1|Craniotomy

Introduction:

In the past, the earliest evidence of craniotomy is most likely found in the
procedure called trephination, which is basically an antiquated medical
intervention in which a hole is drilled or scraped into the human skull, exposing
the dura mater in order to treat health problems concerning intracranial diseases.
Cave painitings also indicate that people believed such practice would cure
epileptic seizures, migraines, and mental disorders. It was also suggested that it
was a primitive, if not the oldest, emergency surgery for head wounds.

In modern medicine, it is a treatment used for epidural and subdural

hematomas, and for surgical access for certain other neurosurgical procedures,
such as intracranial pressure monitoring. Modern surgeons generally use the
term craniotomy for this procedure. The removed piece of skull is typically
replaced as soon as possible. If the bone is not replaced, then the procedure is
considered a craniectomy.

Today, as contemporary era comes in, it has evolved to craniotomy per se,
or considering the word’s etymology, the surgical cutting of the cranium. A
craniotomy is a surgical operation in which part of the skull, called a bone flap, is
removed in order to access the brain. Craniotomies are often a critical operation
performed on patients suffering from brain lesions or traumatic brain injury (TBI),
and can also allow doctors to surgically implant deep brain stimulators for the
treatment of Parkinson's disease, epilepsy and cerebellar tremor. The procedure
is also widely used in neuroscience for extracellular recording, brain imaging, and
for neurological manipulations such as electrical stimulation and chemical
titration.

Because craniotomy is a procedure that is utilized for several conditions

and diseases, statistical information for the procedure itself is not available.
However, because craniotomy is most commonly performed to remove a brain
tumor, statistics concerning this condition are given. Approximately 90% of
 2|Craniotomy

primary brain cancers occur in adults, more commonly in males between 55 and
65 years of age. Tumors in children peak between the ages of three and 12.
Brain tumors are presently the most common cancer in children (four out of
100,000).

In a news article dated April 21, 2009, it was found out that a new type of
brain surgery actually allows patients to stay conscious so there will be foolproof
monitoring of speech and motor functions as doctors basically fiddle with a tumor
or two resting on principal tasks of their brain.

Another innovation to brain surgery published on an earlier date, April 8,

2009, tells us about a new approach to brain surgery leaving no mark behind.
Such feat of using the eyes as a gateway to the brain makes surgery less
invasive, ergo, less risky. This procedure is called eyelid craniotomy, where in an
incision will be made on the eyelid crease and there will be removal of a small
bone from the patient’s eye socket. A smaller incision is almost always correlated
to shorter hospital stay, faster recovery, and less pain. However, it is not for every
patient as it is only used for those with needing brain surgery toward the front of
the skull.

Implications of the above information is almost always suggestive that as

productive members of the society, nurses, or aspiring nurses to be more
specific, as the researchers are, should generally be equipped with pertinent
information and knowledge regarding such high-end surgical intervention to
relieve effects of tumors, bleeding aneurysms, and blood clots in the brain. They
should also be aware how the procedure is to be performed, so they can
anticipate what surgeons are to asked during the course of the surgery. They
must always be in-the-know so they can execute nursing responsibilities and
considerations appropriately for better patient outcome post-operatively.
 3|Craniotomy

Awake Craniotomy will be featured on Methodist

hospital webcast today

New brain surgery allows patients to stay conscious

By Lindsay Melvin (Contact), Memphis Commercial Appeal

Tuesday, April 21, 2009
Diagnosed with an aggressive cancer referred to even in medical publications as "The Terminator," Sheila
Mullins couldn't find a neurosurgeon who would go near her brain tumor.
"They said it would leave me paralyzed," said the Oakland resident, who
has stage four glioblastoma multiforme.

Scott Fowler/Special to The Commercial Appeal

UT neurosurgical chief resident Dr. Jay Weimar (left) and Dr. Allen K. Sills
perform an "Awake Craniotomy" at Methodist.
STORY TOOLS

After months of her body being racked by seizures, she finally found a
doctor who could remove the tumor safely.
In May, while surgeons scraped her brain of cancerous cells, Mullins lay
on the operating table reciting the alphabet and wiggling her toes and
fingers.
The "Awake Craniotomy" allowed her to stay conscious during the surgery
so doctors could monitor her speech and other functions as they fiddled
with a tumor resting on key functions of her brain.
People can view the Awake Craniotomy performed on Mullins when Methodist University Hospital streams a
webcast of the procedure today.
Questions about the hourlong webcast will be answered live between 4 and 5 p.m.
The procedure has been in the spotlight recently since U.S. Sen. Ted Kennedy underwent an Awake
Craniotomy last year to remove a tumor.
Executing these awake surgeries for the last decade, Methodist is the only facility in the Mid-South qualified
to do the procedure.
The hope is that by educating the public that this procedure is painless and safer than brain surgery of the
past, Methodist hopes to expand its visibility to patients and referring doctors, hospital officials say.
"All of us fear the unknown, particularly when it comes to medical procedures," said Dr. Allen Sills, one of
two neurosurgeons featured in the webcast.
Very sick patients have refused brain surgery because they were too frightened, said the director of
Methodist Healthcare's Neuroscience Institute.
 4|Craniotomy

Sills is also associate professor of neurosurgery for the University of Tennessee Health Science Center.
"Everyone wants to know if they're going to hurt or be uncomfortable," he said. "This helps the patient to
know exactly what to expect."
-- Lindsay Melvin: 529-2445

A new approach to brain surgery that leaves no

scar behind.

Staff Writer
9:33 AM CDT, April 8, 2009

More than half a million people will have brain surgery this year.
Large scars and lenghty recoveries typically go along with the surgery.
Now Doctors are using the eyes as the gateway to the brain to make surgery less invasive.
Swelling aside, you'd never guess Mike Hogan had life-saving brain surgery just a few weeks ago.
"The doctor ordered a CAT scan. When they did the CAT scan, the aneurysm showed up."
Doctors determined the aneurysm was in danger of ruptureing.
Hogan's surgeons used a new and unusual technique to treat it.
Neurosurgeon Dr. Khaled Aziz "when we do the standard procedure we make an incision behind the hairline
-- from here, all the way to here."
Instead, surgeons fixed the aneurysm through a tiny hole in his eyelid.
During the eyelid Craniotomy a Neuro-Opthamologist marks the eyelid crease then makes an incision and
removes a
small piece of bone from the patient's eye socket.
Next a Neurosurgeon reaches the front of the brain, clips the blood vessel that feeds the aneurysm and then
puts the bone back in place.
Doctors say a smaller incision means a shorter hospital stay, faster recovery and less pain.
"In the long run, I think this it's more helpful for the patient outcome rather than standard surgical
approaches."
Mike has no scar, little pain, and more importantly more time to watch his grandchildren grow up.
"It's amazing what they can do."
Doctor Aziz says the eyelid approach is not for every patient.
It only works for patients who need brain surgery toward the front of the skull
Neurosurgeons also use the eyelid surgery to operate on certain brain tumors.
Copyright © 2009, WQAD-TV
 5|Craniotomy

II. Anatomy and Physiology

The Nervous System

The nervous system is a network of specialized cells that communicate
information about an animals surroundings and its self, it processes this
information and causes reactions in other parts of the body. It is composed of
neurons and other specialized cells called glia, that aid in the function of the
neurons.
The nervous system is
divided broadly into two
categories; the peripheral nervous
system and the central nervous
system. Neurons generate and
conduct impulses between and
within the two systems. The
peripheral nervous system is
composed of sensory neurons
and the neurons that connect
them to the nerve cord, spinal
cord and brain, which make up the
central nervous system. In
response to stimuli, sensory
neurons generate and propagate
signals to the central nervous
system which then process and
conduct back signals to the
muscles and glands.
The neurons of the nervous
systems of animals are
interconnected in complex
arrangements and use electrochemical signals and neurotransmitters to transmit
 6|Craniotomy

impulses from one neuron to the next. The interaction of the different neurons
form neural circuits that regulate an organism’s perception of the world and what
is going on with its body, thus regulating its behavior. Nervous systems are found
in many multicellular animals but differ greatly in complexity between species
The central nervous system (CNS) is the largest part of the nervous
system, and includes the brain and spinal cord. The spinal cavity holds and
protects the spinal cord, while the head contains and protects the brain. The CNS
is covered by the meninges, a three layered protective coat. The brain is also
protected by the skull, and the spinal cord is also protected by the vertebrae.
Brain is a part of the Central Nervous System, it plays a central role in the
control of most bodily functions, including awareness, movements, sensations,
thoughts, speech, and memory. Some reflex movements can occur via spinal
cord pathways without the participation of brain structures.
The cerebrum is the largest part of the brain and controls voluntary
actions, speech, senses, thought, and memory.

The surface of the cerebral cortex has grooves or infoldings (called sulci), the
largest of which are termed fissures. Some fissures separate lobes.

The convolutions of the cortex give it a wormy appearance. Each convolution is

delimited by two sulci and is also called a gyrus (gyri in plural). The cerebrum is
divided into two halves, known as the right and left hemispheres. A mass of fibers
called the corpus callosum links the hemispheres. The right hemisphere controls
voluntary limb movements on the left side of the body, and the left hemisphere
controls voluntary limb movements on the right side of the body. Almost every
person has one dominant hemisphere. Each hemisphere is divided into four
lobes, or areas, which are interconnected.

• The frontal lobes are located in the front of the brain and are responsible
for voluntary movement and, via their connections with other lobes,
participate in the execution of sequential tasks; speech output;
organizational skills; and certain aspects of behavior, mood, and memory.
 7|Craniotomy

• The parietal lobes are located behind the frontal lobes and in front of the
occipital lobes. They process sensory information such as temperature,
pain, taste, and touch. In addition, the processing includes information
about numbers, attentiveness to the position of one’s body parts, the
space around one’s body, and one's relationship to this space.

• The temporal lobes are located on each side of the brain. They process
memory and auditory (hearing) information and speech and language
functions.

• The occipital lobes are located at the back of the brain. They receive and
process visual information
• The Cardiovascular System
• The heart and circulatory system make up the cardiovascular system. The
heart works as a pump that pushes blood to the organs, tissues, and cells
of the body. Blood delivers oxygen and nutrients to every cell and removes
the carbon dioxide and waste products made by those cells. Blood is
carried from the heart to the rest of the body through a complex network of
arteries, arterioles, and capillaries. Blood is returned to the heart through
venules and veins.
• The one-way circulatory system carries blood to all parts of the body. This
process of blood flow within the body is called circulation. Arteries carry
oxygen-rich blood away from the heart, and veins carry oxygen-poor blood
back to the heart. In pulmonary circulation, though, the roles are switched.
It is the pulmonary artery that brings oxygen-poor blood into the lungs and
the pulmonary vein that brings oxygen-rich blood back to the heart.
• Twenty major arteries make a path through the tissues, where they branch
into smaller vessels called arterioles. Arterioles further branch into
capillaries, the true deliverers of oxygen and nutrients to the cells. Most
capillaries are thinner than a hair. In fact, many are so tiny, only one blood
cell can move through them at a time. Once the capillaries deliver oxygen
and nutrients and pick up carbon dioxide and other waste, they move the
 8|Craniotomy

blood back through wider vessels called venules. Venules eventually join
to form veins, which deliver the blood back to the heart to pick up oxygen.
• Vasoconstriction or the spasm of smooth muscles around the blood
vessels causes and decrease in blood flow but an increase in pressure. In
vasodilation, the lumen of the blood vessel increase in diameter thereby
allowing increase in blood flow. There is no tension on the walls of the
vessels therefore, there is lower pressure.
• Various external factors also cause changes in blood pressure and pulse
rate. An elevation or decline may be detrimental to health. Changes may
also be caused or aggravated by other disease conditions existing in other
parts of the body.
• The blood is part of the circulatory system. Whole blood contains three
types of blood cells, including: red blood cells, white blood cells and
platelets.
• These three types of blood cells are mostly manufactured in the bone
marrow of the vertebrae, ribs, pelvis, skull, and sternum. These cells travel
through the circulatory system suspended in a yellowish fluid called
plasma. Plasma is 90% water and contains nutrients, proteins, hormones,
and waste products. Whole blood is a mixture of blood cells and plasma.
• Red blood cells (also called erythrocytes) are shaped like slightly
indented, flattened disks. Red blood cells contain an iron-rich protein
called hemoglobin. Blood gets its bright red color when hemoglobin in red
blood cells picks up oxygen in the lungs. As the blood travels through the
body, the hemoglobin releases oxygen to the tissues. The body contains
more red blood cells than any other type of cell, and each red blood cell
has a life span of about 4 months. Each day, the body produces new red
blood cells to replace those that die or are lost from the body.
• White blood cells (also called leukocytes) are a key part of the body's
system for defending itself against infection. They can move in and out of
the bloodstream to reach affected tissues. The blood contains far fewer
white blood cells than red cells, although the body can increase production
 9|Craniotomy

of white blood cells to fight infection. There are several types of white
blood cells, and their life spans vary from a few days to months. New cells
are constantly being formed in the bone marrow.
• Several different parts of blood are involved in fighting infection. White
blood cells called granulocytes and lymphocytes travel along the walls of
blood vessels. They fight bacteria and viruses and may also attempt to
destroy cells that have become infected or have changed into cancer
cells.
• Certain types of white blood cells produce antibodies, special proteins that
recognize foreign materials and help the body destroy or neutralize them.
When a person has an infection, his or her white cell count often is higher
than when he or she is well because more white blood cells are being
produced or are entering the bloodstream to battle the infection. After the
body has been challenged by some infections, lymphocytes remember
how to make the specific antibodies that will quickly attack the same germ
if it enters the body again.
• Platelets (also called thrombocytes) are tiny oval-shaped cells made in the
bone marrow. They help in the clotting process. When a blood vessel
breaks, platelets gather in the area and help seal off the leak. Platelets
survive only about 9 days in the bloodstream and are constantly being
replaced by new cells.
• Blood also contains important proteins called clotting factors, which are
critical to the clotting process. Although platelets alone can plug small
blood vessel leaks and temporarily stop or slow bleeding, the action of
clotting factors is needed to produce a strong, stable clot.
• Platelets and clotting factors work together to form solid lumps to seal
leaks, wounds, cuts, and scratches and to prevent bleeding inside and on
the surfaces of our bodies. The process of clotting is like a puzzle with
interlocking parts. When the last part is in place, the clot is formed.
 10 | C r a n i o t o m y

• When large blood vessels are cut the body may not be able to repair itself
through clotting alone. In these cases, dressings or stitches are used to
help control bleeding.
• In addition to the cells and clotting factors, blood contains other important
substances, such as nutrients from the food that has been processed by
the digestive system. Blood also carries hormones released by the
endocrine glands and carries them to the body parts that need them.
• Blood is essential for good health because the body depends on a steady
supply of fuel and oxygen to reach its billions of cells. Even the heart
couldn't survive without blood flowing through the vessels that bring
nourishment to its muscular walls. Blood also carries carbon dioxide and
other waste materials to the lungs, kidneys, and digestive system, from
where they are removed from the body.
11 | C r a n i o t o m y
 12 | C r a n i o t o m y

III. Patient and his Illness

Pathophysiology of Hemmorhagic Cerebrovascular Accident with Subdural Hematoma formation

Non-modifiable Factors Modifiable Factors

- Age – 55 y/o and above - Alcohol use -
- A family history of stroke, heart attack or TIA Thrombocytopenia
- Blacks - Obesity - Coagulopathy
- Familial history of fragile blood vessels - Diabetes
- History of ischemic attacks - Oral Contraceptives
- History of epileptic attack - Smoking
- Hypertension
- Diet pills
Enlarged subdural space due - Stress
to shrinking brain tissue

Brittle Defective clotting BV ↑ Fatty Thrombus CNS

↑ risk for veins formation Constriction Viscosity Deposits formation Depressio
acquiring the of blood n
same disease

↓
elasticity
of BV Sluggish
blood flow
↑ blood vessel
resistance Apneustic
Breathing

Vascular damage Impaired

respiratory Bradycardia,
function ↑SBP,
widened
Leak of blood to
pulse
the meninges
Impaired pressure
cardiovascular
↓ organ function
Mass ↓
formation venous
return
Lactic acid
↑ ICP Impaired ↓ renal ↓ cerebral
Brain compression formation
optic and GIT functionin
function function g
Pain, malaise
Neurologic affectation
↓ ROM retinal Bladder and Headache, dizziness,
changes bowel behavioral changes
Slurred speech hemiplegia drowsiness syncope
incontinence
 13 | C r a n i o t o m y

b. Synthesis of the Disease

Subdural hematoma- The brain is

covered by a membrane (layer of tissue)
called the dura. If the veins located
below the dura (subdural area) leak
blood, then pressure in this area may
build up and injure the brain, this blood
then will collect into a mass called
hematoma. Hematoma may have
different classification depending on the
site of the hematoma. If the hematoma on
the subarachnoid area, it will be then
classified as a subarachnoid hematoma, more so, a hematoma found on
the subdural area is classified as subdural hematoma.

Hematoma is one of the deadliest reason of mortality related to

brain injury if it is not managed well; as the mass formed my the
hematoma will then compress the brain tissue altering the normal
perfusion of the brain tissue thus altering the sensorial and motor function
of the brain depending on the affected area, this will also be accompanied
by hypoxia, which will result to ischemic attack specifically Transient
Ischemic Attack (TIA) and when not managed will result to brain cell
atrophy, which will progress to Cerebrovascular Attack damaging the brain
cell later on cell death which will progress to brain death (Comatose state),
inhibition of the regulatory mechanism of the brain including respiration
and circulation resulting to death.

Most commonly, the major factors contributing to subdural

hematoma are of lifestyle practices and underlying conditions such as
alcoholism, cigarette smoking, and decreased integrity of the blood vessel,
hypertension, diabetes mellitus, arteriosclerosis, and thrombocytopenia.
 14 | C r a n i o t o m y

This is most commonly accompanied by the following signs and

symptoms headache, contralateral weakness, seizure, sensorial
alteration, increased ICP, nausea, personality changes, confusion,
decreased LOC, impaired vision, eye droop, speech difficulties, numbness
of decreased sensation of a limb, and papillary dilatation.

Subdural Hematomas are managed with different treatment

modalities such as follows:

• Goal is to reduce pressure on the brain

• Circulation support (intravenous fluids and medications to
maintain blood pressure)
• Respiratory support (oxygen and mechanical ventilation if
necessary)
• Dexamethasone (a corticosteroid medication) may be used to
decrease the inflammation of the brain
• Mannitol (a diuretic) may be used to decrease the swelling of
the brain
• Dilantin (a seizure medication) may be used to prevent or
control Seizures
• Reversal of blood thinning agents such as Coumadin or Heparin
• Emergency Surgery may be needed to drain the hematoma
(blood clot), and relieve the pressure on the brain. The
hematoma is outside the brain, but still puts pressure on it.
Therefore, the surgery involves drilling small holes in the skull
and evacuating the blood. Occasionally, if the hematoma is very
large or has solidified, a large opening in skull may be needed (this is
called a craniotomy).

Cerebrovascular Accident (Stroke)- A Cerebrovascular accident

is the sudden disruption of O2 supply to the nerve cells, generally caused
 15 | C r a n i o t o m y

by obstruction or rupture in one or more of the blood vessels that supply

the brain. There two main types of stroke:

• Ischemic- is the most common type of stroke, 85% of

cerebrovascular cases are of the ischemic type. Ischemic type of
CVA has three main mechanism:
o Thrombosis- results from the blockage of a blood supply to
the brain tissue due to atherosclerosis.
o Emboli- embolic type of ischemic CVA is also a result of a
blockage of the blood supply to the brain tissues only it is
due to emboli.
o Systemic hypoperfusion- this is usually a result of decreased
cerebral blood flow owing to circulatory failure. Circulatory
failure results from too little blood, too low BP, or failure of
the heart to pump blood adequately. Hypoxia from any cause
can also produce this syndrome.

Transient ischemic attack (TIA) is one of the indicators of CVA; this

is a temporary neurologic deficit that resolves completely without
permanent damage, it usually occurs when the artery cannot
deliver enough blood to meet the brain’s O2 demand.

• Hemorrhagic- this is due to neural tissue destruction because of

infiltration and accumulation of blood. Ischemia and infarction may
occur distal to the hemorrhage because of the interrupted blood
supply. Although hemorrhage is usually brought about by
hypertension or an aneurysm, this could be also because of
trauma. This is usually accompanied by increased Intracranial
Pressure (ICP) due to the mass effect brought about by the blood
leakage from either of the meninges.
 16 | C r a n i o t o m y

Mostly, patient having a CVA does not get any clue that they are having a
stroke, but there are some manifestations that one must be alerted if he is
experiencing the following manifestations below as this could be an
indication of a stroke.

• Trouble with walking. If you're having a stroke, you may stumble

or have sudden dizziness, loss of balance or loss of coordination.

• Trouble with speaking. If you're having a stroke, you may slur

your speech or may not be able to come up with words to explain
what is happening (aphasia). Try to repeat a simple sentence. If
you can't, you may be having a stroke.

• Paralysis or numbness on one side of the body. If you're

having a stroke, you may have sudden numbness, weakness or
paralysis on one side of the body. Try to raise both your arms over
your head at the same time. If one arm begins to fall, you may be
having a stroke.

• Trouble with seeing. If you're having a stroke, you may suddenly

have blurred or blackened vision or may see double.

• Headache. A sudden, severe "bolt out of the blue" headache or an

unusual headache, which may be accompanied by a stiff neck,
facial pain, pain between your eyes, vomiting or altered
consciousness, sometimes indicates you're having a stroke.

Many factors can increase your risk of a stroke. A number of these

factors can also increase your chances of having a heart attack. Stroke risk
factors include:

• A family history of stroke, heart attack or TIA

• Being age 55 or older
 17 | C r a n i o t o m y

• High blood pressure — a systolic blood pressure of 140

millimeters of mercury (mm Hg) or higher, or a diastolic pressure
of 90 mm Hg or higher
• High cholesterol — a total cholesterol level of 200 milligrams per
deciliter (mg/dL), or 5.2 mmOl/L, or higher
• Cigarette smoking
• Diabetes
• Obesity — a body mass index of 30 or higher
• Cardiovascular disease, including heart failure, a heart defect,
heart infection, or abnormal heart rhythm
• Previous stroke or TIA
• Use of birth control pills or other hormone therapy

In relation with Mr. Enfarcion’s case, his CVA was initially brought
about by a hemorrhagic type of CVA due to a leak of venous blood from
the subdural meninges of the brain brought about by an increased
pressure on the blood vessels due to an increased vascular resistance
due to hypertension and viscosity of the blood related to his diabetes
mellitus. This resulted to a decreased volume of the circulating blood due
to a decreased venous return, and a depression of the brain due to the
mass formation. This resulted to neurologic deficits manifested by severe
headache, hemiparesis, decreased LOC, and dizziness.
 18 | C r a n i o t o m y

IV. Clinical Intervention

1.1 Description of the prescribed surgical treatment

Craniotomy is any bony opening that is

cut into the skull. A section of skull, called
a bone flap, is removed to access the
brain underneath. There are many types
of craniotomies, which are named
according to the area of skull to be
removed (Fig. 1). Typically the bone flap
is replaced. If the bone flap is not
replaced, the procedure is called a craniectomy.

Who performs the procedure?

A craniotomy is performed by a neurosurgeon; some have additional training in

skull base surgery. A neurosurgeon may work with a team of head-and-neck,
otologic, oculoplastic and reconstructive surgeons. Ask your neurosurgeon about
their training, especially if your case is complex.

What happens before?

You will typically undergo tests (e.g., blood test, electrocardiogram, chest X-ray)
several days before surgery. In the doctors office you will sign consent forms and
complete paperwork to inform the surgeon about your medical history (i.e.,
allergies, medicines, anesthesia reactions, previous surgeries). You may wish to
donate blood several weeks before surgery. Discontinue all non-steroidal anti-
inflammatory medicines (Naproxin, Advil, etc.) and blood thinners (coumadin,
aspirin, etc.) 1 week before surgery. Additionally, stop smoking, chewing tobacco,
and drinking alcohol 1 week before and 2 weeks after surgery because these
activities can cause bleeding problems.
 19 | C r a n i o t o m y

What happens during?

There are 6 main steps during a craniotomy. Depending on the underlying

problem being treated and complexity, the procedure can take 3 to 5 hours or
longer.

Step 1. Patient preparation

No food or drink is permitted past midnight the

night before surgery. Patients are admitted to
the hospital the morning of the craniotomy.
With an intravenous (IV) line placed in your
arm, general anesthesia is administered while
you lie on the operating table. Once asleep,
your head is placed in a 3-pin skull fixation
device, which attaches to the table and holds
your head in position during the procedure
(Figure 2).

Insertion of a lumbar drain in your lower back

helps remove cerebrospinal fluid (CSF), thus
allowing the brain to relax during surgery. A
brain-relaxing drug called mannitol may be given.

Step 2. Skin incision

After the scalp is prepped with an antiseptic, a skin incision is made, usually
behind the hairline. The surgeon attempts to ensure a good cosmetic result after
surgery. Sometimes a hair sparing technique can be used that requires shaving
only a 1/4-inch wide area along the proposed incision. Sometimes the entire
incision area may be shaved.
 20 | C r a n i o t o m y

Step 3. Craniotomy, opening the skull

The skin and muscles are lifted off the bone

and folded back. Next, one or more small
burr holes are made in the skull with a
drill. Inserting a special saw through the burr
holes, the surgeon uses this craniotome to
cut the outline of a bone flap (Figure 3). The
cut bone flap is lifted and removed to
expose the protective covering of the brain
called the dura. The bone flap is safely
stored until it is replaced at the end of the
procedure.

Step 4. Exposure of the brain

After opening the dura with surgical

scissors, the surgeon folds it back to
expose the brain (Figure 4). Retractors
placed on the brain gently open a corridor
to the area needing repair or removal.
Neurosurgeons use special magnification
glasses, called loupes, or an operating
microscope to see the delicate nerves and
vessels.

Step 5. Correct the problem

Because the brain is tightly enclosed inside the bony skull, tissues cannot be
easily moved aside to access and repair problems. Neurosurgeons use a variety
of very small tools and instruments to work deep inside the brain. These include
long-handled scissors, dissectors and drills, lasers, ultrasonic aspirators (uses a
fine jet of water to break up tumors and suction up the pieces), and computer
 21 | C r a n i o t o m y

image-guidance systems. In some cases, evoked potential monitoring is used to

stimulate specific cranial nerves while the response is monitored in the brain.
This is done to preserve function of the nerve and make sure it is not further
damaged during surgery.

Step 6. Closure

With the problem removed or repaired, the

retractors holding the brain are removed
and the dura is closed with sutures. The
bone flap is replaced back in its original
position and secured to the skull with
titanium plates and screws (Figure 5). The
plates and screws remain permanently to
support the area; these can sometimes be
felt under your skin. In some cases, a drain may be placed under the skin for a
couple of days to remove blood or fluid from the surgical area. The muscles and
skin are sutured back together. A turban-like or soft adhesive dressing is placed
over the incision.

What happens after?

After surgery, you are taken to the recovery room where vital signs are monitored
as you awake from anesthesia. The breathing tube (ventilator) usually remains in
place until you fully recover from the anesthesia. Next, you are transferred to the
neuroscience intensive care unit (NSICU) for close observation and monitoring.
You are frequently asked to move your arms, fingers, toes, and legs.
 22 | C r a n i o t o m y

1.2 Indication of prescribed surgical treatment

INDICATIONS:
Craniotomy is of course, usually performed for problems with the brain and head
injuries. Indications for such procedure include:

• Brain tumors
o An abnormal growth of cells within the brain or inside the skull,
which can be cancerous or non-cancerous.
• Bleeding (hemorrhage)
o A loss of blood in the circulatory system
• Blood clots (hematomas)
o A collection of blood outside the blood vessels generally the result
of hemorrhage, or more specifically, internal bleeding. It is named
based on the site of injury. Examples of which is subdural
hematoma (between the dura mater and arachnoid mater) and
epidural hematoma (between the dura mater and the skull).
• Weaknesses in blood vessels (cerebral aneurysms)
o A localized, blood-filled dilation (balloon-like bulge) of a blood
vessel caused by disease or weakening of the vessel wall. As the
size of an aneurysm increases, there is an increased risk of
rupture, which can result in severe hemorrhage or other
complications including sudden death.
• Relief from increased intracranial pressure
• Damage to tissues covering the brain (dura)
• Pockets of infection in the brain (brain abscesses)
o Abscess caused by inflammation and collection of infected material
coming from local (ear infection, dental abscess, infection of
paranasal sinuses, infection of the mastoid air cells of the temporal
bone, epidural abscess) or remote (lung, heart, kidney etc.)
 23 | C r a n i o t o m y

infectious sources within the brain tissue. The infection may also be
introduced through a skull fracture following a head trauma or
surgical procedures. Brain abscess is usually associated with
congenital heart disease in young children. It may occur at any age
but is most frequent in the third decade of life.
• Severe nerve or facial pain (such as trigeminal neuralgia or tic douloureux)
o A neuropathic disorder of the trigeminal nerve that causes episodes
of intense pain in the eyes, lips, nose, scalp, forehead, and jaw.
• Epilepsy
o A common chronic neurological disorder characterized by recurrent
unprovoked seizures
• Chiari malformations
o A malformation of the brain. It consists of a downward displacement
of the cerebellar tonsils and the medulla through the foramen
magnum, sometimes causing hydrocephalus as a result of
obstruction of cerebrospinal fluid (CSF) outflow. The cerebrospinal
fluid outflow being caused by phase difference in outflow and influx
of blood in the vasculature of the brain

BENEFITS VERSUS RISKS:

Benefits of craniotomy include removal of brain tumors for return of motor

or sensory impairment and relief from seizure attacks, control of bleeding to
prevent death especially from ruptured aneurysm, evacuation of blood clots to
decrease ICP, drainage of brain abscesses to manage infection, and alleviation
of pain from neuropathic disorders and for modality in skull fractures. This would
lead to an improved quality of life and more time for the patient to live.

All operations carry some risks. Brain surgery carries more than most. Any
operation can be complicated by heart trouble, chest infection, blood clots in the
leg (thrombosis) and wound infection. The chances of these complications are
greater in elderly or unhealthy patients and, in particular, those who smoke or
 24 | C r a n i o t o m y

drink heavily. The major specific complications of brain surgery are damage to
the brain at the time of surgery and bleeding within the head after the operation.
Meningitis and epilepsy occasionally follow craniotomy. When bleeding is
suspected, you would have to return to operating room within a few hours of the
operation for a reopening of the wound. Sometimes deterioration is due to brain
swelling and the bone flap is left out, being stored frozen in antibiotic solution. It
may then be replaced at a later date when the swelling has settled down.

Consequently, damage to normal brain tissue may cause injury to an area

and subsequent loss of brain function. Loss of function in specific areas can
cause memory impairment. Some other examples of potential harm that may
result from this procedure include deafness, double vision, numbness, paralysis,
blindness, or loss of the sense of smell.

The actual risk in a particular case will depend on the complexity of the
operation.

RISKS ON UNDERGOING RISKS ON NOT UNDERGOING

CRANIOTOMY CRANIOTOMY
General surgery risk (bleeding, chest Unresolved brain tumors and blood
and wound infection, DVT, heart clots leading to cell death, compression
trouble, untoward reaction to of brain structures and increased
anesthesia) intracranial pressure
Unresolved increase in intracranial
Intracranial bleeding
pressure
Subsequent loss of brain function r/t
brain damage AEB motor and sensory Unresolved bleeding leading to shock
impairment

Unresolved infection due to brain

abscesses.
Unresolved chronic pain from
neuropathic disorders precipitates poor
quality of life
25 | C r a n i o t o m y
 26 | C r a n i o t o m y

1.3Required Instruments, Devices, Supplies, Equipment and Facilities

INSTRUMENTS
Basic Set
 Mosquito
 Kelly curves
 Allis
 Babcock
 Needle holder
 Tissue forcep
 Thumb forcep
 Army navy
 Kidney basin
 Towel clips
 Straight clamp
 Mixter

Craniotomy Surgical Set

 2Jansen Retractor
 2Weitlaner Retractor
 1Scalpel Handle #3
 1Scalpel Handle #4
 1Scalpel Handle #7
 4Solid Bar Handle For Gigli Saw
 2Adson (Ewald) Dressing Forceps
 2Adson Tissue Forceps
 12Backhaus Towel Clamp
 2Cushing Brain Forceps
 2Cushing Brain Forceps
 1Echlin Rongeur
 6Foerster Sponge Forceps
 27 | C r a n i o t o m y

 6Foerster Sponge Forceps

 18Halsted Mosquito Forceps
 18Halsted Mosquito Forceps
 1Luer Bone Rongeur
 1Stille-Liston Rongeur
 2Mayo-Hegar Needle Holder
 1Gigli Saw Wire
 1Gigli Saw Wire
 1Operating Scissors
 1Mayo-Stille Dissecting Scissors
 1Mayo-Stille Dissecting Scissors
 1Metzenbaum Dissecting Scissors
 1Taylor Dural Scissors
 28 | C r a n i o t o m y

Jansen Retractor

Weitlaner retractor

Scalpel

Adson (Ewald) Dressing Forceps

 29 | C r a n i o t o m y

Adson Tissue Forceps

Backhaus Towel Clamp

Cushing Brain Forceps (Delicate Serrated)

 30 | C r a n i o t o m y

Echlin Rongeur

Foerster Sponge Forceps

Halsted Mosquito Forceps

 31 | C r a n i o t o m y

Halsted Mosquito Forceps

Luer Bone Rongeur

stille-Liston Rongeur

Mayo-Hegar Needle Holder

 32 | C r a n i o t o m y

Gigli Saw Wire

Operating Scissors

Mayo-Stille Dissecting Scissors

 33 | C r a n i o t o m y

Mayo-Stille Dissecting Scissors curved

Taylor Dural Scissors

EQUIPMENTS
 Suction
 Electrosurgical unit
 34 | C r a n i o t o m y

FACILITIES

Emergenc
y
Cart

Surgic ANESTHESIOLOGIST
`
al Surgic
light al
light

P
S A
U A S
`
R S
G T I
E S
O T
I A
N
N
E T

SCRUB T

SUTURE

SUCTION
TUBE

Electrosurgical
 35 | C r a n i o t o m y

1.4 Perioperative Tasks and Responsibilities of the Nurse

SCRUB NURSE
 Pre-operative Responsibilities
1. Assist with the preparation of the room for the designated surgical procedure,
including gathering supplies for the procedure.
2. Scrub, dry hands, gown, and glove.
3. Assist person scrubbed in first position with:
a. Setting up back table, mayo, and basins
b. Arrangement of instruments
c. Preparation of suture and needles
d. Preparation and counting sponges
e. Arrangement and preparation of other necessary items
f. Gowning and gloving surgeon and assistants
g. Assist with draping
h. Arrangement of sterile field
 Intra-operative Responsibilities
1. During the procedure, progress from double-scrubbed position. Train self to
keep eyes on field, and learn steps of procedure.
2. Begin developing methods of anticipating needs of surgeon and assistant.
3. After closing the skin:
a. Assist with care of instruments and counts if necessary
b. Care of specimen
c. Assist with dressing of wound
 Post-operative Responsibilities
1. After the completion of the Procedure:
a. Assist with the gathering of all materials used during the procedure
b. Discard items as necessary being careful to discard sharp items in
designated places
c. Return all items to respective area
d. Assist with cleaning of room
 36 | C r a n i o t o m y

e. Clean the materials used properly and arrange them after drying
2. Perform any duties which will speed up the surgical procedure to follow in that
room.

CIRCULATING NURSE
 Pre-operative Responsibilities
1. Care for the patient before surgery by:
a. Greeting patient and assist nurse with identification
b. Checking patient's chart, preparation, etc.
2. Prepare the room by:
a. Obtaining instruments, supplies, and equipment for the designated
operative procedure
b. Opening unsterile supplies
c. Assisting in gowning
d. Observing breaks in sterile technique
e. Assisting anesthesiologist as necessary
f. Assisting with skin preparation and positioning
g. Assisting with forming of the sterile field
3. Count the instruments, sharps and sponges before the procedure and confirm
with scrub nurse.
 Intra-operative Responsibilities
1. During the Procedure:
a. Remain in room and dispense materials as necessary
b. Observe procedure as closely as possible
c. Begin establishing method of anticipating needs of surgical team
d. Care of specimen as indicated
e. Care of operative records as indicated
f. Assist with application of dressing
g. Monitor the instruments, sharps and sponges used and take note of
additional instruments.
 37 | C r a n i o t o m y

2. Before the closing of the organ or peritoneum, count all instruments, sharps
and sponges and confirm with scrub nurse.
3. Inform the surgeon and assistant surgeon of a report of the instruments.
 Post-operative Responsibilities
1. Properly document all the necessary information on the patient’s chart.
2. Assist in the cleaning of the Operation Room as necessary.

Prior to operation:
• A careful history and physical examination are performed
• Intravenous fluids are given to correct volume depletion and any electrolyte
imbalances are measured and corrected. Monitor and regulate IVFs
• The nurse instructs the patient about the need to avoid smoking to enhance
pulmonary recovery postoperatively and avoid respiratory complications. It is
also important to instruct the patient to avoid the use of aspirin and other
agents that can alter coagulation and other biochemical process
• On of the most important responsibility of the nurse is to let the patient sign
an informed consent regarding the surgery.
• The patient is given anaesthesia prior to surgery and the patient is under
NPO.

During the operation

• Monitoring the vital signs of the patient is one of the responsibilities of the
nurse during the surgery.
• Assisting the anesthesia care provider during induction of general anesthesia
• Ensuring adequate oxygenation and hydration

After the operation

• After recovery, the nurse places the patient in the low fowler’s position. IV
fluids may be given. Water and other fluids are given in about 24hours, and
soft diet is started when bowel sounds returned.
 38 | C r a n i o t o m y

• Placing warm blankets on the patient to enhance comfort and preserve the
patient's body temperature
• Assessing the patient's vital signs, oxygen saturation level, level of
consciousness, circulation, pain, IV site, fluid rate, and hydration status, as
well as the status of the surgical site and dressing and all related monitoring
equipment
• The nurse helps in relieving the pain by instructing the patient regarding
proper positioning.
• The nurse helps in improving the respiratory status by instructing the patient
regarding deep breathing exercises.
• The nurse also provides skin care like cleaning the incision part and providing
clean dressing following a strict aseptic technique
• The nurse instructs the patient about the medications that are prescribed by
the physician
• Discussing recommended follow-up management with the physician and the
surgeon

1.5. Expected Outcomes of the Surgical Treatment Performed

Most clients are discharged on the day of surgery or the day after. As the
days and weeks go by after the surgery, there would be a verbalization of a
decrease in pain from the patient he could do splinting properly and adhere to
medication therapy for pain. Another expected outcome is that the patient
demonstrates appropriate respiratory function as evidenced by the
achievement of a full respiratory excursion and coughs effectively.
The patient’s incision should also be free from the presence of foul-
smelling discharge or pus around the incision. Absence of fever or
inflammation is indicative of the absence of infection. The patient should also
know and demonstrate proper wound cleaning or wound care as well as the
correct management of drainage tube if applicable. A report of a return in
appetite, no vomiting, bleeding should come from the patient together with
normal and stable vital signs.
 39 | C r a n i o t o m y

Since there would be the elimination of the signs and symptoms such as
pain, there would be a better quality of life for the patient which could increase
productivity and minimize hospital or clinic visits, upon discharge clients may
be given information regarding:
Discomfort
1. After surgery, headache pain is managed with narcotic medication. Because
narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks).
Their regular use may also cause constipation, so drink lots of water and eat high
fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) may be bought
without a prescription. Thereafter, pain is managed with acetaminophen (e.g.,
Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin;
ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve).
2. A medicine (anticonvulsant) may be prescribed temporarily to prevent
seizures. Common anticonvulsants include Dilantin (phenytoin), Tegretol
(carbamazepine), and Neurontin (gabapentin). Some patients develop side
effects (e.g., drowsiness, balance problems, rashes) caused by these
anticonvulsants; in these cases, blood samples are taken to monitor the drug
levels and manage the side effects.
Restrictions
1. Do not drive after surgery until discussed with your surgeon and avoid sitting
for long periods of time.
2. Do not lift anything heavier than 5 pounds (e.g., 2-liter bottle of soda),
including children.
3. Housework and yardwork are not permitted until the first follow-up office visit.
This includes gardening, mowing, vacuuming, ironing, and loading/unloading the
dishwasher, washer, or dryer.
4. Do not drink alcoholic beverages.
Activity
5. Gradually return to your normal activities. Fatigue is common.
6. An early exercise program to gently stretch the neck and back may be
advised.
 40 | C r a n i o t o m y

7. Walking is encouraged; start with short walks and gradually increase the
distance. Wait to participate in other forms of exercise until discussed with your
surgeon.
Bathing/Incision Care
8. You may shower and shampoo 3 to 4 days after surgery unless otherwise
directed by your surgeon.
9. Sutures or staples, which remain in place when you go home, will need to be
removed 7 to 14 days after surgery. Ask your surgeon or call the office to find out
when.
When to Call Your Doctor
10. If you experience any of the following:
• A temperature that exceeds 101º F
• An incision that shows signs of infection, such as redness, swelling, pain,
or drainage.
• If you are taking an anticonvulsant, and notice drowsiness, balance
problems, or rashes.
• Decreased alertness, increased drowsiness, weakness of arms or legs,
increased headaches, vomiting, or severe neck pain that prevents
lowering your chin toward the chest.
Recovery
The recovery time varies from 1 to 4 weeks depending on the underlying disease
being treated and your general health. Full recovery may take up to 8 weeks.
Walking is a good way to begin increasing your activity level. Start with short,
frequent walks within the house and gradually try walks outside. It’s important not
to overdo it, especially if you are continuing treatment with radiation or
chemotherapy. Ask your surgeon when you can expect to return to work.
What are the risks?
No surgery is without risks. General complications of any surgery include
bleeding, infection, blood clots, and reactions to anesthesia. Specific
complications related to a craniotomy may include:
• stroke
 41 | C r a n i o t o m y

• seizures
• swelling of the brain, which may require a second craniotomy
• nerve damage, which may cause muscle paralysis or weakness
• CSF leak, which may require repair
• loss of mental functions
• permanent brain damage with associated disabilities

1.6 Medical Management (this is based form previous handled patient in the
medicine ward with a diagnosis of CVA)
a. IVF’s, BT, NGT Feedings, Nebulization, TPN, Oxygen Therapy.etc.
General
IV Fluids Indication(s)or Purposes
Description
PNSS Normal Saline It is used as a source of fluid and
Plane Normal solution is a electrolytes. Normal saline is most
Saline Solution solution of sodium commonly used as an intravenous (IV)
chloride, or salt, in infusion, administered through an IV
sterile water. drip to prevent dehydration in patients
Normal saline who cannot consume liquids and
solution is 0.9% nutrients by mouth.
sodium chloride. It
is isotonic. An
isotonic solution is
less irritating to
the body cell

Nursing Implication:

 Before:
1. Check the physician’s order for IV solution and explain to the client the
procedure.
2. Check the potency of IV line and needle
3. Check the type of infusion, condition of the vein and medical condition of the
patient

 During:
1. Maintenance of Aseptic Technique
2. Proper procedure and steps in infusing IV solution
3. Count drops per minute in drip chamber.
 42 | C r a n i o t o m y

 After:
1. Monitor IV infusion at least every 2 hour
2. Adjust IV clamp as needed and recount drop per minute.
3. Monitor client for fluid overflow
4. More frequent check maybe prn if a medication(s) are being infused.
5. More frequent check maybe prn if a medication(s) are being infused.
6. Inspect site for pain, swelling, coolness or pallor at the site of insertion, which
may indicate infiltration of IV
7. Inspect site for redness, swelling, heat and pain which may indicate phlebitis

b. Drugs
Route, Dosage &
Name of Drug Frequency of Indication(s) or Purposes
administration
Generic Name: Cefazolin is used for treating bacterial infections
Cefazolin or preventing bacterial infections before, during,
1gram IV q 8 ° or after certain surgeries. Cefazolin is a
Brand Name: cephalosporin antibiotic. It works by killing
Ancef sensitive bacteria.
Used in short-term treatment of active duodenal
Generic Name:
ulcer, duodenal ulcer associated with H.Pylori
Omeprazole
,short-term treatment of active benign gastric
40mg IV q 12 °
ulcer, long term treatment of hypersecretory
Brand Name:
conditions, treatment of heartburn and symptoms
Prilosec
associated with GERD
1gram IV q 12 °
Citicholine is used to treat cerebrovascular
Generic Name: 9/15/08
disorders, head injury, and Parkinson’s disease
Citicholine Shifted to oral:
500mg 1cap BID
Cefuroxime is a cephalosporin antibiotic. It works
Generic Name:
by fighting bacteria in your body. Cefuroxime is
Cefuroxime
used to treat many kinds of bacterial infections.
500mg BID
Surgical prophylaxis, prophylaxis against
Brand Name:
infection in cardiac, pulmonary, esophageal &
Ceftin
vascular surgery.
To boost metabolism, enhance the immune
Vitamin B system and nervous system, keep the skin and
1cap BID
Complex muscles healthy, encourage cell growth and
division.
Nursing Implication

 Before:
1. Check and confirm the order (dosage, frequency and route) for the said drug
2. Check and recheck the drug indication and computation
3. Check the patient’s identity
4. Inform the patient, its purpose and action
5. Explain the importance of strict compliance to medical regimen.
 43 | C r a n i o t o m y

 During:
1. Maintenance of Aseptic Technique
2. Administer IV Meds slowly

 After:
1. Maintain hydration
2. Monitor vital signs carefully monitor therapeutic response and the occurrence
of adverse reactions
3. Inform the patient to report adverse reactions without delay
Instruct patient to report discomfort at the IV site immediately

c. Diet
Type
Of General description indication
diet
The clear liquid diet helps to keep
Liquids that you can see through at you hydrated (body fluids, salts and
room temperature (about 78-72 minerals) and helps to get the body
Clear degrees Fahrenheit are considered used to food after long periods of
Liquid diet clear liquids. This includes clear time without food. The clear liquid
juices, broths, hard candy, ices and diet is easy to digest and does not
gelatin leave much residue in the stomach
and intestines.
Very similar to regular diet except To provide a transitional diet
Soft Diet that the textures of foods have between liquids and regular food for
been modified. patients who have undergone
surgery.
A full, well-balanced diet containing To attain optimal growth, tissue
Diet as all of the essential nutrients repair and normal functioning of the
Tolerated needed. It is a regular diet with no organs.
(DAT) food restrictions as tolerated by the For maintenance of nutrition & for
patient. promotion of wellness through food
intake via regular diet per orem.
Nursing Responsibilities for soft diet

● Check the doctor’s order.

● Educate the patient and significant others on the right foods to be taken.
● Discuss to the patient the importance of nutrition.
● Provide a variety of choices of foods.
● Assess patient’s appetite.

Nursing Responsibilities for DAT

● Check the doctor’s order.

● Educate the patient and significant others on the right foods to be taken.
● Discuss to the patient the importance of nutrition.
● Provide a variety of choices of foods.
● Present foods which are appealing and pleasing to the eyes and attract interest.
● Assess patient’s appetite.
 44 | C r a n i o t o m y

d. Activity/ Exercise
Type General description indication
Of
exercise
High Back A type of activity or exercise To reduce oxygen demand and prevent
Rest wherein the patient is kept on bed fatigue. Rest decreases body metabolic
with the head of bed held at at least rate.
45° with limitations to other
activities.
May Sit on A type of activity wherein the client This is to prevent bed sores and promote
Bed is held on a sitting position for a strength gaining.
period of time to facilitate
circulation and prevent bed sores.
Nursing Responsibilities
● Assist patient if with such privilege in going to the bathroom.
● Change client’s position from time to time, to promote circulation and prevent bed sores.
45 | C r a n i o t o m y
 46 | C r a n i o t o m y

1.7 Nursing Management

a. Nursing Care Plans (this is based form previous handled patient in the medicine ward with a diagnosis
of CVA)
Nursing Scientific
Assessment Objectives Interventions Rationale Evaluation
Diagnosis Explanation
S> Ø Impaired skin A craniotomy Short term: > Establish > To gain trust of Short term:
O> received integrity r/t which is a After 4 hrs. of rapport patient/SO The patient’s
patient on bed presence of surgical nursing > Monitor and > To obtain SO shall have
conscious, suture over the operation in intervention the recoded vital baseline data been
coherent head which part of the patient’s SO will signs participated in
> with intact skull called participate in > Assess > To assess prevention
suture over the “bone flap” is prevention patient’s causative/contribu measures such
head removed in measures such condition ting factors as infection
> with complaint order to access as infection and > Note changes > To assess and treatment
of tolerable pain the brain that is treatment in color, texture extent of program
> no dyspnea made program towards & turgor involvement/injury towards wound
> no pallor specifically in wound > Identify > To assess repair/healing
> no cyanosis the subdural repair/healing underlying causative/contribu after 4 hrs. of
noted and subacute condition/patholo ting factors nursing
> skin is moist component lobe Long Term: gy involved intervention
> with good skin to discharge or After 4 days of > Note presence > To determine
turgor expel subdural nursing of impact of Long term:
hematoma in intervention, the uncompromised condition
which it is a patient will vision, hearing The patient
form of display timely or speech shall have
traumatic brain healing of skin > Provide wound > To assist client been able to
injury where in lesions/wounds/ care w/ correcting/ display timely
blood gathers pressure sores minimizing healing of skin
between the without condition & to lesions/wounds
dura and complication promote optimal / pressure
arachnoid. After healing sores without
the surgery, a > Emphasize > A first line complication
 47 | C r a n i o t o m y

suture then is proper hand defense against after 4 days of

made to hold washing nosocomial nursing
skin, thus techniques by all infections/ cross- intervention
breaking the caregivers b/w contamination to
completeness or therapies/clients reduce/ correct
wholeness of existing risk
the skin. factors
> Encourage > To promote
client to wellness
verbalize
feelings esp.
pain
> Assist the > Enhances
client/ SO in commitment to
understanding plan, optimizing
and following outcomes
medical regimen
and developing
program of
preventive care
and daily
maintenance
> Provide > To aid in
optimum healing, to
nutrition, maintain general
increase protein good health and
intake and Vit.C for tissue repair
 48 | C r a n i o t o m y

Nursing Scientific Nursing Expected

Assessment Objective Rationale
Diagnosis Explanation Interventions Outcome
S=Ø Language deficit The patient’s Short Term: >Establish >To gain trust and Short term:
O= The patient (aphasia) related condition After 5° of rapport cooperation of the The patient
manifested the to brain surgery happens due to Nursing patient shall have
following: (decrease surgical Intervention, >Monitor and >To obtain baseline demonstrated
>Unable to circulation to the operation of the the patient will record vital data and to note behavior on
speak brain and brain in which the be able to signs significant changes in how to
dominant damage to the left side of the demonstrate the vital signs of the improve
languages left side of the brain is being behavior on patient communication
>Speaks or brain responsible damaged and how to >To assess for little by little as
verbalizes with for this left side of improve >Assess improvements/change evidenced by
difficulty speech/language the brain is communicatio patient’s s in the patient’s compliance
>Has difficulty ) responsible for n little by little general condition with the
in expressing the motor as evidence by condition >In order for the treatment
thoughts functions of the compliance patient to easily regimen and
verbally body specifically with the understand and health
>has difficulty speech or treatment >Keep communicate verbally teachings
in language regimen and communicatio and to express being given
comprehendin resulting to health n simple, using thoughts or feelings
g and Aphasia. teachings all modes for and needs without Long Term:
maintaining the Aphasia is a being given. accessing much effort to exert The patient
usual disorder that information: >To enhance patient’s shall have
communication results from Long Term: visual, auditory understanding of what established
pattern damage to the After 4 days of and kinesthetic is being communicated method of
>Unable or has parts of the brain Nursing >Maintain eye and in order for them communication
difficulty in use that contain Intervention, contact with to easily comply with in which needs
of facial or language. the patient will the patient the interventions being are being
body Aphasia causes be able to when speaking given expressed as
expressions problems with establish >To clarify evidenced by
any or all of the method of discrepancies between patient
=The patient following: communicatio verbal and non-verbal demonstrated
may manifest speaking, n in which >Use cues behavior in
the following: listening, needs can be confrontation constructing
 49 | C r a n i o t o m y

>Stuttering reading, and expressed as skills, when simple

>Disorientation writing. Muscles evidence by appropriate, sentences
in three of the lips and constructing within an without
spheres of tongue may be simple established >To enhance exerting much
time, space, weaker sentences nurse-client communication skills effort to speak.
person (dysarthria) or which does not relationship and to regain his
>Inappropriate less coordinated require much >Encourage normal verbal
verbalization (apraxia).Speec effort to speak. patient to try to communication
>Absence of h may not be say words or
eye contact clear. Breathing simple
>Willful refusal muscles may be sentences little
to speak weaker, affecting by little
the patient's
ability to speak
loudly enough to
be heard in
conversation.

Nursing Scientific Nursing Expected

Assessment Objective Rationale
Diagnosis Explanation Interventions Outcome
S=Ø Ineffective The condition of Short term: >Establish rapport >To gain trust and Short Term:
cerebral the patient is After 5° of Nursing cooperation of the The patient
O= The patient tissue brought about by Intervention, the patient shall have
manifested the perfusion many factors patient will demonstrated
following: related to such as lifestyle demonstrate >Monitor and >To obtain behavior on
>Numbness impaired (smoking, behavior on how record vital signs baseline data how to manage
on the left transport of alcohol intake), to manage his his condition,
extremities the O₂ age, nature of condition, therapy >Assess patient’s >To identify therapy
>dizziness across work and his regimen, side- general condition underlying factors regimen, side-
>headache alveolar/ or health history effects of the that contribute to effects of the
>increased capillary (Diabetes medication and his condition and medication and
 50 | C r a n i o t o m y

blood pressure membrane Mellitus and when to contact to note if there are when to contact
>altered secondary hypertension). health care improvements/ health care
mental status; to Diabetes Cigarette, which professional as changes in the professional as
Speech Mellitus contains evidence by patient’s condition evidenced by
abnormalities nicotine, and compliance with compliance with
>difficulty of alcohol intake the medication >Determine the >To note the the medication
swallowing cause and health duration of the severity of the and health
constriction of teachings being problem/frequency patient’s condition teachings being
= The patient the blood given. of recurrence, and to also assess given.
may manifest vessels which precipitating or for the
the following: impaired blood Long Term: aggravating factors interventions Long Term:
>Restlessness flow to the After 4 days of appropriate for the The patient
>Confusion different parts of Nursing patients condition shall have
>Lethargy the body Intervention, the >Determine demonstrated
>Seizure particularly in the patient will presence of visual, >To obtain reliable, lifestyle
activity brain. Also demonstrate sensory/motor objective way of modification as
>Pupillary because of his lifestyle changes, recording the evidenced by
changes lifestyle, he modification to headache, conscious state of cessation of
>Decreased developed improve circulation dizziness, altered a person smoking, dietary
reaction to hypertension as evidence by mental status changes and
light that has lead as cessation of (Glassgow Coma exercise.
well in increased smoking, dietary Scale)
intracranial changes and >Elevate head of >To promote
pressure. exercise. bead, and maintain circulation or
Another factor, head/neck in venous drainage
which is midline or neutral and decrease
Diabetes, position intracranial
causes viscosity pressure
of the blood.
Vasoconstriction >Administer >To improve the
and viscosity of medications as patient’s condition
the blood of the directed
patient have
impaired the >Administer oxygen >To saturate
 51 | C r a n i o t o m y

Oxygen supply as needed circulating

to the brain, and hemoglobin and
because of too increase the
much pressure effectiveness of
the blood has to blood that is
exert going to reaching the
the brain, the ischemic tissue
cerebral arteries
are forced to >Encourage patient >To promote
dilate resulting to to quit smoking as wellness and
increase intra this is one of the educate the client
cranial pressure contributing factors about the factors
and hyperfusion. to his condition that could
aggravate his
condition if he
continuously
>Instruct the patient smoke
to avoid fatty,
greasy highly >In order for the
seasoned food patient to prevent
further
complication such
as chest pain and
high blood
pressure
 52 | C r a n i o t o m y

Nursing Scientific
Assessment Objectives Interventions Rationale Evaluation
Diagnosis Explanation
S> Ø Risk for injury r/t One of the Short term: > Establish > To gain trust of the patient and
O> received to generalized complications After 4 hrs. of rapport patient/SO his SO shall
patient on bed weakness and that may arise nursing > Monitor and > To obtain have
conscious, limited ROM after a CVA is intervention the recoded vital baseline data participated in
coherent the numbness, patient and his signs prevention
> with intact paralysis, or SO will > Assess > To assess measures of
suture over the weakening of participate in patient’s causative/contribu possible
head either the half of prevention condition ting factors injuries
> appears weak the body or the measures of > Note changes > To assess
>Unable to whole body this possible injuries in color, texture extent of
move left depends on the & turgor involvement/injury
extremities brain that was Long Term: > Identify > To assess the patient
been damaged. After 4 days of underlying causative/contribu shall have
nursing condition/patholo ting factors displayed
intervention, the gy involved management
patient will > Note presence > To determine of simple ADL’s
display of impact of with the apt
management of uncompromised condition support of the
simple ADL’s with vision, hearing SO
the apt support of or speech
the SO > Provide wound > To assist client
care w/ correcting/
minimizing
condition & to
promote optimal
healing
> modify client’s > to prevent
activity fatigue
> Encourage > To promote
client to wellness
 53 | C r a n i o t o m y

verbalize
feelings esp.
pain
> free clients > to minimize
bedside from chances of
articles that may acquiring injury
promote injury
> Instruct the SO > To involve
on how to assist patients family in
their patient in his care and to
doing his ADL’s maximize clients
willingness
>refer client to > for continuity of
rehab to regain care
strength

Nursing Scientific Expected

Assessment Objectives Interventions Rationale
Diagnosis Explanation Outcome
S> Ø Activity A patient who is Short Term > establish > to gain patient’s Short-Term
Intolerance r/t always on bed rapport trust and The pt’s. SO
O> the pt may decreased rest may feel a After 2-3 hours of cooperation shall
manifest muscle strength decreased in NI patient’s SO verbalized
muscle strength will verbalize > monitor and > to serve as understanding
> decreased in due to lack of understanding of record VS baseline data of methods
muscle strength movement. The methods and and techniques
muscles may techniques to > assess > to provide to increase pt.
> generalized feel stiff and increase patient’s patient’s appropriate muscle
weakness weak because muscle strength. condition interventions strength
> fatigue they are not immediately
 54 | C r a n i o t o m y

exercised and Long Term

> muscle atrophy used. Lack of Long-Term
movement may After 2-3 days of > provide > for proper blood
also cause NI, patient will massage on circulation Patient’s shall
muscle atrophy, demonstrate extremities demonstrated
wherein there is activity tolerance activity
also a decrease AEB doing self- > provide > to minimize tolerance is
in muscle care with minimal patient enough patient’s anxiety increased AEB
strength. When support. time to perform when doing tasks performing
muscle strength activities self-care.
is decreased,
the person may
show > increase > to avoid
intolerance in activity level overexertion
performing, gradually
even simple,
activities. The > provide quiet > to regain
person may environment strength
easily feel suitable for rest
fatigue even in
just doing easy
tasks.
55 | C r a n i o t o m y
 56 | C r a n i o t o m y

V. Conclusion
Craniotomy, as repeatedly being emphasized on this report, involves the
surgery that is performed through an opening in the skull. It is basically a type of
brain surgery. It may be performed to treat or remove cancer, to correct a brain
disorder, or to repair injuries. Because this is very specialized surgery with many
risks, craniotomy mortality rates may be high even at hospitals that rely on highly
experienced neurosurgical teams.

Craniotomy has a long history and is of interest for a number of reasons.

With respect to the brain blood circulation, the skull integrity was shown to be
important for its normal functioning. Disturbance of this integrity should influence
the ratio of the function of the vascular and cerebrospinal fluid systems of the
brain, and, therefore, the circulatory and metabolic maintenance of its function.
Craniotomy is usually performed during neurosurgery, and the trephine opening
remains, as a rule, in the postsurgical period. It is obvious that the disturbance of
the skull integrity caused by trephination changes radically the intracranial
hemodynamics and CSF dynamics.

With this case report, the researchers realized that physical and
psychological implications involved in this procedure. Medically, the procedure
may be life-saving at its best. However, social stigma often pinned down the
person as terminally ill. This would definitely affect the person’s self concept and
hope over his disease condition. As aspiring nurses, they should always consider
better patient outcomes so as to provide efficient and effective care delivery.
 57 | C r a n i o t o m y

VI. Reference/ Bibliography

BOOKS
• Black, Joyce et al. Medical-Surgical Nursing. St. Louis Missouri. 2005
• Bullock, Barbara L. et al. Pathophysiology Adaptation and Alterations in
Functions. 3rd Edition. Philadelphia: J.B. Lippincott. 1992
• Human Anatomy and Physiology Book, Marieb (et al.)
• Kumar, Abbas, Fausto. Pathological Basis of Disease. 7th Edition. 2004
• Seeley, Stephens, Tate. Essential Anatomy and Physiology. New York: Mc
Graw Hill. 2005
• Smeltzer, S. et. al. (2008). Brunner and Suddarth’s Textbook of Medical-
Surgical Nursing 11th edition. Philadelphia: Lippincott-Williams & Wilkins
• Spratto, G. and Woods, A. (2008). 2008 Edition PDR® Nurse’s Drug
Handbook. New York: Thomson Delmar Learning.
• Berman, A. et. al. (2008). Kozier & Erb’s Fundamentals of Nursing: Concepts,
Process and Practice 8th edition Jurong, Singapore: Pearson Education South
Asia
• Seely, R., Stephens, T., Tate, P. (2007). Essentials of Human Anatomy &
Physiology 6th edition. New York: McGraw-Hill.

INTERNET:
• http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Craniotomy?o
pen
• http://www.mayfieldclinic.com/PE-Craniotomy.htm
• http://www.gastromd.com/diets/clearliquid.html
 58 | C r a n i o t o m y

Angeles University Foundation

Angeles City

“Craniotomy”
A Surgical Case Report
In partial fulfillment of the requirements in
Nursing Care Management – Related Learning Experience 103 (NCM
RLE 103)
Mabalacat District Hospital – OR, 2nd Rotation
April 27 – 30, 2009

Submitted By:
Ano, Carl Elexer
Cabrera, Kristina Edna
Calma, Ariane Camille
Palcis, Daniel

BSN III- 1

Submitted To:
Jerry Ligawen, R.N.

April 29, 2009