CASE PRESENTATION ON

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CASE PRESENTATION ON

• CRANIOTOMY

Prepared by Sumi Mathew
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DEMOGRAPHIC DATA

•  
• NAME Mr A M A
• AGE/SEX 27YRS/ MALE
• MRN NO 203915
• DATE OF ADMISSION 16/05/13
• DIAGNOSIS ACUTE SDH, HEAD
  
• 
  TRAUMAFALL FRom
• 
  height
  
  
• SURGERY POSTERIOR FOSSA
  
• 
  CRANIOTOMYSDH
• 
  EVACUATION
• 
  duraplasty

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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

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• 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.

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•  EYES
• Redness on right eye
• No discharges
• pupils 1mm sluggish.
• EARS
• No unusual discharges noted 
• NOSE AND SINUSES
• Pink nasal mucosanot perforated
• No nasal discharge

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• 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

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• 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

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• 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 fibulalegs can
  adbuct and adduct

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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 .

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• PRESENT SURGICAL HISTORY
• Patient had undergone LEFT POSTERIOR FOSSA
  CRANIOTOMY EVACUATION OF SDHDURAPLASTY on
  16/05/13.
•  INVESTIGATIONS DONE FOR THE PATIENT
• X-ray Chest
• CT Brain And Lumbar Spine
• MRI Scan of Brain

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• BLOOD INVESTIGATIONS
• CBC
• Electrolytes
• Urea Creatinin

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LAB VALUES
ITEMS PATIENT VALUE NORMAL VALUE
HEMATOLOGY Hemoglobin(Hb) 9.5gm/dl 12-16 gm/dl
CHEMISTERY
Sodium 143 135 - 150
Potassium 3.7 3.5 - 5
Chloride Urea 103 6.7 98 - 111 1.8 - 8.3
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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
Inj Perfalgan 1gm I.V Analgesics
Inj Mannitol 100gm I.V Osmotic Diuretic
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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

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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.
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sutures of the skull
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Brain
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• The brain is composed of
• three parts
• CEREBELLUM
• CEREBRUM.
• BRAINSTEM

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SURFACE OF BRAIN

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• DEEP STRUCTURES
• Hypothalamus

• Thalamus

• Pituitary gland
• Pineal gland

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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.
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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.
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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.
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Cranial nerves
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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
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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
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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
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• 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.
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• ETIOLOGY
• Head injury
  
• Fallfromheight
• Motorvehiclecollision
  
• Assault.
• People with a bleeding disorder
  
• People who take blood thinners .

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

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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

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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.
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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
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Step 5 correct the problem Step 6 close
the craniotomy
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• 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

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• 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 every 8
  hours or per order.

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3. Assess spontaneous activity (i.e. frequent
posturechanges, breathing pattern, vomiting,
twitches or seizures
4.MonitorIO 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
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a.) Diminished response to stimuli b)Fluctuations
of vital signs c.) Restlessness d.) Weakness
and paralysis of extremities e.) Increasing
headache f.) Changeinvision/pupillarychanges
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PRIORITIZATION OF NURSING PROBLEMS 1) 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
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• 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.

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ASSESSMENT NSG DIAGNOSIS PLANNING IMPLEMENTATION RATIONAL E EVALUATON
Subjective data - Not appilicable Objective data Unresponsive to verbal stimulus Changes in motor or sensory responses restlessness Poor motor function Altered 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.
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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. Displ ays no further Deterior atetion or Recurre nce of deficits.
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• 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.

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• 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.

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• 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 .

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• BIBILIOGRAPHY
• Wikipedia
• Lippincatt manual nursing practice 9th edition
• Mayfield clinic
• Medical-Surgical Standards Review
• Intensive Care Unit Standards

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