Craniotomy Surgical Case Report

1|Craniotomy

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

2|Craniotomy

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.

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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.

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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

peripheral

two

systems.

nervous

system

The 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

response

to

system.

stimuli,

In

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

interconnected

animals in

are

complex

arrangements and use electrochemical signals and neurotransmitters to transmit

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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.

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•

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

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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

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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.

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•

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.

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III. Patient and his Illness Pathophysiology of Hemmorhagic Cerebrovascular Accident with Subdural Hematoma formation

Non-modifiable Factors - Age – 55 y/o and above

Modifiable Factors - Alcohol use

A family history of stroke, heart attack or TIA Blacks - Familial history of fragile blood vessels - History of ischemic attacks - History of epileptic attack

-

-

Enlarged subdural space due to shrinking brain tissue

Brittle veins

↑ risk for acquiring the same disease

Defective clotting formation

BV Constriction

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

↑ Viscosity of blood

↓ elasticity of BV

Fatty Deposits

Apneustic Breathing

Vascular damage

Impaired respiratory function

Leak of blood to the meninges

Brain compression

↓ venous return ↑ ICP

Impaired cardiovascular function

↓ organ

Lactic acid formation

Impaired optic function

↓ renal and GIT function

Pain, malaise ↓ ROM

retinal changes

Bladder and bowel incontinence

Slurred speech

CNS Depressio n

Sluggish blood flow

↑ blood vessel resistance

Mass formation

Thrombus formation

hemiplegia

drowsiness

syncope

Bradycardia, ↑SBP, widened pulse pressure

↓ cerebral functionin g Neurologic affectation Headache, dizziness, behavioral changes

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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.

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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

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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.

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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

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•

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.

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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 antiinflammatory 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.

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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.

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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

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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.

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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.)

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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

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

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 RISKS ON NOT UNDERGOING CRANIOTOMY CRANIOTOMY General surgery risk (bleeding, chest Unresolved brain tumors and blood and wound infection, DVT, heart clots leading to cell death, compression trouble, untoward reaction to of brain structures and increased anesthesia) intracranial pressure Unresolved increase in intracranial Intracranial bleeding pressure Subsequent loss of brain function r/t brain damage AEB motor and sensory Unresolved bleeding leading to shock impairment Unresolved abscesses.

infection

due

to

brain

Unresolved chronic pain from neuropathic disorders precipitates poor quality of life

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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

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 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

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

Jansen Retractor

Weitlaner retractor

Scalpel

Adson (Ewald) Dressing Forceps

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

Adson Tissue Forceps

Backhaus Towel Clamp

Cushing Brain Forceps (Delicate Serrated)

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Echlin Rongeur

Foerster Sponge Forceps

Halsted Mosquito Forceps

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Halsted Mosquito Forceps

Luer Bone Rongeur

stille-Liston Rongeur

Mayo-Hegar Needle Holder

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Gigli Saw Wire

Operating Scissors

Mayo-Stille Dissecting Scissors

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Mayo-Stille Dissecting Scissors curved

Taylor Dural Scissors

EQUIPMENTS  Suction  Electrosurgical unit

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FACILITIES

Emergenc y Cart Surgic al light

`

S U R G E O N

ANESTHESIOLOGIST

`

Surgic al light

P A T I E

A S S I S T A N T

N SCRUB

T

SUTURE SUCTION TUBE Electrosurgical

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

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

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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.

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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.

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•

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 foulsmelling 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.

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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.

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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

complications related to a craniotomy may include: •

stroke

to anesthesia. Specific

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

•

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 Fluids PNSS Plane Normal Saline Solution

General Description 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

Indication(s)or Purposes 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 solution 3. Count drops per minute in drip chamber.

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 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 Drug

Route, Dosage & Frequency of administration

Generic Name: Cefazolin 1gram IV q 8 ° Brand Name: Ancef Generic Name: Omeprazole 40mg IV q 12 ° Brand Name: Prilosec Generic Name: Citicholine

1gram IV q 12 ° 9/15/08 Shifted to oral: 500mg 1cap BID

Generic Name: Cefuroxime 500mg BID Brand Name: Ceftin Vitamin B Complex

1cap BID

Indication(s) or Purposes 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. 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 Citicholine is used to treat cerebrovascular disorders, head injury, and Parkinson’s disease 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. 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.

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 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 reactions 3. Inform the patient to report adverse reactions without delay Instruct patient to report discomfort at the IV site immediately

c. Diet Type Of diet

General description

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

Soft Diet

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

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.

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

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d. Activity/ Exercise Type Of exercise High Back Rest

May Sit on Bed

General description

indication

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.

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.

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1.7 Nursing Management a. Nursing Care Plans (this is based form previous handled patient in the medicine ward with a diagnosis of CVA) Assessment S> Ø O> 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

Nursing Diagnosis Impaired skin integrity r/t presence of suture over the head

Scientific Explanation 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

Objectives

Interventions

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

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

Long Term: After 4 days of nursing intervention, the patient will display timely healing of skin lesions/wounds/ pressure sores without complication

> Emphasize

Rationale > To gain trust of patient/SO > To obtain baseline data > To assess causative/contribu ting factors > To assess extent of involvement/injury > To assess causative/contribu ting factors > To determine impact of condition > To assist client w/ correcting/ minimizing condition & to promote optimal healing > A first line

Evaluation 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

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

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

proper hand 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

defense against nosocomial infections/ crosscontamination 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

after 4 days of nursing intervention

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

Assessment S=Ø O= The patient manifested the following: >Unable to speak dominant languages >Speaks or verbalizes with difficulty >Has difficulty in expressing thoughts verbally >has difficulty in comprehendin g and maintaining the usual communication pattern >Unable or has difficulty in use of facial or body expressions =The patient may manifest the following:

Nursing Diagnosis 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 )

Scientific Explanation 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,

Objective Short Term: After 5° of Nursing Intervention, the patient will be able to demonstrate behavior on how to improve communicatio n 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 communicatio n in which needs can be

Nursing Interventions >Establish rapport >Monitor and record vital signs

>Assess patient’s general condition >Keep communicatio n simple, using all modes for accessing information: visual, auditory and kinesthetic >Maintain eye contact with the patient when speaking

>Use confrontation

Rationale >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/change s 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

Expected Outcome 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 constructing

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

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

Assessment S=Ø O= The patient manifested the following: >Numbness on the left extremities >dizziness >headache >increased

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

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

Scientific Explanation 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

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

Objective Short term: After 5° of Nursing Intervention, the patient will demonstrate behavior on how to manage his condition, therapy regimen, sideeffects of the medication and

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

Nursing Interventions >Establish rapport

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

Rationale >To gain trust and cooperation of the patient

>Monitor and record vital signs

>To obtain baseline data

>Assess patient’s general condition

>To identify underlying factors that contribute to his condition and

simple sentences without exerting much effort to speak.

Expected Outcome Short Term: The patient shall have demonstrated behavior on how to manage his condition, therapy regimen, sideeffects of the medication and

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

blood pressure >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

membrane secondary to Diabetes Mellitus

Mellitus and 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

when to contact 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.

to note if there are improvements/ changes in the patient’s condition >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

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

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

Long Term: The patient shall have demonstrated >To obtain reliable, lifestyle objective way of modification as recording the evidenced by conscious state of cessation of a person smoking, dietary changes and exercise. >To promote circulation or venous drainage and decrease intracranial pressure

>Administer medications as directed

>To improve the patient’s condition

>Administer oxygen

>To saturate

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

Oxygen supply 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.

as needed

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

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

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

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

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

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

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

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

Scientific Explanation 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.

Objectives

Interventions

Short term: After 4 hrs. of nursing intervention the patient and his SO will participate in prevention measures of possible injuries

> Establish rapport > Monitor and recoded vital signs > Assess patient’s condition > Note changes in color, texture & turgor Long Term: > Identify After 4 days of underlying nursing condition/patholo intervention, the gy involved patient will > Note presence display of management of uncompromised simple ADL’s with vision, hearing the apt support of or speech the SO > Provide wound care

> modify client’s activity > Encourage client to

Rationale > To gain trust of patient/SO > To obtain baseline data > To assess causative/contribu ting factors > To assess extent of involvement/injury > To assess causative/contribu ting factors > To determine impact of condition > To assist client w/ correcting/ minimizing condition & to promote optimal healing > to prevent fatigue > To promote wellness

Evaluation 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

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verbalize feelings esp. 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

Assessment S> Ø O> the pt may manifest > decreased in muscle strength > generalized weakness > fatigue

Nursing Diagnosis Activity Intolerance r/t decreased muscle strength

Scientific Explanation 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

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

Interventions

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

Rationale

> establish rapport

> to gain patient’s trust and cooperation

> monitor and record VS

> to serve as baseline data

> assess patient’s condition

> to provide appropriate interventions immediately

Expected Outcome Short-Term The pt’s. SO shall verbalized understanding of methods and techniques to increase pt. muscle strength

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

> muscle atrophy

exercised and used. Lack of 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.

Long Term Long-Term After 2-3 days of NI, patient will demonstrate activity tolerance AEB doing selfcare with minimal support.

> provide massage on extremities

> for proper blood circulation

> provide patient enough time to perform activities

> to minimize patient’s anxiety when doing tasks

> increase activity level gradually

> to avoid overexertion

> provide quiet environment suitable for rest

> to regain strength

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

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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.

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

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

•

Kumar, Abbas, Fausto. Pathological Basis of Disease. 7th 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 MedicalSurgical Nursing 11th 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 8th edition Jurong, Singapore: Pearson Education South Asia

•

Seely, R., Stephens, T., Tate, P. (2007). Essentials of Human Anatomy & Physiology 6th edition. New York: McGraw-Hill.

INTERNET: •

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

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

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

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Angeles University Foundation Angeles City

“Craniotomy” A Surgical Case Report In partial fulfillment of the requirements in Nursing Care Management – Related Learning Experience 103 (NCM RLE 103) Mabalacat District Hospital – OR, 2nd Rotation April 27 – 30, 2009

Submitted By: Ano, Carl Elexer Cabrera, Kristina Edna Calma, Ariane Camille Palcis, Daniel BSN III- 1

Submitted To: Jerry Ligawen, R.N. April 29, 2009