I. Introduction

Like any other part of the body, the brain is susceptible to bleeding,

infection, trauma, and other forms of damage. This damage or alteration in

brain function sometimes requires brain surgery to diagnose or treat these

problems. A craniotomy is a surgical operation in which part of the skull,

called a bone flap, is removed in order to have access to the brain. Human

craniotomy is usually performed under general anesthesia but can also be

done with the patient awake using a local anesthetic; the procedure generally

does not involve significant discomfort for the patient. In general, a

craniotomy will be preceded by an MRI scan which provides a picture of the

brain that the surgeons use to plan the precise location of the bone removal

and for the appropriate angle of access to the relevant brain areas. The

amount of skull that needs to be removed depends to a large extent on the

type of surgery being performed. Most small holes can heal with no difficulty.

When larger parts of the skull must be removed, surgeons will usually try to

retain the bone flap and replace it immediately after surgery. It is held in place

temporarily with metal plates and rather quickly integrates with the intact part

of the skull, at which point metal plates are removed.

Some of the conditions that require craniotomy and surgical repair

include:

Brain Cancers – refers to the abnormal growth of cells in the brain. Cancer is

a term reserved for malignant tumors. Malignant tumors grow and spread

aggressively, overpowering healthy cells by taking their space, blood and

nutrients. Genetic factors, various environmental toxins, radiation, and

cigarette smoking have all been linked to cancers of the brain, but in most

cases, no clear cause can be shown. Not all brain tumors cause symptoms,

and some (such as tumor of the pituitary gland) are found mainly after death.

The symptoms of brain tumors are numerous and not specific; the only way to

know for sure what is causing the symptoms is to undergo diagnostic testing.

The following symptoms are most common: headache, weakness,

clumsiness, difficulty walking and seizures. Other nonspecific signs and

symptoms includes altered mental status, nausea, vomiting, abnormalities in

vision and difficulty with speech.

Brain Infection – the brain, spinal cord, and its surrounding structures could

become infected by a large spectrum of microorganisms. The infecting

microorganisms cause an inflammation of the area invaded. Depending on

the location of the infection, different names are given to diseases (e.g.

meningitis – inflammation of the meninges, encephalitis – inflammation of the

brain itself). In general, people older than 2 years with acute bacterial

infection develop high fever, severe headache, stiff neck, nausea and

vomiting. Newborns and infants can usually be fussy, irritable, and sleepy.

Severe forms of brain infection could cause shock with complete loss of

consiousness.

Brain Abscess – is a rare, life-threatening infection of the brain. Infectious

agents such as bacteria, fungi, or viruses enter the brain’s tissue and cause a

pus-filled swelling (an abscess). Symptoms vary depending on the part of the

brain affected, but commonly reported symptoms of the brain includes

headache, fever, confusion, and weakness or paralysis on one side of the

body. A brain abscess can be extremely serious because the welling can

damage the brain. The swelling can also disrupt the blood and oxygen supply

to the brain which can be fatal if left untreated. There is also a risk that the

abscess may burst (rupture) which could also cause serious brain damage,

and possibly death.

In vision. The three most common routes for an injection to enter the brain are

via the blood where an infection that occurs in another part of the body spreads

through the blood, by passes the blood – brain barrier, and then infects the brain;

Direct contagion – where an infection that occurs in one cavities in the skull,

such as the ears or nose, manages to spread into the brain, and Direct trauma –

where damage to the skull occurs due to being hit by a blunt object or a gunshot

wound for example, allows an infection to pass through the skull and into the

brain;

Cerebral Edema – is an excess accumulation of water in intracellular

and/or extracellular space of the brain, usually in reaction to a particular

precipitant. Swelling causes reduced function of the affected part of the brain. In

addition, brain tissue can be compressed against natural structures and herniate,

potentially leading to death. Diffuse crebral edema may develop soon after head

injury. Symptoms of cerebral edema can include headache, loss of coordination

(ataxia), weakness and decreasing levels of consciuosness including

disorientation, loss of memory, hallucinations, psychotic behavior and comma;

and

C erebral Hemorrhage (Intracerebral Hemorrhage) – is a subtype of

intracranial hemorrhage that occurs within the brain tissue itself. Intarcerebral

hemorrhage can be caused by brain trauma, or it can occur spontaneously in

hemorrhagic stoke. Non – traumatic intracerebral hemorrhage is a

spontaneousbleeding in the brain tissue. High blood pressure raises the risk of

spontaneous intracerebral hemorrhage by 2-6 times. More common in adults

than in children, intraparenchymal bleeds due to trauma are susually due to

penetrating head trauma, but can also be due to depressed skull fractures,

acceleration – deceleration trauma, rupture of an aneurysm or arteriovenous

malformation (AVM), and bleeding within the tumor. A very small portion is due to

cerebral venous sinus thrombosis. Patients with cerebral bleeding have

symptoms that correspond to the functions controlled by the area of brain that sis

damaged by the bleed. Other symptoms include those that indicate a rise in

intracranial pressure due to a large mass putting pressure on the brain.

If left untreated, any condition requiring brain surgery can cause further

damage to the brain. Pressure on the brain can be harmful as it forces the brain

against the skull, causing damage as well as hampering the brains ability to

function properly. This drop in function can lead to long-lasting brain damage or

even death.

Because craniotomy is a procedure that is ulitized for several condition

and diseases, statistical information for the procedure itself is not availabale.

Howerever, because craniotomy is the most common performed to remove brain

tumor, statistical information for the procedure correcting this condition are given.

Approximately 90% of primary brain cancer occur in adults, more commonly in

males between 55 and 65 years of age. Tumors in children peak between the

ages of 3 and 12. Brain tumors are presently the most common cancer in

children (4 out of 100, 00).

Neurosurgeons from the University of California, San Francisco are

repoting significant results of a new brain mapping technique that allows for the

safe removal of the tumors near language pathways in the brain. The technique

minimizes brain exposure and reduces the amount of the time a patient must be

awake during surgery. The technique is known as “negative brain mapping” and

this was pioneered by Mitchel Berger, M.D., professor and chairman of the UCSF

Depatment of Neurological Sugery and Director of the UCSF brain Tumor

Research Center. The technique eliminates neurosurgeons’ defence on

traditional languagemapping methods that typically require the removal of large

secrtions of the skull and extensive brain mapping while the patietn is awake. It

also allows for smaller craniotomies that expose only the tumor and a small

margin of surrounding brain tissue, rather than several centimeters or more of the

patient’s brain. After the craniotomy, the neurosurgeon \’maps” the brain by

stimulating a section (1cm by 1cm) at a time with bipolar electrode. The strategy

does not require positive identification of language sites (definedas an arrest in

speech, inability to name objects or read, or difficulty in articulating words), as in

traditional brain mapping, but rather is driven by localizing negative sites – areas

that contain no language function.

Over eight years ,Berger and his team tested negative language mapping

on a trail of 250 conservative patients )146 men and 104 women), all of whom

had gliomas – a common and often brain tumor affecting the dominant

hemispher of their brain.

One week following surgery, 194 of the 250 patients (77.6%) retained the

language function they had prior to surgery. Six months later, only four of the 243

surviving patients (1.6%) exhibited worsened language function. (umulatively, the

neurosurgeons stimulated 3281 cortical sites in the brain of the 250 patients.

(Source: http: // www,sciencedaily.com/releases/2008/01/080102222904.htm)

Nurses, to be able to become productive members of the society should

first ready themselves by being equipped with the right combination of

knowledge, skills, as well as attitude towards their work. Today, in the fast phase

of innovation that is occuring, nurses must always remain updated with the latest

trends as well as with the advancements involving their prfession. This is very

important for them to be able to render the best care in every patient that they

would be handling. Life is an unending process for the quest of knowledge that is

why continuos education is very necessary in order to cope up with changes as

well as to meet demands of the society.. because as time passes, life turns out to

be more and more complex at the the same time challenging. The above

information would not only supply new information to health care providers

especially nurses but at the same time it will also serve a reinforcement in order

to further enhance what they already know regarding the topic. Since Craniotomy

is considered as a very complex procedure because of the wide range of

information that it encompasses, the above information would really be of big

help because through them the type of diseases requireing the surgical

procedure, the possible complications that may occur, the management or

clinical interventions needed, and the considerations that has to be put to mind

with regards to the procedure could be not only in ones thought process but as

well with ones emotions and it is involve to almost everything that an individual

does. That is why affection of the ones brain could lead to so many many

disorders. It could also affect the normal functioning of various systems which

could cause further complications leading to the acquisition of sever diseases

and sometimes even death. The following information would not only increase

one’s awareness but at the same time it will also encourge every person to

perform precautionary measures and be responsive enough to value and take

good care of theit health.

B. Synthesis of the Disease:

Brain Cancer is a disease of the brain where cancer cells (malignant)

grows in the brain tissue. Cancer cells grow to form a mass cancer tissue (tumor)

that interferes with the brain tissue functions such as muscle control, Sensation,

Memory and other normal body functions. Tumors composed of cancer cells are

malignant tumors, and those composed of noncancerous cells are called benign

tumors. Cancer cells that develop from brain tissue are called primary brain

tumors.

Predisposing/ Precipitating Factors

Primary Brain tumors arise from may types of brain tissue (for example,

glial cells, ostrocytes, and other brain cell types). Metastatic brain cancer is

caused by the spread of cancer cells from a body organ to the brain.

However,the cause for the change from normal cells to cancer cells in both

metastatic and primary brain tumors are not fully understood. Data gathered by

researchers on research scientist shows that people with certain risk factors

(Situation or the things associated with people that increase the probability of

developing problems) are more likely to develop brain cancer.Individuals with risk

factors such as having jobs in an oil refinery, as a chemist, embalmer, or rubber-

industry worker shows higher rates of brain cancer. Some families have several

members with brain cancer, but heredity as a cause for brain tumors has not

been proven. Other risk factors such as smoking, radiation exposure and viral

infection (HIV) have been suggested but not proven to cause brain cancer. There

is no good evidence that brain cancer is contagious, caused by head trauma or

caused by cellphones use.

Signs and Symptoms w/ Rationale

A brain tumor can obstruct the flow of cerebrospinal fluid (CSF), which

results in the accumulation of (CSF) – hydrocephalus – and increase intracranial

pressure (IICP). Nausea, Vomiting, and headaches are common symptoms.

Brain tumors can damage vital neurologic pathways and invade and

compress brain tissue. Symptoms usually develop overtime and their

characteristics depend on the location and size of the tumor. A brain tumor in the

Frontal lobe may cause the following:

- Behavioral and Emotional changes

- Impaired judgment

- Impaired Sense of smell

- Memory Loss

- Paralysis on one side of the body (hemiplegia)

- Reduced Mental capacity (cognitive function)

- Vision Loss and Inflammation of the optic nerve (papilledema)

A tumor located in both the right and left hemispheres of the frontal lobe

often cause behavioral changes, cognitive changes and a clumsy, uncoordinated

gait. A tumor in the parietal lobe may cause the following symptoms:

- Impaired Speech

- Inability to write

- Lack of recognition

- Seizures

- Spatial Disorders

Vision Loss in one or both eyes and seizures may result from a tumor

located in the Occipital Lobe. Tumors that develop in the Temporal Lobe

are often asymptomatic but some may cause impaired speech and

seizures.

Tumors in the brain stem may produce the following symptoms:

- Behavioral and emotional changes

- Difficulty in speaking and swallowing

- Drowsiness

- Headache, especially in the morning

- Hearing Loss

- Muscle weakness on one side of the face

- Muscle weakness on one side of the body

- Uncoordinated gait

- Vision Loss, Drooping Eyelid, or Crossed eyes

- Vomiting

Brain Abscess (Brain / Cerebral Infection) – is an 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.), infectious sources within the brain tissue. The infection

may also be introduced through a skull fracture following a head trauma or

surgical procedures.

Predisposing/Precipitating Factors

Brain abscess is usually associated with congenital heart disease in young

children. It may occur at any age but is more frequent in the third decade of life.

There is no particular association existing between cerebral abscess and race.

There is also no particular predilection noted in either sex. Bacterial

meningitis is the most common cause of cerebral abscess in neonates and

infants. Fungal and nocardial infections tends to occur in patients with diabetes

or other causes of immunosuppression that are more common in elderly patients.

In neonates, cerebral abscess is causes more commonly by Citrobacter, Proteus,

Pseudomonas, and Serratia species as well as Stahpyloccocus Aureus. Brain

abscess due to toxoplasmosis is most common in patients with AIDS. Nocardial

infection is seen most commonly in patients with immunosuppresson, including

patients who have undergone organ transplantation. Fungal brain infections,

including mucormycosis, are almost always associated with diabetes, renal

failure, or another cause of immunosuppression.

Signs and Symptoms with Rationale:

The symptoms of brain abscess are caused by a combination of increased

ICP due to a space-occupying lesion (headache, vomiting, confusion, coma),

infection (fever, fatigue) and focal neurologic brain tissue damage (hemiparesis,

hemiplegia etc.). the most frequent presenting symptoms are headache,

drowsiness, confusion, seizures, hemiparesis or speech difficulties together with

fever with a rapidly progressive course. The symptoms and findings depend

largely on the specific location of the abscess in the brain. An abscess in the

cerebellum, for instance, may cause additional complaints as a result of brain

stem compression and hydrocephalus. Neurologic examination may reveal a stiff

neck in occasional case (erroneously suggesting meningitis). The famous triad of

fever, headache and focal neurologic findings are highly suggestive of brain

abscess but are observed only in minority of the patients.

Cerebral edema – is a condition characterize by the presence of a large amount

of water in the brain. If not treated, it can be fatal, or cause severe damage, and

the quicker a patient is treated, the better his or her chances of recovery.

Because this condition can be extremely serious, evaluations to check for signs

of cerebral edema are common when patients are brought in for head trauma,

because doctors want to catch is as early as possible.

When a patient has cerebral edema, there is a way more fluid in the skull than

there should be. This causes the brain to swell, which has a number of

consequences. As brain swells, it can compromise its own blood flow, much like

a hose will turn off if you step on it. Decreased blood flow to the brain can Cause

Brain Damage or Death. The increased pressure in the skull may also force the

brain to move around in the skull, which is not designed to do.

Predisposing / Precipitating Factors

People who have suffered brain injuries are the most at risk of developing

cerebral edema, especially if the injuries were severe. The brain does not take

kindly to being sloshed around or smashed abruptly into things and it may

respond by starting to retain water. Cerebral Edema can also develop at high

attitude, causing what is known as high attitude Cerebral Edema (HACE), a

condition which can rapidly turn fatal if the climber does not descend.

Signs and Symptoms with rationale

Someone with developing cerebral edema may start to demonstrate an

latered level of consciousness, confusion, dizziness, nausea, lack of

coordination, or numbness. A high pitch cry is a late sign of increased ICP.

Typically, the infant also displays bulging fontanels, increased head

circumference and widened sutures. Sign and Symptoms of cerebral edema

includes seizures, Bradycardia, possible vomiting, dilated pupils, decreased

LOC, increased systolic blood pressure, a widened pulse pressure, and an

altered respiratory pattern. Such Symptoms is the result of swelling of brain

tissue from leakage of fluids from the capillaries due to the effect of hypoxia on

the mitochondria- rich endothelial cells of the blood-brain barrier. Other

symptoms include the following: loss of coordination (ataxia), loss of Memory,

hallucinations, psychotic behaviors, and coma.

Cerebral Hemorrhage / Cerebral Bleeding

Occurs when a blood vessel burst inside the brain.The brain is very

sensitive to bleeding and damage can occur very rapidly, either because of the

prescence of the blood itself or because the fluid increase pressure on the brain

and harms it by pressing it against the skull.

Bleeding irritates the brain tissue, causing swelling. The surrounding

tissue of the brain resist the expansion of the bleeding, which is finally contained

by forming a mass (hematoma). Both swelling and hematoma will compress and

displace normal brain tissue

Predisposing / Precipitating Factors

Most often, Cerebral Hemorrhage is associated with high blood pressure,

which stresses the artery walls until they break.

Another cause of cerebral hemorrhage is an aneurysm. This is a weak

spot in an artery wall, which balloons out because of the pressure of the blood

circulating inside the affected artery. Eventually, it can burst and caused harm.

The larger the aneurysm, the more likely it is to burst. It is unclear why people

develop aneurysm, but genes may play a role since aneurysm run in families.

Amyloid Protein is also implicated in the brain damage related to

Alzheimer’s disease, but the difference is that people with alzheimers disease

have amyloid accumulation in the brain tissue instead of in the arteries.

Therefore people with Alzheimer’s usually do not develop brain bleeding.

In some people, however, a brain artery may connect to a vein, instead of

gong through the capillaries first. This is called an arterial – venous malformation

since blood pressure in the arteries is much greater than in the veins, the veins

may rupture, causing bleeding in the brain.

In addition, the brain hemorrhage can occur when people have problems

forming blood clots. Clots, which are the body’s way of stopping any bleeding,

are formed by proteins called coagulation factors and by sticky blood cells called

platelets. Whenever coagulation or platelets do not work well or are insufficient in

quantity, people may develop a tendency to bleed excessively.

Signs and Symptoms:

Cerebral Hemorrhage Symptoms are typically of sudden onset and may

quickly become worse. The following is a list of possible problems:

- Weakness or inability to move a body part

- Numbness or loss of sensation

- Decreased or loss of vision (may be partial)

- Speech difficulties

- Inability to recognize or identify familiar things

- Sudden headache

- Vertigo ( sensation of spinning around)

- Dizziness

- Loss of coordination

- Swallowing difficulties

- Sleepy, Stuporous, lethargic, comatose / unconscious

- Cushing’s Triad

IV. CLINICAL INTERVENTION

1.1 Prescribed Surgical Treatment Performed

The hair on part of the scalp is shaved. An incision is made through the

scalp and a hole is drilled through the skull. A piece of the skull may be removed

while the brain is being operated on and replaced before the skin is stitched

closed. The surgery in which the brain is accessed through the skull is called

"craniotomy".

An opening through the frontal and temporal

bones is made by making holes in the bone

and connecting them with a side cutting saw

The patient is anesthetized and the skin

incision is drawn. The skin is prepped and

draped for sterility

The draped skull

The scalp has been pulled upward and the

temporalis muscle retracted to expose the skull

The bone flap has been removed to

expose the dura, which lines the inner skull

and covers the brain

The dural is opened and the frontal lobe

retracted backwards with the metal retractor to

expose the arteries at the base of the brain

The left retractor retracts the

frontal lobe and the right retractor

retracts the temporal lobe exposing the

optic nerve (yellow and the internal

carotid artery (red)

A clip is placed across the neck

of the aneurysm which originates from

the

carotid artery carotid artery and

posterior communicating aneurysm

two clips obliterate the aneurysm

All bleeding is controlled and the dura is closed. The bone flap is secured

to the surrounding skull by small titanium plates and screws. Finally the scalp is

closed with sutures and staples. Craniotomies may last several hours to

accomplish a satisfactory result.

1.2. Indication/s of Prescribed Surgical Treatment

Brain surgery may be needed to treat:

brain tumors

bleeding (hemorrhage) or blood clots (hematomas) from injuries (subdural

hematoma or epidural hematomas)

weaknesses in blood vessels (cerebral aneurysms)

damage to tissues covering the brain (dura)

pockets of infection in the brain (brain abscesses)

severe nerve or facial pain (such as trigeminal neuralgia or tic douloureux)

epilepsy

1.3. Required Instruments, Devices, Supplies, Equipment, and Facilities

Before surgery the patient may be given medication to ease anxiety and to

decrease the risk of seizures, swelling, and infection after surgery. Blood thinners

(Coumadin, heparin, aspirin) and nonsteroidal anti-inflammatory drugs

(ibuprofen, Motrin, Advil, aspirin, Naprosyn, Daypro) have been correlated with

an increase in blood clot formation after surgery. These medications must be

discontinued at least seven days before the surgery to reverse any blood thinning

effects. Additionally, the surgeon will order routine or special laboratory tests as

needed. The patient should not eat or drink after midnight the day of surgery. The

patient's scalp is shaved in the operating room just before the surgery begins.

Human craniotomy is usually performed under general anesthesia but can

be also done with the patient awake using a local anaesthetic; the procedure

generally does not involve significant discomfort for the patient. In general, a

craniotomy will be preceded by an MRI scan which provides a picture of the brain

that the surgeon uses to plan the precise location for bone removal and the

appropriate angle of access to the relevant brain areas. The amount of skull that

needs to be removed depends to a large extent on the type of surgery being

performed. Most small holes can heal with no difficulty. When larger parts of the

skull must be removed, surgeons will usually try to retain the bone flap and

replace it immediately after surgery. It is held in place temporarily with metal

plates and rather quickly reintegrates with the intact part of the skull, at which

point the metal plates are removed.

SETUP OF THE OR

There are many similarities in preparing for aneurysm clipping and

endovascular coiling procedures. Both procedures require that preoperative and

postoperative cerebral angiography be performed; so ideally, the surgical

procedure is performed in a room that has angiographic capability. No matter

which procedure will be performed, one back table is prepared for cerebral

angiography. The angiography back table includes

* an angiography pack,

* a gown and gloves for the neurosurgeon,

* a syringe and needle for administering local anesthesia,

* a percutaneous entry needle,

* an arterial pressure monitoring kit,

* a customized kit for delivering heparinized saline,

* extension tubing,

* a femoral-artery introducing sheath,

* a selection of arterial sealing devices,

* angiographic guide wires and catheters, and

* contrast dye and heparinized saline in labeled containers.

CRANIOTOMY FOR ANEURYSM CLIPPING SETUP.

- a second back table is prepared for a craniotomy. The table includes

* a craniotomy instrument set;

* a craniotomy pack;

* a drill with accessories;

* a selection of suction tips;

* aneurysm clips and clip appliers;

* a micro-Doppler probe;

* monopolar and bipolar electro-surgery unit (ESU) supplies;

* physician-preferred retractors and dissectors; and

* various sizes of cottonoids and hemostatic agents (eg, wax, hemoclips,

hemostatic sponges).

The circulating nurse ensures that dura repair supplies and materials are readily

available but not opened until they are needed. The circulating nurse aseptically

delivers medications into containers that the scrub person has labeled on the

back table, including

* the physician's preferred local anesthesia,

* antibiotic irrigation, and

* thrombin mixed with gelfoam.

The circulating nurse ensures that the following equipment is in the room and

functioning properly before the patient is brought into the room:

* a radiolucent OR bed designed for both angiographic and craniotomy

procedures;

* a radiolucent, neurosurgical, three-point headrest and table attachment;

* a microscope;

* monopolar and bipolar ESUs; and

* a foot pedal for the drill.

ENDOVASCULAR COILING SETUP.

The risk of aneurysm rupture during an endovascular coiling procedure is low;

however, the circulating nurse and scrub person should have supplies for a

ventriculostomy readily available should a rupture occur. In addition to a cerebral

angiography pack, the circulating nurse and scrub person open

* gowns and gloves,

* a femoral artery introducing sheath,

* a percutaneous entry needle, and

* an arterial pressure monitoring kit.

They also ensure that a full supply of endovascular wires, catheters, coils, and

stents are available. The circulating nurse aseptically delivers medications into

containers that the scrub person has labeled on the angiography back table,

including

* local anesthesia as requested by the surgeon,

* contrast dye, and

* heparinized saline for irrigation.

The circulating nurse prepares additional heparinized saline for patient

systemic heparinization during the procedure. The circulating nurse delivers this

additional heparinized saline to the surgical field via tubing that is attached to

sterile extension tubing and a delivery kit on the surgical field. The surgeon will

administer this systemic heparinized solution via the femoral artery.

1.4. Perioperative Tasks and Responsibilities of the Nurse

PREOPERATIVE NURSING CARE

After the patient completes the admission process, an admission clerk

escorts or directs him or her to the preoperative area. The preoperative nurse

greets the patient and instructs him or her to change into a hospital gown. After

taking the patient's vital signs, the preoperative nurse obtains the patient's health

history and verifies his or her NPO status and allergies. After ensuring that

appropriate laboratory results are in the patient's medical record, the nurse

performs a baseline neurological assessment and documents any deficits. The

nurse no-titles the anesthesia care provider and the surgeon about any

abnormalities. The preoperative nurse puts thromboembolic disease (TED)

stockings and intermittent pneumatic compression (IPC) cuffs on the patient.

The surgeon arrives in the preoperative area and obtains informed

consent for cerebral angiography and craniotomy for aneurysm clipping or

endovascular coiling, depending on the procedure to be performed. The

anesthesia care provider arrives and obtains the patient's informed consent for

anesthesia, including placement of central lines. The preoperative nurse then

assists the surgeon or anesthesia care provider during insertion of an arterial

line, which allows for accurate intraoperative blood pressure monitoring.

The diagnosis of cerebral aneurysm and the prospect of undergoing a

craniotomy are very frightening for patients; therefore, it is important for all

perioperative nurses to monitor the emotional state of the patient and his or her

family members. The perioperative nurses offer reassurance and support, giving

the patient and family members an opportunity to express fears and concerns.

The preoperative nurse assesses the patient's understanding of the procedure

and tells the patient what to expect in the immediate postoperative period.

The circulating nurse goes to the preoperative area to interview the patient

and review the patient's medical record. The circulating nurse ensures that the

consent forms are signed and dated by the patient and surgeon or anesthesia

care provider and that the preoperative nurse who witnessed the patient's

signature has signed the forms. The circulating nurse ensures that all laboratory

results are available and that the surgeon and anesthesia care provider have

been notified of any abnormal laboratory test results. The circulating nurse greets

the patient and performs a preoperative assessment, after which he or she

develops a care plan specific to this patient (Table 3). When the patient and chart

are ready, the circulating nurse transports the patient to the OR suite.

INTRAOPERATIVE NURSING CARE

After assisting the patient onto the OR bed, the circulating nurse places

the safety strap across the patient's thighs, and secures the patients arms to the

padded arm boards. After placing padding under the patient's heels, the

circulating nurse assists the anesthesia care provider with applying monitoring

devices and ensures that the electrocardiograph leads are placed in a position

that will not interfere with fluoroscopic image clarity. The circulating nurse then

applies an upper-body, temperature-regulating blanket on the patient and warm

blankets on the patient's lower body. The circulating nurse checks and

documents the patient's bilateral dorsalis pedis and posterior tibial pulses for a

baseline measurement. The nurse then connects the IPC tubing to the IPC cuffs

and activates the IPC device.

The circulating nurse and scrub person then perform a count of sponges,

sharps, and instruments. The circulating nurse ensures that the count is

documented properly. When all members of the intraoperative team are present,

the circulating nurse initiates a surgical time out. All OR personnel ensure that

noise and the activity level in the room are kept to a minimum, particularly during

induction of anesthesia. The circulating nurse assists the anesthesia care

provider during induction and endotracheal intubation.

The circulating nurse inserts an indwelling urinary catheter. He or she

places a monopolar, ESU dispersive pad on one of the patient's thighs for

aneurysm clipping procedures. The circulating nurse pads the patient's arms and

tucks them at the patient's sides. The nurse evaluates the patient's position,

ensuring that all bony prominences and pressure points are adequately padded.

The nurse uses a clippers to remove hair from the patient's bilateral groin areas

and performs a surgical prep of the area in anticipation of the preprocedure

cerebral angiogram.

The circulating nurse and anesthesia care provider document procedural

events and implantation of coils, if pertinent, and monitor blood loss. The

circulating nurse provides updates by telephone to the family during the surgery.

CRANIOTOMY WITH ANEURYSM CLIPPING

The neurosurgeon, circulating nurse, and anesthesia care provider place

the patient's head in the neurosurgical, three-point headrest using sterile

technique and sterile head pins. The circulating nurse applies antibiotic ointment

around the puncture sites. Good body alignment is vital, and it is particularly

important that the patient's neck is carefully positioned. If the patient's head is

turned far to one side for access to the aneurysm, it may be necessary to place a

supportive pad under the affected shoulder to prevent neck strain.

The neurosurgeon clips the hair from the surgical area of the patient's

head, and the circulating nurse performs the surgical skin prep. While this is

occurring, the scrub person drapes the microscope. After the scrub person and

surgeon drape the surgical area, the circulating nurse positions and connects the

unipolar and bipolar ESUs, foot pedals (eg, bipolar ESU, power drill), and suction

devices.

The location of the surgical incision depends on the location of the

cerebral aneurysm. After making the initial incision, the neurosurgeon applies

scalp clips to the skin edges. He or she performs soft tissue separation from

underlying bone with an elevator and then attaches dura hooks to a separate

Mayo stand to secure the scalp flap. After drilling burr holes into the cranium at

the four corners of the incision site, the neurosurgeon saws between the burr

holes and separates the bone flap from the underlying dura with elevators and

dissectors in order to turn the bone flap.The circulating nurse moves the

microscope into position, and the neurosurgeon uses it to locate and carefully

isolate the aneurysm and the blood vessels that feed it. Delicate movements are

used to prevent disruption of surrounding brain tissue. The neurosurgeon

carefully separates the aneurysm from the surrounding tissue and then places

one or more small aneurysm clips across the neck of the aneurysm (Figure 6).

The neurosurgeon then closes the dura and replaces the bone flap with screws

and plates. He or she then closes the scalp. The circulating nurse assists the

neurosurgeon with removing the neurosurgical, three-point headrest from the

patient's head and applying a cranial wound dressing.

When the craniotomy is complete, the neurosurgeon performs a repeat

cerebral angiogram to examine the cerebral blood flow. The surgeon seals the

femoral artery with an artery sealing device and applies pressure for several

minutes before applying a femoral wound dressing.

ENDOVASCULAR COILING PROCEDURE

The endovascular coiling procedure is performed by an interventional

neurosurgeon or neuroradiologist. The neurosurgeon or neuroradiologist inserts

an endovascular catheter into the patient's femoral artery and performs a

preprocedure cerebral angiogram to locate the aneurysm. The surgeon or

radiologist delivers heparinized saline systemically via the femoral artery during

the procedure. Aided by fluoroscopy, the surgeon or radiologist threads the

catheter to the aneurysmal site. When the correct position is obtained, he or she

introduces a detachable coil into the lumen and uses an electrical impulse to

detach the coil from the catheter

One or more coils may be needed to fill the aneurysm sac. If the neck of

the aneurysm is too wide to hold the coils, the surgeon or radiologist may place a

stent across the neck of the aneurysm. The stent allows for safe deposition of the

coils without allowing a coil mass to protrude into the main artery. The surgeon or

radiologist removes the catheter when the coils have been successfully

deployed. He or she places an arterial sealing device in the femoral artery

puncture site after the procedure is complete and applies pressure to the area for

several minutes before applying a femoral wound dressing.

POSTOPERATIVE NURSING CARE

As the patient is waking from anesthesia in the OR, the anesthesia care

provider reminds the patient not to move the leg in which the angiogram was

performed. The surgical team then carefully transfers the patient to a hospital

bed. The circulating nurse secures a sheet over the patient's surgical leg and

tucks it under the mattress on both sides of the bed to help prevent unnecessary

leg movement. The anesthesia care provider and circulating nurse transport the

patient to the postanesthesia care unit (PACU), where both provide a detailed

hand-off report to the receiving PACU nurse. The circulating nurse ensures that

the PACU nurse is aware of any neurological deficits that the patient may have

presented with preoperatively.

The PACU nurse documents the patient's arrival vital signs and performs

a neurological assessment. The nurse checks the cranial and femoral dressings

for bleeding and checks the patient's pedal pulses for evidence of occlusion. The

patient remains on bed rest with the affected leg extended for a period of time

determined by the surgeon. The PACU nurse remains vigilant and immediately

reports any signs and symptoms of a retroperitoneal bleeding (eg, low systolic

blood pressure, abdominal pain or discomfort) or evidence of hemorrhage or

vasospasm (eg, neurological deterioration).Typically, a patient who has

undergone craniotomy for aneurysm clipping spends two nights in an intensive

care unit (ICU) and an additional three nights in a medical-surgical unit before

being discharged home. In contrast, a patient who has undergone an

endovascular coiling procedure typically spends one night in ICU and one

additional night in a medical-surgical unit. Either treatment course may require

rehabilitation before the patient is discharged home, depending on how the

patient recovers or if he or she experiences complications.

1.5. Expected Outcomes of Surgical Treatment Performed

After surgery, the patient is taken to the recovery room where vital signs

are monitored as the patient is awake from anesthesia. The breathing tube

(ventilator) usually remains in place until the patient fully recovers from the

anesthesia. Next, the patient is transferred to the neuroscience intensive care

unit (NSICU) for close observation and monitoring. the patient is frequently asked

to move his arms, fingers, toes, and legs.

A nurse will check the patient’s pupils with a flashlight and ask questions,

such as "What is your name?" The patient may experience nausea and

headache after surgery; medication can control these symptoms. Depending on

the type of brain surgery, steroid medication (to control brain swelling) and

anticonvulsant medication (to prevent seizures) may be given. When the patient’s

condition stabilizes, the patient will be transferred to a regular room where he will

continue to be monitored and begin to increase your activity level.

The length of the hospital stay varies, from only 2–3 days or 2 weeks

depending on the surgery and development of any complications. When released

from the hospital, the patient is given discharge instructions. Stitches or staples

are removed 7–10 days after surgery in the doctor’s office.

The results of craniotomy depend on the underlying condition being

treated.

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

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 of Physiologic Outcomes

Take medicine as directed: Instruct patient to call the caregiver if having side

effects. Do not quit taking medicines unless discussed with the physician.

Antibiotics: This medicine is given to fight or prevent an infection caused by

bacteria. Emphasize to keep taking this medicine until it is completely gone, even

if the patient feels better.

Pain medicine: Postoperative pain is one of the main postoperative adverse

outcomes that causes distress to patients and can have a deteriorative effect on

the recovery of the patient. Opioid analgesics are the cornerstone of

pharmacological postoperative pain management, especially for surgical

procedures that cause moderate to severe pain. Opioids may be administered by

a variety of routes; oral dosing is usually the most convenient and least expensive

route of administration. It is appropriate as soon as the patient can tolerate oral

intake and is the mainstay of pain management in the ambulatory surgical

population.Controlled-release codeine has been shown to provide similar levels

of analgesia compared to immediate-release codeine preparations. A perceived

issue by clinicians about the use of controlled-release opioids for shorter-term

pain is that the onset of analgesia is substantially slower than immediate-release

preparations. A prompt onset of analgesia, similar to immediate-release

preparations, has also been demonstrated for controlled-release oxycodone. This

profile suggests that controlled-release codeine or oxycodone may be useful in

the treatment of pain caused by acute traumatic injuries lasting a few days or

more. The potential advantages of controlled-release codeine compared to

immediate-release preparations in the treatment of acute pain include an

extended duration of action, more uniform plasma concentrations and clinical

effects, a reduced dosing frequency with greater convenience, improved

compliance, and uninterrupted night-time sleep, thereby providing the potential

for more effective continuous postoperative analgesia.ostoperative pain in

ambulatory surgical patients in the hospital and at home should not be

underestimated. New analgesic techniques, such as the use of controlled-release

opioids, that are effective and do not increase the incidence of postoperative

adverse outcomes should be considered.

Diet: Tell the patient to eat a variety of healthy foods from all the food groups

every day. Include whole grain bread, cereal, rice and pasta, a variety of fruits

and vegetables, including dark green and orange vegetables and legumes (dry

beans). Include dairy products such as low-fat milk, yogurt and cheese. Choose

protein sources such as lean meat and poultry (chicken), fish, beans, eggs and

nuts

Wound care: When the patient is allowed to bathe or shower, carefully wash the

incisions with soap and water. Afterwards, put on clean, new bandages. Change

the bandages any time they get wet or dirty.

1.7. Nursing Management of Physiologic, Physical and Psychosocial Outcomes (NCPs)

Cues Nursing

Diagnosis

Scientific

Explanation

Objectives Nursing

Interventions

Rationale Expected

Outcome

S > Ø

O > the patient

may manifest:

>

guarded/protect

ive behavior

> sleep

disturbance

> irritability

> restlessness

Acute

pain

A gallbladder

attack, whether in

acute or chronic

cholecystitis,

begins as pain.

The pain of

cholecystitis is

similar to that

caused by

gallstones (biliary

colic) but is more

severe and lasts

longer—more

than 6 hours and

often more than

Short Term:

After 4 hours

of NI, the

patient will

report relief

from pain

Long Term:

After 2 days of

NI, the patient

will be able to

demonstrate

>Establish rapport

>Assess pt.

general condition

>observe patients

non verbal cues

such as facial

expression

>monitor vital

signs

> to gain

patients trust

> to have a

baseline data

> indicates need

for further

evaluation

> usually altered

in acute pain

>to provide non-

Short Term:

The patient

should have

demonstrated

report relief

from pain

Long Term:

The patient

should have

been able to

actions of

pain relieved.

>facial grimace12 hours. The

pain peaks after

15 to 60 minutes

and remains

constant. It

usually occurs in

the upper right

part of the

abdomen. The

pain may become

excruciating. Most

people feel a

sharp pain when

a doctor presses

on the upper right

part of the

abdomen.

Breathing deeply

may worsen the

pain. The pain

often extends to

actions of pain

relieved. >provide comfort

measures such

as back rubs

providing

diversional

activities, and

massages

>Perform

comprehensive

assessment to

pain.

>Perform pain

assessment each

time pain occurs,

note changes

pharmacologic

pain

management

>To assess

contributing

factors to pain

>To rule out

worsening of

condition.

>Help in

the lower part of

the right shoulder

blade or to the

back.

from previous

reports

>Make time to

listen and

maintain frequent

contact with

patient.

>Provide

adequate rest

periods.

>Encourage and

instruct to

increase fluid

intake.

alleviating

anxiety and

relieve pain.

>To prevent

fatigue that will

worsen the pain

>To prevent

dehydration &

promote wound

healing

>To increase

the body’s

resistance

against possible

complication.

>Encourage and

instruct patient to

eat nutritious

foods.

>Suggest patient

to assume

position of

comfort while in

bed. Promote

bedrest as

indicated.

>Encourage

diversional

activities

>Sufficient rest

is necessary to

limit the pain.

>To distract the

patient & reduce

pain

>To facilitate

pain tolerance.

>Administer

analgesics as

ordered.

Cues Nursing

Diagnosis

Scientific

Explanation

Objectives Nursing

Interventions

Rationale Expected

Outcome

S > Ø

O > the patient

may manifest:

>lack of

cooperation

>irritability

during Ni’s

>avoidance

Fear r/t

unfamiliarity to

environmental

experiences

(medications

and nursing

interventions)

Fear is

characterized

by significant

anxiety

induced by

exposure to

certain social

or

performance

situations,

often resulting

in avoidance.

Short Term:

After 4 hours

of NI, the

patient will

display

appropriate

range of

feelings and

lessened fear.

Long Term:

After 2 days of

>Assess patients

general condition

> monitor vital

signs

>provide comfort

measures

>encourage

adequate rest

>to have a

baseline data

>to have a

baseline data

> to provide

non-

pharmacologic

pain

management

Short Term:

The patient

should have

displayed

appropriate

range of

feelings and

lessened fear.

Long Term:

The patient

should have

NI, the patient

will be able to

lessened her

fear

period

>compare verbal

& nonverbal

responses

>stay with the

patient

>provide

information &

speak in simple

sentences &

concrete terms

>provide

opportunity for

>to prevent

fatigue

>to note

congruencies or

misperceptions

of situations

>sense of

abandonment

can exacerbate

fear

>facilitates

understanding

and retention of

information

been able to

lessened he

fear.

questions &

answer honestly

>encourage

contact with other

patients who has

successfully dealt

with a similar

fearful situation

>always explain

procedures

>enhances

sense of trust &

nurse-client

relationship

>provides a role

model & client is

more likely to

believe others

who had similar

experiences

>to prevent

confusion

Cues Nursing

Diagnosis

Scientific

Explanation

Objectives Interventions Rationale Expected

Outcome

S > Ø

O > the

patient

may

manifest

the

following:

>

inappropri

ate or

exaggerat

ed

behavior

>

unfamiliari

ty to

Deficient

Knowledge

r/t

unfamiliarity

with

information

resources

Deificient

Knowledge

is the

absence or

deficiency of

cognitive

information

necessary

for the

client/SOs to

make

informed

choices

regarding

the

condition,

treatment or

lifestyle

Short Term:

After 3 hours

of nursing

interventions

, the pt. will

be able to

Exhibit

increased

interest/assu

me

responsibility

for own

learning and

begin to look

for

information

and ask

Monitor,

Assess and

Record the

Vital Signs of

the patient.

Ascertain level

of knowledge,

including

anticipatory

needs.

Determine

client’s ability

To become

aware of any

abnormalities

and

irregularities of

the patients vital

signs

To know what is

the level of

understanding

of the person to

know what

information

should be

reinforced.

Right timing is

Short Term:

The pt. shall

have

exhibited

increased

interest/assu

me

responsibility

for own

learning and

begin to look

for

information

and ask

question.

disease

condition

>

inaccurate

follow

through of

instruction

The

patient

may

manifest:

>

incomplian

ce to the

treatment

regimen

changes. question.

Long Term:

After 2 days

of Nursing

Interventions

, the pt. will

be able to

initiate

necessary

lifestyle

changes and

participate in

treatment

regimen.

to learn

Noted

personal

factors

Determine

Barriers to

learning

important in

giving

information,

knowing the

client’s ability

gives the nurse

idea on what

way will he/she

present the

information.

Personal

Factors are

important in

learning,

because

learning is

individualized

To make some

techniques to

Long Term:

The pt. shall

have initiated

necessary

lifestyle

changes and

participate in

treatment

regimen.

Identify

motivating

factors for the

individual

Provide

information

relevant to the

situation

Determine

patient’s most

urgent need

Recognize

level of

achievement,

avoid being

affected by

those barriers

This will help

the individual to

learn

To let the client

know about the

present

situation.

Knowing to

prioritize the

patient’s

learning needs

increases the

effectivity of the

time factors,

and short term

and long term

goals

teaching plan

To know what

are the purpose

of the patient

teaching

Cues Nursing

Diagnosis

Scientific

Explanation

Objectives Nursing

Interventions

Rationale Expected

Outcome

S> ө

O> patient

may manifest:

>afebrile

>pale

palpebral

conjunctiva

>pale oral

mucosa

>good skin

turgor

>good capillary

Risk for

Infection

related to

inadequate

primary

defense

There is a risk

for infection or

being invaded

by pathogenic

organisms due

to inadequate

primary and/or

secondary

defenses, and

because of the

chronic

disease or

insufficient

knowledge to

avoid the

exposure to

the pathogen.

Short term:

After 6 hrs. of

nursing

interventions

pt. will identify

interventions to

reduce/prevent

risk of

infections

Long Term:

After 2 days of

nursing

interventions

pt. will

>monitor and

recorded vital

signs

> stress proper

hand washing

techniques by

all caregivers

>cleanse

insertion/incision

sites daily and

prn with

povidone iodine

or other

>to obtain

baseline data

>a first line

defense

against

nosocomial

infections/cross

contamination

>to prevent

infection

Short term:

The pt. shall

have identified

interventions to

reduce/prevent

risk of

infections

Long Term:

The pt. shall

have

demonstrated

techniques,

refill time

>jaundice

sclera

>with pain

when moving

>with JP drain

intact

The may

patient

manifest:

>fever

>decrease

capillary refill

time

demonstrate

techniques,

lifestyle

changes to

promote safe

environment.

appropriate

solution

>maintain

adequate

hydration

>change

dressings daily

and prn

>encourage

early ambulation

>instruct client

in techniques to

protect the

integrity of the

skin, care for

lesions, and

>to avoid

bladder

distention

>to prevent

soiling

>to prevent

pressure ulcers

>to have

knowledge of

the continuity

of care and for

lifestyle

changes to

promote safe

environment.

>poor skin

turgor

prevention of

spread of

infection.

>emphasize

necessity of

taking antibiotics

the client to be

dependent

from care

>premature

discontinuation

of treatment

when client

begins to feel

well may result

in return of

infection

III. CONCLUSION

Craniotomy is any bony opening that is cut into the skull. A section of

skull, called a blone 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.

The case report has given the researchers an opportunity to take a

glimpse on operative nursing, in general and in the specific methods used in the

selected case, craniotomy. The work of a perioperative nurse includes assisting

with minor surgery using local anesthetics through to major surgery as a result of

injury or disease.

LEARNING DERIVED

Peri-operative nurses work in operating rooms assisting in all areas

surgical procedures. This area of nursing requires skills and abilities that both

challenge and reward the people who work in this environment. Teamwork is a

key issue, as it has a very inter-dependant role as well as an autonomous role to

fulfill. The nurse, as well as being a skilled clinician and technologist, should be

adept at communication, problem solving, and being a patient advocate. It is all

about caring for the patient, and often the family of the patient, as they undergo

surgery. It involves preparing an individual for surgery, offering comfort and

support, using sound nursing skills and problem solving techniques together with

specialized skills to ensure a safe and effective experience. These are some of

the things which we have realized in conducting this case report.

References

Books:

Second Home Edition, the Merck Manual of Medical Information by Merck

& Co., 2003

Smeltzer, S.C. et al. Brunner & Suddarth's Textbook of Medical – Surgical

Nursing (11th Edition)

Web Sources:

http://www.mayfieldclinic.com/PE-Craniotomy.htm

http://en.wikipedia.org/wiki/Craniotomy

http://www.surgeryencyclopedia.com/Ce-Fi/Craniotomy.html

http://www.sd-neurosurgeon.com/practice/craniotomy.html

http://www.myoptumhealth.com/portal/ADAM/item/

c7a615f059259110VgnVCM1000005220720a____

http://findarticles.com/p/articles/mi_m0FSL/is_6_85/ai_n19312267/?

tag=content;col1

http://www.thinknursing.com/nursing_midwifery/pathways/perioperative