1. CASE PRESENTATION ON
CRANIOTOMY
Prepared by: Sumi Mathew

2. DEMOGRAPHIC DATA NAME :Mr A M A AGE/SEX : 27YRS/ MALE MRN NO :203915
NAME :Mr A M A
AGE/SEX : 27YRS/ MALE
MRN NO :203915
DATE OF ADMISSION :16/05/13
DIAGNOSIS :ACUTE SDH, HEAD
TRAUMA&FALL FRom
height
SURGERY : POSTERIOR FOSSA
CRANIOTOMY+SDH
EVACUATION&
duraplasty

3. 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
SpO :94%

4. No palpable mass or lesions
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.

5. NOSE AND SINUSES EARS No discharges pupils 1mm sluggish.
 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

6. No mass and lesions seen CHEST & LUNGS
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

7. CARDIO VASCULAR SYSTEM
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

8. Normal positions of tibia & fibula;legs can adbuct and adduct
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

9. 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 .

10. 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

11. BLOOD INVESTIGATIONS
CBC
Electrolytes
Urea Creatinin

12. LAB VALUES ITEMS PATIENT VALUE NORMAL VALUE HEMATOLOGY Hemoglobin(Hb)
9.5gm/dl
12-16 gm/dl
CHEMISTERY
Sodium
143
Potassium
3.7
Chloride
Urea
103
6.7

13. Histamine2-receptor antagonists
MEDICATION
DRUG
DOSE
ROUTE
ACTION
Inj Augmentin
1.2gm
I.V
Antibiotic
Inj Ceftriaxone
1gm
Inj Risek
40mg
Histamine2-receptor antagonists
Inj Tramadol
100mg
Antipyretics
Inj Perfalgan
Analgesics
Inj Mannitol
100gm
Osmotic Diuretic

14. 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

16. 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.

18. sutures of the skull

19. Brain

20. The brain is composed of three parts:
CEREBELLUM
CEREBRUM.
BRAINSTEM

21. SURFACE OF BRAIN

22. DEEP STRUCTURES
Hypothalamus
Thalamus
Pituitary gland
Pineal gland

23. 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.

24. Cerebrospinal fluid cavities called ventricles Inside the
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.

25. 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.

26. Cranial nerves

27. Number Name Function I olfactory Smell II optic sight III oculomotor
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

28. 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

29. 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

31. The outermost layer is called the
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.

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

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

34. 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

35. 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.

37. 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

38. Step 5: correct the problem
Step 6: close the craniotomy

39. 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

40. 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.

41. 5. Monitor for seizure activity and maintain safety
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

42. a.) Diminished response to stimuli
b)Fluctuations of vital signs
c.) Restlessness
d.) Weakness and paralysis of extremities
e.) Increasing headache
f.) Changeinvision/pupillarychanges

43. 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

44. 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.

45. ASSESSMENT NSG DIAGNOSIS PLANNING IMPLEMENTATION RATIONAL E EVALUATON
Subjective data :- Not appilicable
Objective data
Unrespo nsive 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.
Demonstr ates stable vital signs and absence of signs of increased ICP.

46. Sensory Displ ays no Languae further intellecal Deterior And atetion
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.

47. 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.

48. 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.

49. 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 .

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

51. THANK YOU