oculoplastic and reconstructive surgeons. Ask your neurosurgeon about

their training, especially if your case is complex.

What happens before?

You will typically undergo tests (e.g., blood test, electrocardiogram, chest X-ray)

several days before surgery. In the doctors office you will sign consent forms and

complete paperwork to inform the surgeon about your medical history (i.e.,

allergies, medicines, anesthesia reactions, previous surgeries). You may wish to

donate blood several weeks before surgery. Discontinue all non-steroidal anti-

inflammatory medicines (Naproxin, Advil, etc.) and blood thinners (coumadin,

aspirin, etc.) 1 week before surgery. Additionally, stop smoking, chewing

tobacco, and drinking alcohol 1 week before and 2 weeks after surgery because

these activities can cause bleeding problems.


What happens during?

There are 6 main steps during a craniotomy. Depending on the underlying

problem being treated and complexity, the procedure can take 3 to 5 hours or

longer.

Step 1. Patient preparation

No food or drink is permitted past midnight the

night before surgery. Patients are admitted to

the hospital the morning of the craniotomy.

With an intravenous (IV) line placed in your

arm, general anesthesia is administered while

you lie on the operating table. Once asleep,

your head is placed in a 3-pin skull fixation

device, which attaches to the table and holds

your head in position during the procedure

(Figure 2).

Insertion of a lumbar drain in your lower back

helps remove cerebrospinal fluid (CSF), thus

allowing the brain to relax during surgery. A

brain-relaxing drug called mannitol may be given.

Step 2. Skin incision

After the scalp is prepped with an antiseptic, a skin incision is made, usually

behind the hairline. The surgeon attempts to ensure a good cosmetic result after

surgery. Sometimes a hair sparing technique can be used that requires shaving

only a 1/4-inch wide area along the proposed incision. Sometimes the entire

incision area may be shaved.


Step 3. Craniotomy, opening the skull

The skin and muscles are lifted off the bone

and folded back. Next, one or more small

burr holes are made in the skull with a

drill. Inserting a special saw through the burr

holes, the surgeon uses this craniotome to

cut the outline of a bone flap (Figure 3). The

cut bone flap is lifted and removed to

expose the protective covering of the brain

called the dura. The bone flap is safely

stored until it is replaced at the end of the

procedure.

Step 4. Exposure of the brain

After opening the dura with surgical

scissors, the surgeon folds it back to

expose the brain (Figure 4). Retractors

placed on the brain gently open a corridor

to the area needing repair or removal.

Neurosurgeons use special magnification

glasses, called loupes, or an operating

microscope to see the delicate nerves and

vessels.

Step 5. Correct the problem

Because the brain is tightly enclosed inside the bony skull, tissues cannot be

easily moved aside to access and repair problems. Neurosurgeons use a variety

of very small tools and instruments to work deep inside the brain. These include

long-handled scissors, dissectors and drills, lasers, ultrasonic aspirators (uses a

fine jet of water to break up tumors and suction up the pieces), and computer


image-guidance systems. In some cases, evoked potential monitoring is used to

stimulate specific cranial nerves while the response is monitored in the brain.

This is done to preserve function of the nerve and make sure it is not further

damaged during surgery.

Step 6. Closure

With the problem removed or repaired, the

retractors holding the brain are removed

and the dura is closed with sutures. The

bone flap is replaced back in its original

position and secured to the skull with

titanium plates and screws (Figure 5). The

plates and screws remain permanently to

support the area; these can sometimes be

felt under your skin. In some cases, a drain may be placed under the skin for a

couple of days to remove blood or fluid from the surgical area. The muscles and

skin are sutured back together. A turban-like or soft adhesive dressing is placed

over the incision.

What happens after?

After surgery, you are taken to the recovery room where vital signs are monitored

as you awake from anesthesia. The breathing tube (ventilator) usually remains in

place until you fully recover from the anesthesia. Next, you are transferred to the

neuroscience intensive care unit (NSICU) for close observation and monitoring.

You are frequently asked to move your arms, fingers, toes, and legs.


1.2 Indication of prescribed surgical treatment

INDICATIONS:

Craniotomy is of course, usually performed for problems with the brain and head

injuries. Indications for such procedure include:

Brain tumors

o An abnormal growth of cells within the brain or inside the skull,

which can be cancerous or non-cancerous.

Bleeding (hemorrhage)

o A loss of blood in the circulatory system

Blood clots (hematomas)

o A collection of blood outside the blood vessels generally the result

of hemorrhage, or more specifically, internal bleeding. It is named

based on the site of injury. Examples of which is subdural

hematoma (between the dura mater and arachnoid mater) and

epidural hematoma (between the dura mater and the skull).

Weaknesses in blood vessels (cerebral aneurysms)

o A localized, blood-filled dilation (balloon-like bulge) of a blood

vessel caused by disease or weakening of the vessel wall. As the

size of an aneurysm increases, there is an increased risk of

rupture, which can result in severe hemorrhage or other

complications including sudden death.

Relief from increased intracranial pressure

Damage to tissues covering the brain (dura)

Pockets of infection in the brain (brain abscesses)

o Abscess caused by inflammation and collection of infected material

coming from local (ear infection, dental abscess, infection of

paranasal sinuses, infection of the mastoid air cells of the temporal

bone, epidural abscess) or remote (lung, heart, kidney etc.)

infectious sources within the brain tissue. The infection may also be


introduced through a skull fracture following a head trauma or

surgical procedures. Brain abscess is usually associated with

congenital heart disease in young children. It may occur at any age

but is most frequent in the third decade of life.

Severe nerve or facial pain (such as trigeminal neuralgia or tic douloureux)

o A neuropathic disorder of the trigeminal nerve that causes episodes

of intense pain in the eyes, lips, nose, scalp, forehead, and jaw.

Epilepsy

o A common chronic neurological disorder characterized by recurrent

unprovoked seizures

Chiari malformations

o A malformation of the brain. It consists of a downward displacement

of the cerebellar tonsils and the medulla through the foramen

magnum, sometimes causing hydrocephalus as a result of

obstruction of cerebrospinal fluid (CSF) outflow. The cerebrospinal

fluid outflow being caused by phase difference in outflow and influx

of blood in the vasculature of the brain

BENEFITS VERSUS RISKS:

Benefits of craniotomy include removal of brain tumors for return of motor

or sensory impairment and relief from seizure attacks, control of bleeding to

prevent death especially from ruptured aneurysm, evacuation of blood clots to

decrease ICP, drainage of brain abscesses to manage infection, and alleviation

of pain from neuropathic disorders and for modality in skull fractures. This would

lead to an improved quality of life and more time for the patient to live.

All operations carry some risks. Brain surgery carries more than most. Any

operation can be complicated by heart trouble, chest infection, blood clots in the

leg (thrombosis) and wound infection. The chances of these complications are

greater in elderly or unhealthy patients and, in particular, those who smoke or

drink heavily. The major specific complications of brain surgery are damage to


the brain at the time of surgery and bleeding within the head after the operation.

Meningitis and epilepsy occasionally follow craniotomy. When bleeding is

suspected, you would have to return to operating room within a few hours of the

operation for a reopening of the wound. Sometimes deterioration is due to brain

swelling and the bone flap is left out, being stored frozen in antibiotic solution. It

may then be replaced at a later date when the swelling has settled down.

Consequently, damage to normal brain tissue may cause injury to an area

and subsequent loss of brain function. Loss of function in specific areas can

cause memory impairment. Some other examples of potential harm that may

result from this procedure include deafness, double vision, numbness, paralysis,

blindness, or loss of the sense of smell.

The actual risk in a particular case will depend on the complexity of the operation.

RISKS ON UNDERGOING CRANIOTOMY

RISKS ON NOT UNDERGOING CRANIOTOMY

General surgery risk (bleeding, chest and wound infection, DVT, heart trouble, untoward reaction to anesthesia)

Unresolved brain tumors and blood clots leading to cell death, compression of brain structures and increased intracranial pressure

Intracranial bleeding Unresolved increase in intracranial pressure

Subsequent loss of brain function r/t brain damage AEB motor and sensory impairment

Unresolved bleeding leading to shock

Unresolved infection due to brain abscesses.

Unresolved chronic pain from neuropathic disorders precipitates poor quality of life



1.3Required Instruments, Devices, Supplies, Equipment and Facilities

INSTRUMENTS

Basic Set

Mosquito

Kelly curves

Allis

Babcock

Needle holder

Tissue forcep

Thumb forcep

Army navy

Kidney basin

Towel clips

Straight clamp

Mixter

Craniotomy Surgical Set

2Jansen Retractor

2Weitlaner Retractor

1Scalpel Handle #3

1Scalpel Handle #4

1Scalpel Handle #7

4Solid Bar Handle For Gigli Saw

2Adson (Ewald) Dressing Forceps

2Adson Tissue Forceps

12Backhaus Towel Clamp

2Cushing Brain Forceps

2Cushing Brain Forceps

1Echlin Rongeur

6Foerster Sponge Forceps


6Foerster Sponge Forceps

18Halsted Mosquito Forceps

18Halsted Mosquito Forceps

1Luer Bone Rongeur

1Stille-Liston Rongeur

2Mayo-Hegar Needle Holder

1Gigli Saw Wire

1Gigli Saw Wire

1Operating Scissors

1Mayo-Stille Dissecting Scissors

1Mayo-Stille Dissecting Scissors

1Metzenbaum Dissecting Scissors

1Taylor Dural Scissors


Jansen Retractor

Weitlaner retractor

Scalpel

Adson (Ewald) Dressing Forceps


Adson Tissue Forceps

Backhaus Towel Clamp

Cushing Brain Forceps (Delicate Serrated)


Echlin Rongeur

Foerster Sponge Forceps

Halsted Mosquito Forceps


Halsted Mosquito Forceps

Luer Bone Rongeur

stille-Liston Rongeur

Mayo-Hegar Needle Holder


Gigli Saw Wire

Operating Scissors

Mayo-Stille Dissecting Scissors


Mayo-Stille Dissecting Scissors curved

Taylor Dural Scissors

EQUIPMENTS

Suction

Electrosurgical unit


FACILITIES

`

`

ANESTHESIOLOGIST

P

A

T

I

E

N

T

SURGEON

ASSISTANT

SCRUB

SUTURE

SUCTIONTUBE

Surgicallight Surgical

light

EmergencyCart

Electrosurgical


1.4 Perioperative Tasks and Responsibilities of the Nurse

SCRUB NURSE

Pre-operative Responsibilities

1. Assist with the preparation of the room for the designated surgical procedure,

including gathering supplies for the procedure.

2. Scrub, dry hands, gown, and glove.

3. Assist person scrubbed in first position with:

a. Setting up back table, mayo, and basins

b. Arrangement of instruments

c. Preparation of suture and needles

d. Preparation and counting sponges

e. Arrangement and preparation of other necessary items

f. Gowning and gloving surgeon and assistants

g. Assist with draping

h. Arrangement of sterile field

Intra-operative Responsibilities

1. During the procedure, progress from double-scrubbed position. Train self to

keep eyes on field, and learn steps of procedure.

2. Begin developing methods of anticipating needs of surgeon and assistant.

3. After closing the skin:

a. Assist with care of instruments and counts if necessary

b. Care of specimen

c. Assist with dressing of wound

Post-operative Responsibilities

1. After the completion of the Procedure:

a. Assist with the gathering of all materials used during the procedure

b. Discard items as necessary being careful to discard sharp items in

designated places

c. Return all items to respective area

d. Assist with cleaning of room


e. Clean the materials used properly and arrange them after drying

2. Perform any duties which will speed up the surgical procedure to follow in that

room.

CIRCULATING NURSE

Pre-operative Responsibilities

1. Care for the patient before surgery by:

a. Greeting patient and assist nurse with identification

b. Checking patient's chart, preparation, etc.

2. Prepare the room by:

a. Obtaining instruments, supplies, and equipment for the designated

operative procedure

b. Opening unsterile supplies

c. Assisting in gowning

d. Observing breaks in sterile technique

e. Assisting anesthesiologist as necessary

f. Assisting with skin preparation and positioning

g. Assisting with forming of the sterile field

3. Count the instruments, sharps and sponges before the procedure and confirm

with scrub nurse.

Intra-operative Responsibilities

1. During the Procedure:

a. Remain in room and dispense materials as necessary

b. Observe procedure as closely as possible

c. Begin establishing method of anticipating needs of surgical team

d. Care of specimen as indicated

e. Care of operative records as indicated

f. Assist with application of dressing

g. Monitor the instruments, sharps and sponges used and take note of

additional instruments.


2. Before the closing of the organ or peritoneum, count all instruments, sharps

and sponges and confirm with scrub nurse.

3. Inform the surgeon and assistant surgeon of a report of the instruments.

Post-operative Responsibilities

1. Properly document all the necessary information on the patient’s chart.

2. Assist in the cleaning of the Operation Room as necessary.

Prior to operation:

A careful history and physical examination are performed

Intravenous fluids are given to correct volume depletion and any electrolyte

imbalances are measured and corrected. Monitor and regulate IVFs

The nurse instructs the patient about the need to avoid smoking to enhance

pulmonary recovery postoperatively and avoid respiratory complications. It is

also important to instruct the patient to avoid the use of aspirin and other

agents that can alter coagulation and other biochemical process

On of the most important responsibility of the nurse is to let the patient sign

an informed consent regarding the surgery.

The patient is given anaesthesia prior to surgery and the patient is under

NPO.

During the operation

Monitoring the vital signs of the patient is one of the responsibilities of the

nurse during the surgery.

Assisting the anesthesia care provider during induction of general anesthesia

Ensuring adequate oxygenation and hydration

After the operation

After recovery, the nurse places the patient in the low fowler’s position. IV

fluids may be given. Water and other fluids are given in about 24hours, and

soft diet is started when bowel sounds returned.


Placing warm blankets on the patient to enhance comfort and preserve the

patient's body temperature

Assessing the patient's vital signs, oxygen saturation level, level of

consciousness, circulation, pain, IV site, fluid rate, and hydration status, as

well as the status of the surgical site and dressing and all related monitoring

equipment

The nurse helps in relieving the pain by instructing the patient regarding

proper positioning.

The nurse helps in improving the respiratory status by instructing the patient

regarding deep breathing exercises.

The nurse also provides skin care like cleaning the incision part and providing

clean dressing following a strict aseptic technique

The nurse instructs the patient about the medications that are prescribed by

the physician

Discussing recommended follow-up management with the physician and the

surgeon

1.5. Expected Outcomes of the Surgical Treatment Performed

Most clients are discharged on the day of surgery or the day after. As the

days and weeks go by after the surgery, there would be a verbalization of a

decrease in pain from the patient he could do splinting properly and adhere to

medication therapy for pain. Another expected outcome is that the patient

demonstrates appropriate respiratory function as evidenced by the

achievement of a full respiratory excursion and coughs effectively.

The patient’s incision should also be free from the presence of foul-

smelling discharge or pus around the incision. Absence of fever or

inflammation is indicative of the absence of infection. The patient should also

know and demonstrate proper wound cleaning or wound care as well as the

correct management of drainage tube if applicable. A report of a return in

appetite, no vomiting, bleeding should come from the patient together with

normal and stable vital signs.


Since there would be the elimination of the signs and symptoms such as

pain, there would be a better quality of life for the patient which could increase

productivity and minimize hospital or clinic visits, upon discharge clients may

be given information regarding:

Discomfort

1. After surgery, headache pain is managed with narcotic medication. Because

narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks).

Their regular use may also cause constipation, so drink lots of water and eat high

fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) may be bought

without a prescription. Thereafter, pain is managed with acetaminophen (e.g.,

Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin;

ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve).

2. A medicine (anticonvulsant) may be prescribed temporarily to prevent

seizures. Common anticonvulsants include Dilantin (phenytoin), Tegretol

(carbamazepine), and Neurontin (gabapentin). Some patients develop side

effects (e.g., drowsiness, balance problems, rashes) caused by these

anticonvulsants; in these cases, blood samples are taken to monitor the drug

levels and manage the side effects.

Restrictions

1. Do not drive after surgery until discussed with your surgeon and avoid sitting

for long periods of time.

2. Do not lift anything heavier than 5 pounds (e.g., 2-liter bottle of soda),

including children.

3. Housework and yardwork are not permitted until the first follow-up office visit.

This includes gardening, mowing, vacuuming, ironing, and loading/unloading the

dishwasher, washer, or dryer.

4. Do not drink alcoholic beverages.

Activity

5. Gradually return to your normal activities. Fatigue is common.

6. An early exercise program to gently stretch the neck and back may be

advised.


7. Walking is encouraged; start with short walks and gradually increase the

distance. Wait to participate in other forms of exercise until discussed with your

surgeon.

Bathing/Incision Care

8. You may shower and shampoo 3 to 4 days after surgery unless otherwise

directed by your surgeon.

9. Sutures or staples, which remain in place when you go home, will need to be

removed 7 to 14 days after surgery. Ask your surgeon or call the office to find out

when.

When to Call Your Doctor

10. If you experience any of the following:

A temperature that exceeds 101º F

An incision that shows signs of infection, such as redness, swelling, pain,

or drainage.

If you are taking an anticonvulsant, and notice drowsiness, balance

problems, or rashes.

Decreased alertness, increased drowsiness, weakness of arms or legs,

increased headaches, vomiting, or severe neck pain that prevents

lowering your chin toward the chest.

Recovery

The recovery time varies from 1 to 4 weeks depending on the underlying disease

being treated and your general health. Full recovery may take up to 8 weeks.

Walking is a good way to begin increasing your activity level. Start with short,

frequent walks within the house and gradually try walks outside. It’s important not

to overdo it, especially if you are continuing treatment with radiation or

chemotherapy. Ask your surgeon when you can expect to return to work.

What are the risks?

No surgery is without risks. General complications of any surgery include

bleeding, infection, blood clots, and reactions to anesthesia. Specific

complications related to a craniotomy may include:

stroke


seizures

swelling of the brain, which may require a second craniotomy

nerve damage, which may cause muscle paralysis or weakness

CSF leak, which may require repair

loss of mental functions

permanent brain damage with associated disabilities

1.6 Medical Management (this is based form previous handled patient in the

medicine ward with a diagnosis of CVA)

a. IVF’s, BT, NGT Feedings, Nebulization, TPN, Oxygen Therapy.etc.

IV FluidsGeneral

DescriptionIndication(s)or Purposes

PNSSPlane Normal Saline Solution

Normal Saline solution is a

solution of sodium chloride, or salt, in

sterile water. Normal saline

solution is 0.9% sodium chloride. It

is isotonic. An isotonic solution is

less irritating to the body cell

It is used as a source of fluid and electrolytes. Normal saline is most

commonly used as an intravenous (IV) infusion, administered through an IV

drip to prevent dehydration in patients who cannot consume liquids and

nutrients by mouth.

Nursing Implication:

Before:1. Check the physician’s order for IV solution and explain to the client the

procedure. 2. Check the potency of IV line and needle 3. Check the type of infusion, condition of the vein and medical condition of the

patient

During:1. Maintenance of Aseptic Technique 2. Proper procedure and steps in infusing IV solution3. Count drops per minute in drip chamber.


After:1. Monitor IV infusion at least every 2 hour 2. Adjust IV clamp as needed and recount drop per minute.3. Monitor client for fluid overflow 4. More frequent check maybe prn if a medication(s) are being infused.5. More frequent check maybe prn if a medication(s) are being infused.6. Inspect site for pain, swelling, coolness or pallor at the site of insertion, which

may indicate infiltration of IV 7. Inspect site for redness, swelling, heat and pain which may indicate phlebitis

b. Drugs

Name of DrugRoute, Dosage &

Frequency of administration

Indication(s) or Purposes

Generic Name: Cefazolin

Brand Name:Ancef

1gram IV q 8 °

Cefazolin is used for treating bacterial infections or preventing bacterial infections before, during,

or after certain surgeries. Cefazolin is a cephalosporin antibiotic. It works by killing

sensitive bacteria.

Generic Name: Omeprazole

Brand Name:Prilosec

40mg IV q 12 °

Used in short-term treatment of active duodenal ulcer, duodenal ulcer associated with

H.Pylori ,short-term treatment of active benign gastric ulcer, long term treatment of

hypersecretory conditions, treatment of heartburn and symptoms associated with GERD

Generic Name: Citicholine

1gram IV q 12 °9/15/08

Shifted to oral: 500mg 1cap BID

Citicholine is used to treat cerebrovascular disorders, head injury, and Parkinson’s disease

Generic Name: Cefuroxime

Brand Name:Ceftin

500mg BID

Cefuroxime is a cephalosporin antibiotic. It works by fighting bacteria in your body. Cefuroxime is used to treat many kinds of bacterial infections.

Surgical prophylaxis, prophylaxis against infection in cardiac, pulmonary, esophageal &

vascular surgery.

Vitamin B Complex

1cap BID

To boost metabolism, enhance the immune system and nervous system, keep the skin and

muscles healthy, encourage cell growth and division.

Nursing Implication

Before:1. Check and confirm the order (dosage, frequency and route) for the said drug 2. Check and recheck the drug indication and computation 3. Check the patient’s identity 4. Inform the patient, its purpose and action 5. Explain the importance of strict compliance to medical regimen.

During:


1. Maintenance of Aseptic Technique 2. Administer IV Meds slowly

After:1. Maintain hydration 2. Monitor vital signs carefully monitor therapeutic response and the occurrence

of adverse reactions3. Inform the patient to report adverse reactions without delay

Instruct patient to report discomfort at the IV site immediately

c. Diet

TypeOf

dietGeneral description indication

Clear Liquid diet

Liquids that you can see through at room temperature (about 78-72 degrees Fahrenheit are considered clear liquids. This includes clear juices, broths, hard candy, ices and gelatin

The clear liquid diet helps to keep you hydrated (body fluids, salts and minerals) and helps to get the body used to food after long periods of time without food. The clear liquid diet is easy to digest and does not leave much residue in the stomach and intestines.

Soft DietVery similar to regular diet except that the textures of foods have been modified.

To provide a transitional diet between liquids and regular food for patients who have undergone surgery.

Diet as Tolerated

(DAT)

A full, well-balanced diet containing all of the essential nutrients needed. It is a regular diet with no food restrictions as tolerated by the patient.

To attain optimal growth, tissue repair and normal functioning of the organs.For maintenance of nutrition & for promotion of wellness through food intake via regular diet per orem.

Nursing Responsibilities for soft diet

● Check the doctor’s order.● Educate the patient and significant others on the right foods to be taken.● Discuss to the patient the importance of nutrition.● Provide a variety of choices of foods.● Assess patient’s appetite.

Nursing Responsibilities for DAT

● Check the doctor’s order.● Educate the patient and significant others on the right foods to be taken.● Discuss to the patient the importance of nutrition.● Provide a variety of choices of foods.● Present foods which are appealing and pleasing to the eyes and attract interest.● Assess patient’s appetite.d. Activity/ Exercise


TypeOf

exercise

General description indication

High Back Rest

A type of activity or exercise wherein the patient is kept on bed with the head of bed held at at least 45° with limitations to other activities.

To reduce oxygen demand and prevent fatigue. Rest decreases body metabolic rate.

May Sit on Bed

A type of activity wherein the client is held on a sitting position for a period of time to facilitate circulation and prevent bed sores.

This is to prevent bed sores and promote strength gaining.

Nursing Responsibilities● Assist patient if with such privilege in going to the bathroom.● Change client’s position from time to time, to promote circulation and prevent bed sores.



1.7 Nursing Management

a. Nursing Care Plans (this is based form previous handled patient in the medicine ward with a diagnosis of CVA)

AssessmentNursing

DiagnosisScientific

ExplanationObjectives Interventions Rationale Evaluation

S> ØO> received patient on bed conscious, coherent> with intact suture over the head> with complaint of tolerable pain> no dyspnea> no pallor> no cyanosis noted> skin is moist> with good skin turgor

Impaired skin integrity r/t

presence of suture over the

head

A craniotomy which is a surgical operation in which part of the skull called “bone flap” is removed in order to access the brain that is made specifically in the subdural and subacute component lobe to discharge or expel subdural hematoma in which it is a form of traumatic brain injury where in blood gathers between the dura and arachnoid. After the surgery, a suture then is

Short term:After 4 hrs. of

nursing intervention the patient’s SO will

participate in prevention

measures such as infection and

treatment program towards

wound repair/healing

Long Term:After 4 days of

nursing intervention, the

patient will display timely healing of skin

lesions/wounds/ pressure sores

without complication

> Establish rapport> Monitor and recoded vital signs> Assess patient’s condition> Note changes in color, texture & turgor> Identify underlying condition/pathology involved> Note presence of uncompromised vision, hearing or speech> Provide wound care

> Emphasize proper hand

> To gain trust of patient/SO> To obtain baseline data

> To assess causative/contributing factors> To assess extent of involvement/injury> To assess causative/contributing factors

> To determine impact of condition

> To assist client w/ correcting/ minimizing condition & to promote optimal healing> A first line defense against

Short term:The patient’s SO shall have

been participated in

prevention measures such

as infection and treatment

program towards wound repair/healing after 4 hrs. of

nursing intervention

Long term:

The patient shall have

been able to display timely healing of skin lesions/wounds

/ pressure sores without complication

after 4 days of


made to hold skin, thus breaking the completeness or wholeness of the skin.

washing techniques by all caregivers b/w therapies/clients

> Encourage client to verbalize feelings esp. pain> Assist the client/ SO in understanding and following medical regimen and developing program of preventive care and daily maintenance> Provide optimum nutrition, increase protein intake and Vit.C

nosocomial infections/ cross-contamination to reduce/ correct existing risk factors> To promote wellness

> Enhances commitment to plan, optimizing outcomes

> To aid in healing, to maintain general good health and for tissue repair

nursing intervention


AssessmentNursing

DiagnosisScientific

ExplanationObjective

Nursing Interventions

RationaleExpected Outcome

S=ØO= The patient manifested the following:>Unable to speak dominant languages>Speaks or verbalizes with difficulty>Has difficulty in expressing thoughts verbally>has difficulty in comprehending and maintaining the usual communication pattern>Unable or has difficulty in use of facial or body expressions

=The patient may manifest the following:

Language deficit (aphasia) related to brain surgery (decrease circulation to the brain and damage to the left side of the brain responsible for speech/language)

The patient’s condition happens due to surgical operation of the brain in which the left side of the brain is being damaged and this left side of the brain is responsible for the motor functions of the body specifically speech or language resulting to Aphasia. Aphasia is a disorder that results from damage to the parts of the brain that contain language. Aphasia causes problems with any or all of the following: speaking, listening, reading, and

Short Term:After 5° of Nursing Intervention, the patient will be able to demonstrate behavior on how to improve communication little by little as evidence by compliance with the treatment regimen and health teachings being given.

Long Term:After 4 days of Nursing Intervention, the patient will be able to establish method of communication in which needs can be

>Establish rapport

>Monitor and record vital signs

>Assess patient’s general condition

>Keep communication simple, using all modes for accessing information: visual, auditory and kinesthetic>Maintain eye contact with the patient when speaking

>Use confrontation

>To gain trust and cooperation of the patient>To obtain baseline data and to note significant changes in the vital signs of the patient>To assess for improvements/changes in the patient’s condition>In order for the patient to easily understand and communicate verbally and to express thoughts or feelings and needs without much effort to exert >To enhance patient’s understanding of what is being communicated and in order for them to easily comply with the interventions being given>To clarify discrepancies between verbal and non-verbal cues

Short term:The patient shall have demonstrated behavior on how to improve communication little by little as evidenced by compliance with the treatment regimen and health teachings being given

Long Term: The patient shall have established method of communication in which needs are being expressed as evidenced by patient demonstrated behavior in


>Stuttering>Disorientation in three spheres of time, space, person>Inappropriate verbalization>Absence of eye contact >Willful refusal to speak

writing. Muscles of the lips and tongue may be weaker (dysarthria) or less coordinated (apraxia).Speech may not be clear. Breathing muscles may be weaker, affecting the patient's ability to speak loudly enough to be heard in conversation.

expressed as evidence by constructing simple sentences which does not require much effort to speak.

skills, when appropriate, within an established nurse-client relationship>Encourage patient to try to say words or simple sentences little by little

>To enhance communication skills and to regain his normal verbal communication

constructing simple sentences without exerting much effort to speak.

AssessmentNursing

DiagnosisScientific

ExplanationObjective

Nursing Interventions

RationaleExpected Outcome

S=Ø

O= The patient manifested the following:>Numbness on the left extremities>dizziness>headache>increased blood pressure

Ineffective cerebral tissue perfusion related to impaired transport of the O₂ across alveolar/ or capillary membrane

The condition of the patient is brought about by many factors such as lifestyle (smoking, alcohol intake), age, nature of work and his health history (Diabetes Mellitus and

Short term:After 5° of Nursing Intervention, the patient will demonstrate behavior on how to manage his condition, therapy regimen, side-effects of the medication and when to contact

>Establish rapport

>Monitor and record vital signs

>Assess patient’s general condition

>To gain trust and cooperation of the patient

>To obtain baseline data

>To identify underlying factors that contribute to his condition and to note if there are

Short Term:The patient shall have demonstrated behavior on how to manage his condition, therapy regimen, side-effects of the medication and when to contact


>altered mental status; Speech abnormalities>difficulty of swallowing

= The patient may manifest the following:>Restlessness>Confusion>Lethargy>Seizure activity>Pupillary changes>Decreased reaction to light

secondary to Diabetes Mellitus

hypertension). Cigarette, which contains nicotine, and alcohol intake cause constriction of the blood vessels which impaired blood flow to the different parts of the body particularly in the brain. Also because of his lifestyle, he developed hypertension that has lead as well in increased intracranial pressure. Another factor, which is Diabetes, causes viscosity of the blood. Vasoconstriction and viscosity of the blood of the patient have impaired the Oxygen supply

health care professional as evidence by compliance with the medication and health teachings being given.

Long Term:After 4 days of Nursing Intervention, the patient will demonstrate lifestyle modification to improve circulation as evidence by cessation of smoking, dietary changes and exercise.

>Determine the duration of the problem/frequency of recurrence, precipitating or aggravating factors

>Determine presence of visual, sensory/motor changes, headache, dizziness, altered mental status (Glassgow Coma Scale)>Elevate head of bead, and maintain head/neck in midline or neutral position

>Administer medications as directed

>Administer oxygen as needed

improvements/ changes in the patient’s condition

>To note the severity of the patient’s condition and to also assess for the interventions appropriate for the patients condition

>To obtain reliable, objective way of recording the conscious state of a person

>To promote circulation or venous drainage and decrease intracranial pressure

>To improve the patient’s condition

>To saturate circulating

health care professional as evidenced by compliance with the medication and health teachings being given.

Long Term:The patient shall have demonstrated lifestyle modification as evidenced by cessation of smoking, dietary changes and exercise.


to the brain, and because of too much pressure the blood has to exert going to the brain, the cerebral arteries are forced to dilate resulting to increase intra cranial pressure and hyperfusion.

>Encourage patient to quit smoking as this is one of the contributing factors to his condition

>Instruct the patient to avoid fatty, greasy highly seasoned food

hemoglobin and increase the effectiveness of blood that is reaching the ischemic tissue

>To promote wellness and educate the client about the factors that could aggravate his condition if he continuously smoke

>In order for the patient to prevent further complication such as chest pain and high blood pressure


AssessmentNursing

DiagnosisScientific

ExplanationObjectives Interventions Rationale Evaluation

S> ØO> received patient on bed conscious, coherent> with intact suture over the head> appears weak>Unable to move left extremities

Risk for injury r/t to generalized weakness and limited ROM

One of the complications that may arise after a CVA is the numbness, paralysis, or weakening of either the half of the body or the whole body this depends on the brain that was been damaged.

Short term:After 4 hrs. of

nursing intervention the patient and his

SO will participate in prevention

measures of possible injuries

Long Term:After 4 days of

nursing intervention, the

patient will display

management of simple ADL’s with the apt

support of the SO

> Establish rapport> Monitor and recoded vital signs> Assess patient’s condition> Note changes in color, texture & turgor> Identify underlying condition/pathology involved> Note presence of uncompromised vision, hearing or speech> Provide wound care

> modify client’s activity > Encourage client to verbalize feelings esp.

> To gain trust of patient/SO> To obtain baseline data

> To assess causative/contributing factors> To assess extent of involvement/injury> To assess causative/contributing factors

> To determine impact of condition

> To assist client w/ correcting/ minimizing condition & to promote optimal healing> to prevent fatigue> To promote wellness

the patient and his SO shall

have participated in

prevention measures of

possible injuries

the patient shall have displayed

management of simple

ADL’s with the apt support of

the SO


pain> free clients bedside from articles that may promote injury> Instruct the SO on how to assist their patient in doing his ADL’s

>refer client to rehab to regain strength

> to minimize chances of acquiring injury

> To involve patients family in his care and to maximize clients willingness> for continuity of care

AssessmentNursing

DiagnosisScientific

ExplanationObjectives Interventions Rationale

Expected Outcome

S> Ø

O> the pt may manifest

> decreased in muscle strength

> generalized weakness> fatigue

> muscle atrophy

Activity Intolerance r/t decreased muscle strength

A patient who is always on bed rest may feel a decreased in muscle strength due to lack of movement. The muscles may feel stiff and weak because they are not exercised and used. Lack of

Short Term

After 2-3 hours of NI patient’s SO will verbalize understanding of methods and techniques to increase patient’s muscle strength.

Long Term

> establish rapport

> monitor and record VS

> assess patient’s condition

> to gain patient’s trust and cooperation

> to serve as baseline data

> to provide appropriate interventions immediately

Short-TermThe pt’s. SO shall verbalized understanding of methods and techniques to increase pt. muscle strength

Long-Term


movement may also cause muscle atrophy, wherein there is also a decrease in muscle strength. When muscle strength is decreased, the person may show intolerance in performing, even simple, activities. The person may easily feel fatigue even in just doing easy tasks.

After 2-3 days of NI, patient will demonstrate activity tolerance AEB doing self-care with minimal support.

> provide massage on extremities

> provide patient enough time to perform activities

> increase activity level gradually

> provide quiet environment suitable for rest

> for proper blood circulation

> to minimize patient’s anxiety when doing tasks

> to avoid overexertion

> to regain strength

Patient’s shall demonstrated activity tolerance is increased AEB performing self-care.



V. Conclusion

Craniotomy, as repeatedly being emphasized on this report, involves the

surgery that is performed through an opening in the skull. It is basically a type of

brain surgery. It may be performed to treat or remove cancer, to correct a brain

disorder, or to repair injuries. Because this is very specialized surgery with many

risks, craniotomy mortality rates may be high even at hospitals that rely on highly

experienced neurosurgical teams.

Craniotomy has a long history and is of interest for a number of reasons.

With respect to the brain blood circulation, the skull integrity was shown to be

important for its normal functioning. Disturbance of this integrity should influence

the ratio of the function of the vascular and cerebrospinal fluid systems of the

brain, and, therefore, the circulatory and metabolic maintenance of its function.

Craniotomy is usually performed during neurosurgery, and the trephine opening

remains, as a rule, in the postsurgical period. It is obvious that the disturbance of

the skull integrity caused by trephination changes radically the intracranial

hemodynamics and CSF dynamics.

With this case report, the researchers realized that physical and

psychological implications involved in this procedure. Medically, the procedure

may be life-saving at its best. However, social stigma often pinned down the

person as terminally ill. This would definitely affect the person’s self concept and

hope over his disease condition. As aspiring nurses, they should always consider

better patient outcomes so as to provide efficient and effective care delivery.


VI. Reference/ Bibliography

BOOKS

Black, Joyce et al. Medical-Surgical Nursing. St. Louis Missouri. 2005

Bullock, Barbara L. et al. Pathophysiology Adaptation and Alterations in

Functions. 3 rd Edition . Philadelphia: J.B. Lippincott. 1992

Human Anatomy and Physiology Book, Marieb (et al.)

Kumar, Abbas, Fausto. Pathological Basis of Disease. 7 th Edition . 2004

Seeley, Stephens, Tate. Essential Anatomy and Physiology. New York: Mc

Graw Hill. 2005

Smeltzer, S. et. al. (2008). Brunner and Suddarth’s Textbook of Medical-

Surgical Nursing 11 th edition . Philadelphia: Lippincott-Williams & Wilkins

Spratto, G. and Woods, A. (2008). 2008 Edition PDR ® Nurse’s Drug

Handbook. New York: Thomson Delmar Learning.

Berman, A. et. al. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts,

Process and Practice 8 th edition Jurong, Singapore: Pearson Education South

Asia

Seely, R., Stephens, T., Tate, P. (2007). Essentials of Human Anatomy &

Physiology 6 th edition . New York: McGraw-Hill.

INTERNET:

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Craniotomy?

open

http://www.mayfieldclinic.com/PE-Craniotomy.htm

http://www.gastromd.com/diets/clearliquid.html


Angeles University FoundationAngeles City

“Craniotomy”A Surgical Case Report

In partial fulfillment of the requirements inNursing Care Management – Related Learning Experience 103 (NCM RLE 103)

Mabalacat District Hospital – OR, 2nd RotationApril 27 – 30, 2009

Submitted By:Ano, Carl Elexer

Cabrera, Kristina EdnaCalma, Ariane Camille

Palcis, Daniel

BSN III- 1

Submitted To:Jerry Ligawen, R.N.

April 29, 2009

Documents

Craniotomy surgical case report