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CASE PRESENTATION ON CRANIOTOMY Prepared by: Sumi Mathew.

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Presentation on theme: "CASE PRESENTATION ON CRANIOTOMY Prepared by: Sumi Mathew."— Presentation transcript:

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

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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.

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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

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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.

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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


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