CRANIOTOMY
Prepared by: Sumi Mathew
DEMOGRAPHIC DATA
 NAME
 AGE/SEX
 MRN NO
 DATE OF ADMISSION
 DIAGNOSIS
 SURGERY
:Mr A M A
: 27YRS/ MALE
:203915
:16/05/13
:ACUTE SDH, HEAD
TRAUMA&FALL FRom
height
: POSTERIOR FOSSA
CRANIOTOMY+SDH
EVACUATION&
duraplasty
PHYSICAL ASSESMENT
GENERAL APPEARANCE
Patient is 27yrs old; male.
He is intubated from E.R and under
sedatives.
His vital signs are
 B.P
:90/70mmHg
 PULSE
:100b/m
 RESPIRATION :14b/m
 TEMPREATURE :36.6 c
 SpO2
:94%


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 present
NECK AND THROAT
No palpable lymph nodes
No mass and lesions seen
CHEST & LUNGS
Thorax is symmetric
Equal chest expansion
No retraction of the intercostal spaces
No tenderness on anterior side
Abrasion present on back
CARDIO VASCULAR SYSTEM
ECG reports shows normal variation and
no changes noted

UPPER EXTREMITIES
Decorticate position of hands
Arms are unable to extend
Abduction and adduction can
possible
ABDOMEN
Its rigid and little distention present
Bowel sounds are normal
GENITO URINARY SYSTEM
No ulceration on perineal area; clean
LOWER EXTREMITIES
Normal positions of tibia &
fibula;legs can adbuct and adduct
PATIENT HISTORY
PAST 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 Chest
 CT Brain And Lumbar Spine
 MRI Scan of Brain
BLOOD INVESTIGATIONS
 CBC
 Electrolytes
 Urea Creatinin
LAB VALUES
ITEMS
PATIENT VALUE
NORMAL VALUE
HEMATOLOGY
Hemoglobin(Hb)
9.5gm/dl
12-16 gm/dl
Sodium
143
135 - 150
Potassium
3.7
3.5 - 5
Chloride
Urea
103
6.7
98 - 111
1.8 - 8.3
CHEMISTERY
MEDICATION
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
1gm
I.V
Analgesics
100gm
I.V
Osmotic Diuretic
Inj Perfalgan
Inj Mannitol
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
sutures of the skull
Brain
The brain is composed of
three parts:
CEREBELLUM
CEREBRUM.
BRAINSTEM
SURFACE OF BRAIN
DEEP STRUCTURES
Hypothalamus
Pituitary gland
Thalamus
Pineal gland
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
THE TWELVE 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
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
•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.
M
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 hour
2. 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
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
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 PROBLEMS
) Altered cerebral tissue perfusion
related to decreased cerebral blood
flow secondary to head injury
1
2) Ineffective airway clearance
related to accumulation of secreation
and decreased LOC
3) Risk of infection related to
surgical procedure.
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.
ASSESS NSG
MENT
DIAGNOSIS
Subjective
data :- Not
appilicable
Objective data




Unrespo
nsive to
verbal
stimulus
Changes
in motor
or
sensory
respons
es;
restlessn
ess
Poor
motor
function
Altered
LOC;
memory
loss
Ineffective
Cerebral
Tissue
Perfusion
Related To
Decrease
d Cerebral
Blood
Flow
Secondar
y To Head
Injury
PLANNING
IMPLEMENTATI RATIONAL E
ON
After 12
hrs of nsg
interventio
n 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.
EVALUATO
N
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.
 Demonstr
ates
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
4.Specific visual
alterations reflect area
of brain involved,
indicate safety
concerns, and
influence choice of
interventions.
5.Assessed higher
functions,
including speech, if
client is alert.
5.Changes in cognition
and speech content are
an indicator of
location and degree of
cerebral involvement
and may indicate
increased ICP.
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.
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.
 Displ
ays no
further
Deterior
atetion
or
Recurre
nce 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
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
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