CRANIOTOMY

Prepared by: Sumi Mathew

DEMOGRAPHIC DATA 

NAME :Mr A M AAGE/SEX : 27YRS/ MALE MRN NO :203915DATE OF ADMISSION :16/05/13DIAGNOSIS :ACUTE SDH, HEAD

TRAUMA&FALL FRom height

SURGERY : POSTERIOR FOSSA CRANIOTOMY+SDH EVACUATION& duraplasty

PHYSICAL ASSESMENT

LEVEL OF CONSCIOUSNESS

Patient was semiconscious on admission ;and was intubated from E.R on fully sedation .

Gcs :8/15

SKIN Fair complexion ;abrasions on back No palpable mass or lesions

HEAD

  Skull slightly asymmetric Cut wound on scalp . Maxillary ,frontal and ethmoid sinuses are not tender.

 EYES Redness on right eye No discharges pupils 1mm sluggish.

EARS No unusual discharges noted 

NOSE AND SINUSES Pink nasal mucosa;not perforated

No nasal discharge

MOUTH Pink and dry oral mucosa Tongue and uvula in midline position

ET tube and OGT are presentNECK AND THROAT No palpable lymph nodes

No mass and lesions seenCHEST & LUNGS  Thorax is symmetric

Equal chest expansion

No retraction of the intercostal spaces No tenderness on anterior side Abrasion present on back

CARDIO VASCULAR SYSTEMECG reports shows normal variation and no changes noted

UPPER EXTREMITIES Decorticate position of hands Arms are unable to extendAbduction and adduction can possible

ABDOMEN Its rigid and little distention present

Bowel sounds are normalGENITO URINARY SYSTEM

No ulceration on perineal area; clean

LOWER EXTREMITIESNormal positions of tibia & fibula;legs can adbuct and adduct

PATIENT HISTORYPAST MEDICAL AND SURGICAL

HISTORY Patient has no past medical and surgical history

PRESENT MEDICAL HISTORY Patient brought to E.R H/O FALL FROM HEIGHT with loss of consciousness .He was intubated from E.R and admitted in ICU on 16/05/13 .

PRESENT SURGICAL HISTORY Patient had undergone LEFT POSTERIOR FOSSA CRANIOTOMY +EVACUATION OF SDH+DURAPLASTY on 16/05/13.

 INVESTIGATIONS DONE FOR THE PATIENT

X-ray ChestCT Brain And Lumbar SpineMRI Scan of Brain

BLOOD INVESTIGATIONS

CBC

Electrolytes

Urea Creatinin

ITEMS PATIENT VALUE NORMAL VALUE

HEMATOLOGYHemoglobin(Hb) 9.5gm/dl 12-16 gm/dl

CHEMISTERY

Sodium 143 135 - 150

Potassium 3.7 3.5 - 5

ChlorideUrea

103 6.7

98 - 111 1.8 - 8.3

LAB VALUES

DRUG DOSE ROUTE ACTION

Inj Augmentin 1.2gm I.V Antibiotic

Inj Ceftriaxone 1gm I.V Antibiotic

Inj Risek 40mg I.V Histamine2-receptor antagonists

Inj Tramadol 100mg I.V Antipyretics

Inj Perfalgan 1gm I.V Analgesics

Inj Mannitol 100gm I.V Osmotic Diuretic

MEDICATION

ANATOMY and physiologyOF BRAIn

The brain is one of the largest and most complex organs in the human body.It is made up of more than 100 billion nerves that communicate in trillions of connections called synapses.The brain is made up of many specialized areas that work together:

The cortex is the outermost layer of brain cells.

The basal ganglia are a cluster of structures in the center of the brain

SKULL

The purpose of the bony skull is to protect the brain from injury. All the arteries, veins and nerves exit the base of the skull through holes, called foramina.

The big hole in the middle (foramen magnum) is where the spinal cord exits.

sutures of the skull

Brain

The brain is composed of three parts:

CEREBELLUM

CEREBRUM.

BRAINSTEM

SURFACE OF BRAIN

DEEP STRUCTURES

Hypothalamus

Pituitary gland

Pineal gland

Thalamus

MENINGES The brain and spinal cord are covered and protected by three layers of tissue called meninges.

From the outermost layer inward they are: The Dura mater, Arachnoid mater, and Piamater.

Ventricles and Cerebrospinal fluid The brain has hollow fluid-filled cavities called ventricles Inside the ventricles is a ribbon-like structure called the choroid plexus that makes clear colorless cerebrospinal fluid.CSF flows within and around the brain and spinal cord to help cushion it from injury. This circulating fluid is constantly being absorbed and replenished.

Nervous system

The nervous system is divided into central and peripheral systems.

The central nervous system (CNS) is composed of the brain and

spinal cord.

The peripheral nervous system(PNS) is composed of spinal

nerves.

That branch from the spinal cord and cranial nerves that branch

from the brain.

Cranial nerves

Number Name Function

I olfactory Smell

II optic sight

III oculomotor moves eye, pupil

IV trochlear moves eye

V trigeminal face sensation

VI abducens moves eye

THE TWELVE CRANIAL NERVES

VII facial moves face, salivate

VIII vestibulocochlear hearing, balance

IX glossopharyngeal taste, swallow

X vagus heart rate, digestion

XI accessory moves head

XII hypoglossal moves tongue

Blood supply

Blood is carried to the brain by two paired arteries, the internal carotid arteries and the vertebral arteries. The internal carotid arteries supply most of the cerebrum.

The vertebral arteries supply the cerebellum, brainstem, and the underside of the cerebrum

Etiology •Head injury fall fromheight Motor vehicle collision Assault. •People with a bleeding disorder people who take blood thinners . •Elderly people are at higher risk for chronic subdural hematoma

TOPIC PRESENTATION

Subdural Hematoma

In a subdural hematoma, blood collects between the layers of tissue that surround the brain. The outermost layer is called the durra. In a subdural hematoma, bleeding occurs between the durra and the arachnoids.

ETIOLOGY• Head injury

• Fallfromheight

• Motorvehiclecollision

• Assault.

• People with a bleeding disorder

• People who take blood thinners .

Signs and Symptoms

•Headache• Confusion• Change in behavior• Dizziness• Nausea and vomiting• Lethargy or excessive drowsiness• Weakness• Apathy• Seizures• Lose of consciousness and •coma

Treatment• Burr hole trephination. A hole is drilled in the skull over the area of the subdural hematoma, and the blood is suctioned out through the hole.• Craniotomy. A larger section of the skull is removed, to allow better access to the subdural hematoma and reduce pressure. • Craniectomy. A section of the skull is removed for an extended period of time, to allow the injured brain to expand and swell without permanent damage

craniotomy Craniotomy is a cut that opens the cranium.During this surgical procedure, bone flap, is removed to access the brain underneath.Craniotomies are often named for the bone being removed. Some common craniotomies include frontotemporal, parietal, temporal, and suboccipital.A craniotomy is cut with a special saw called a craniotome.

STEPS OF PROCEDURE

There are 6 main steps craniotomy..

Step 1: prepare the patient

Step 2: make a skin incision.

Step 3: perform a craniotomy, open the skull

Step 4: exposure the brain

Step 5: correct the problem

Step 6: close the craniotomy

COMPLICATIONS •Complications of anesthesia •Infection•Hemorrhage andpost-operative hematoma•Leak of cerebrospinal fluid•Brain swelling•Raised intracranial pressure•Paralysis•Hydrocephalus•Loss of sensation•Loss of vision•Loss of speech•Memory loss

NURSING INTERVENTIONS •Cardiovascular/Circulation

1 For ICU patients, vital Signs every 1 hour2. For non-ICU patients, vital Signs every 4 hours•Neurological

1. For ICU patients, perform neurological assessment every1 hour.2. For non-ICU patients, perform neurological assessmentevery 4 hours x 24 hours, then every 8 hours or per order.

3. Assess spontaneous activity (i.e. frequent posturechanges, breathing pattern, vomiting, twitches or seizures

4.MonitorI&O per order. Fluids may be restricted to prevent fluid shift and cerebral edema.

5. Monitor for seizure activity and maintain safety 6. Evaluate patient for signs and symptoms of Increasing intracranial pressure. These include

a.) Diminished response to stimuli

b)Fluctuations of vital signs

c.) Restlessness

d.) Weakness and paralysis of extremities

e.) Increasing headache

f.) Changeinvision/pupillarychanges

PRIORITIZATION OF NURSING PROBLEMS1) Altered cerebral tissue perfusion related to decreased cerebral blood flow secondary to head injury

2) Ineffective airway clearance related to accumulation of secreation and decreased LOC

4)Ineffecive breathing pattern related to Neurological dysfunction

5)Risk for injury related to disorientation & restlessness

6)Risk for impaired skin integrity related to immobility.

3)Risk of infection related to surgical procedure.

ASSESSMENT

NSG DIAGNOSIS

PLANNING IMPLEMENTATION

RATIONAL E EVALUATON

Subjective data :- Not appilicable Objective data

Unresponsive to verbal stimulusChanges in motor or sensory responses; restlessnessPoor motor functionAltered LOC; memory loss

Ineffective Cerebral Tissue Perfusion Related To Decreased Cerebral Blood Flow Secondary To Head Injury

After 12 hrs of nsg intervention patient will have effective cerebral tissue Perfusion.

1. Determined factors related to individual situation, cause for coma, decreased cerebral perfusion, and potential for ICP.

2 .Monitord and document neurological status frequently and compare with baseline.

3.Monitored vital signs noting: Hypertension or hypotension; compare blood pressure (BP) readings in both arms

1.Influences choice of interventions Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity

2.Assessment trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CNS damage.

3.Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor.

After 12 hrs of nsg interventions the goals were partially met as evidenced by

Maintains usual or improved LOC, cognition, and motor and sensory function.Demonstrates stable vital signs and absence of signs of increased ICP.

Sensory

Languae

intellecal

And

emotioal

deficits

Changes

in vital signs

4. . Document ed changes in vision, such as reports of blurred vision and alterations in visual field or depth perception

5.Assessed higher functions, including speech, if client is alert.

6. Positioned with head slightly elevated and in neutral position.

7.Maintain bedrest, provide quiet environment, and restrict visitors or activities, as indicated. Provide rest periods between care activities, limiting duration of procedures.

4.Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.

5.Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate increased ICP.

6. Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation and perfusion

7. Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent recurrence of bleeding, in the case of hemorrhagic stroke.

Displays no further Deterioratetion or Recurrence of deficits.

Health education

1.Instruct the patient

•Do not drive after surgery until discussed with surgeon. •Avoid sitting for long periods of time. •Do not lift anything heavier than 5 pounds.•Housework and yardwork are not permitted until the first follow-up office visit.

2. An early exercise program to gently stretch the neck and back.3. Encourage walking 4.Instruct When to Call Doctor•A temperature that exceeds 101º F •An incision that shows signs of infection. •If taking an anticonvulsant, and notice drowsiness, balance problems, or rashes. •Decreased alertness, increased drowsiness, weakness of arms or legs, increased headaches, vomiting.

CONCLUSION•Patient was intubaA case of fall from height with acute SDH was brought in ER on 16/05/13 •ted from the ER upon arrival •His GCS Was 8/15 •The patient was then shifted to OR for emergency POSTERIOR FOSSA CRANIOTOMY +SDH EVACUATION +DUROPLASTY .•Patient was shifted to ICU after surgery and was on ventillator for 10 days .•He was extubated after 10 days .

BIBILIOGRAPHY

•Wikipedia

•Lippincatt manual nursing practice 9th edition

•Mayfield clinic

•Medical-Surgical Standards Review

•Intensive Care Unit Standards