Nursing Case Analysis

Burr-Hole Craniotomy for Evacuation of Chronic Subdural Hematoma


I. Assessment A. Demographic Profile B. History i. History of Past Illness ii. History of Present Illness iii. Nursing History C. Assessment (PCR) D. Laboratory and Diagnostic Examinations E. Nurse’s Notes II. Anatomy and Physiology III. Pathophysiology IV. OR Procedure V. Drug Analysis VI. Nursing Care Plans A. Pre-operative B. Intraoperative C. Post-operative VII. References

I. Assessment A. Demographic Data Name of Patient: Gascon, Dominador R. Date of Admission: 7/12/09 Room no.: 313 I Hospital no.: 09600302

Chief Complaint: Decreased level of consciousness

Diagnosis: Left Frontoparietal Chronic Subdural Hematoma Surgery: Emergency Left Frontoparietal Burr-hole Craniostomy for Evacuation of Chronic Subdural Hematoma Date of surgery: 7/12/09 Age: 81 Sex: Male Time Started/ Ended: 6:42PM to 7:50PM Citizenship: Filipino Civil Status: Married Religion: United Methodist Occupation: Farmer

Birth date: April 30, 1928

Address: Brgy. Centro East Ballesteros, Cagayan B. History i. History of Past Illness • (+) Prostate, enlargement, 2004 o • Medical treatment

(+) Arthritis o Voltaren as medication

(-) Allergies

ii. History of Present Illness • 4 months prior to admission, patient sustained a fall on his head, no consult done, no medicines taken, no accompanying signs and symptoms. 2 weeks PTA, patient had flight of ideas and claimed to have pain on the head with no other accompanying symptoms. Patient was given Mefenamic Acid and Amoxicillin which provided slight relief of symptoms.

6 days PTA, patient was admitted to St. Paul Hospital in Tuguegarao. CT Scan done showed subdural hematoma. Medicines given were unrecalled. 4 days PTA, patient was discharged against medical advice because relatives thought that there was no more chance for the patient. 2 days PTA, patient was brought to local clinic where he was given Mannitol, Dexamethasone, Citicholine, Levoflaxin. Patient was then referred to our institution, hence admission.

iii. Nursing History Date taken: 7/16/09 Comfort, Rest and Sleep Patient was not experiencing pain on surgical site (head) as verbalized by the patient’s daughter. Prior to admission, patient complained of pain on the head and was given Mefenamic acid and Amoxicillin to relieve the pain. Patient was relieved of the pain after taking the medicines. Patient was experiencing pain on his knees due to his arthritis. Patient had also experienced joint pains before admission and was taking Voltaren as medication. Patient also has fever with temperature at 38.5 0C. According to informant, patient has not verbalized difficulty in sleeping except when he experiences joint pains. Safety Patient is bedbound and is partially assisted. Patient has slight difficulty in seeing and hearing but is not wearing any assistive device. Fluids and Nutrition Patient is on modified diet (1800 Kcal/day 0.8g CHON 60% MBV divided into 3 meals and 2 snacks). Patient drinks 2-3 glasses of water a day and is on IVF (PNSS). Patient has no problem in the diet except with risk for aspiration. Patient is wearing dentures. Patient’s weight is normal. Elimination Patient is with indwelling catheter to hospicare bag. Patient experienced dysuria before insertion of IC due to patient’s enlargement of prostate. Patient’s urine output is about 500600cc per day. Patient’s urine is yellow and slightly turbid. Patient has not moved his bowel for 8 days according to informant. Information Obtained from: Patient’s Daughter

D. Laboratory and Diagnostic Examinations CBC (7/12/09) Result Reference value Hgb HCT RBC WBC 108 0.31 3.34 10.50 neutrophils 0.76 Blood Chemistry (7/12/09) Value Na 136 K 3.7 Reference Value 137-147 3.8-5 Patient has decreased levels of sodium and potassium. This results to fluid shift which can lead to water retention that causes edema which is manifested in the patient’s lower extremities. The decrease in NA may be brought about by hemorrhage and intake of diuretics (Mannitol) 120-170 0.37-0.54 4.0-6.0 4.5- 10.0 0.50-0.20 Patient’s WBC count is elevated which accounts for the patient’s febrile state. Patient’s haemoglobin, RBC and hematocrit are decreased which may be indicative of hemorrhage.

Coagulation Assay (7/12/09) results Reference values Prothrombin time 13.1 s 10.3-14.1s

Normal Control


Prothrombin ratio International normalized ratio Activated PTT

1.1 1.1 35.4 s 27.0-45.4s Patient’s coagulation assay results are normal which shows that the patient has no problem in bleeding and clotting. Patient is good for surgery.

C. Nurse’s Notes 7/12 5pm

5:40pm 5:45pm 6:00pm



> Received patient from ward accompanied by daughter brought to OR per stretcher. Transferred to OR bed secured with body strap. Patient has the following contraptions PNSS 1L @ 20 gtts/min from ER with 500mL more to infuse. Foley catheter fr.16 drain to urine bag. Draining yellowish color urine. Patient was hooked on monitors. Initial VS are as follows: PR-72; RR20; BP- 130/80; SPO2- 96%. Cautery pad placed on left leg. Initial count of needles, sponges and instruments done. > A line was inserted by Dr. Gonzaga using abocath g20 > Anesthesia given by Dr. Gonzaga assisted by Dr. Tan and Galvan per GETA using ET8 level 20 using sevoflurane as anesthetic agent. Another line was inserted on brachial arm using g.16 needle. Shaving done by Dr. Pagcu followed by prepping. Prepping agent used was Betadine antiseptic and cleanser.Infiltration done using sensorcaine 10mL diluted with .05 epinephrine. > Operation started done by Dr. Pagcu assisted by IIC and CIC. Initial and final count of cottonoids, needles,

II. Anatomy and Physiology Anatomy of the Brain

The Cerebrum 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. 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 cortex, also called gray matter, is the most external layer of the brain and predominantly contains neuronal bodies (the part of the neurons where the DNA-containing cell nucleus is located). The gray matter participates actively in the storage and processing of

information. An isolated clump of nerve cell bodies in the gray matter is termed a nucleus (to be differentiated from a cell nucleus). The cells in the gray matter extend their projections, called axons, to other areas of the brain. Fibers that leave the cortex to conduct impulses toward other areas are termed efferent fibers, and fibers that approach the cortex from other areas of the nervous system are termed afferent (nerves or pathways). Fibers that go from the motor cortex to the brainstem (for example, the pons) or the spinal cord receive a name that generally reflects the connections (that is, corticopontine tract for the former and corticospinal tract for the latter). Axons are surrounded in their course outside the gray matter by myelin, which has a glistening whitish appearance and thus gives rise to the term white matter. Cortical areas receive their names according to their general function or lobe name. If in charge of motor function, the area is called the motor cortex. If in charge of sensory function, the area is called a sensory or somesthetic cortex. The calcarine or visual cortex is located in the occipital lobe (also termed occipital cortex) and receives visual input. The auditory cortex, localized in the temporal lobe, processes sounds or verbal input. Knowledge of the anatomical projection of fibers of the different tracts and the relative representation of body regions in the cortex often enables doctors to correctly locate an injury and its relative size, sometimes with great precision. Central Structures of the Brain The central structures of the brain include the thalamus, hypothalamus, and pituitary gland. The hippocampus is located in the temporal lobe but participates in the processing of memory and emotions and is interconnected with central structures. Other structures are the basal ganglia, which are made up of gray matter and include the amygdala (localized in the temporal lobe), the caudate nucleus, and the lenticular nucleus (putamen and globus pallidus). Because the caudate and putamen are structurally similar, neuropathologists have coined for them the collective term striatum.

The thalamus integrates and relays sensory information to the cortex of the parietal, temporal, and occipital lobes. The thalamus is located in the lower central part of the brain (that is, upper part of the brainstem) and is located medially to the basal ganglia. The brain hemispheres lie on the thalamus. Other roles of the thalamus include motor and memory control. The hypothalamus, located below the thalamus, regulates automatic functions such as appetite, thirst, and body temperature. It also secretes hormones that stimulate or suppress the release of hormones (for example, growth hormones) in the pituitary gland. The pituitary gland is located at the base of the brain. The pituitary gland produces hormones that control many functions of other endocrine glands. It regulates the production of many hormones that have a role in growth, metabolism, sexual response, fluid and mineral balance, and the stress response.

The ventricles are cerebrospinal fluid-filled cavities in the interior of the cerebral hemispheres.

The Base of the Brain The base of the brain contains the cerebellum and the brainstem. These structures serve complex functions. Below is a simplified version of these roles:

Traditionally, the cerebellum has been known to control equilibrium and coordination and contributes to the generation of muscle tone. It has more recently become evident, however, that the cerebellum plays more diverse roles such as participating in some types of memory and exerting a complex influence on musical and mathematical skills. The brainstem connects the brain with the spinal cord. It includes the midbrain, the pons, and the medulla oblongata. It is a compact structure in which multiple pathways traverse from the brain to the spinal cord and vice versa. For instance, nerves that arise from cranial nerve nuclei are involved with eye movements and exit the brainstem at several levels. Damage to the brainstem can therefore affect a number of bodily functions. For instance, if the corticospinal tract is injured, a loss of motor function (paralysis) occurs, and it may be accompanied by other neurologic deficits, such as eye movement abnormalities, which are reflective of injury to cranial nerves or their pathways in the brainstem.

The midbrain is located below the hypothalamus. Some cranial nerves that are also responsible for eye muscle control exit the midbrain. The pons serves as a bridge between the midbrain and the medulla oblongata. The pons also contains the nuclei and fibers of nerves that serve eye muscle control, facial muscle strength, and other functions. The medulla oblongata is the lowest part of the brainstem and is interconnected with the cervical spinal cord. The medulla oblongata also helps control involuntary actions, including vital processes, such as heart rate, blood pressure, and respiration, and it carries the corticospinal (that is, motor function) tract toward the spinal cord.



Meninges Three connective tissue membranes, the meninges, surround and protect the brain and spinal cord. The most superficial and thickest of the meninges is the dura mater. The dura mater around the brain is tightly attached to the periosteum of the skull to form a single functional layer. The second meningeal layer is the very thin and wispy arachnoid mater. The space between the dura mater and arachnoid mater is the subdural space, which is normally only a potential space containing a very small amount of serous fluid.

III. Pathophysiology Chronic Subdural Hematoma A Risk factors:subdural hematoma is a collection of blood between the brain and its outer lining (the Causes (injuries): agedura mater).Subdural hematomas typically develop when trauma to the head causes the tiny older than 60 years Sports injuries veins that connect the brain to the dura mater (known as bridging veins) to tear and leak blood. alcohol abuse Vehicular accidents use of anticoagulant drugs Falls SYMPTOMS Objects fall on head bleeding disorders Blow on head male gender subdural hematoma, bleeding develops much more slowly--usually over weeks With a chronic or months. Symptoms are similar to those of acute subdural hematoma but tend to be milder and subtler and can include: TRAUMA

Headache; • Memory loss; • Primary Damage problems; and Balance or vision (direct) • Personality changes. Skull fractur e Tissue compress ed by bone Tissue lacerated by bone fragment Contusio n Brain motion

Secondary Damage

Rotation of brain and shearing of tissue

Additional counterco up injury

Bleeding Inflammation and Edema Hematoma Possible Infection

Tissue damage and bleeding

Edema and minor bleeding

Tissue damage and bleeding

Increased Intracranial Pressure

Compress brain stem

Compress blood vessel

Respiratory and cardiovascular

Loss of Vital Functions

Ischemia and Necrosis

IV. OR Procedure Emergency Left Frontoparietal Burr-hole Craniostomy For Evacuation of Chronic Subdural Hematoma

The first illustration shows the pre-operative condition in a left lateral view of the brain, indicating an acute left fronto-parietal subdural hematoma. The second illustration shows the hemorrhage in a cut-away view of the brain from above. The third illustration shows the first step in the procedure, including the creation of two 5 cm incisions into the left side of the head. The fourth illustration is an enlargement of the surgical area, showing the drilling of a hole through the skull at each incision site. The fifth illustration shows the evacuation of the blood from the surface of the brain. Procedure description A burr hole for subdural hematoma is performed to remove a hemorrhage (blood clot) from around the surface of the brain. The location of the blood clot is beneath the firm covering of the brain known as the dura mater, and is therefore called subdural hematoma. Generally, when a blood clot is moderately old (at least two to three weeks), it may be drained through a small hole in the skull, and a large craniotomy flap (opening in the skull) might be avoided.

The patient will be taken to the operating room and put to sleep under general anesthesia. The head will be partially shaved, to expose the area of operation. The head may simply rest on towels, or it may be placed in three fixation points (Mayfield head pins). The area where surgery is to be performed is then "prepped and draped" using an antibiotic solution. Next, the surgeon will make an incision, and reflect the scalp over the area of the hematoma. Then, an air powered drill is used to make a hole in the skull. The dura mater (tough covering of the brain) is then opened. The hematoma (blood clot) is now seen, and the surgeon will irrigate some of it out, and may pass a drain around the brain to provide postoperative drainage. The surgeon will then close the scalp. Procedure Risks A. Risks related to the operative site: Surgical Exposure: The patient is placed in a supine position (on their back). There is risk of non healing of the scalp post operatively. Although very uncommon, there can be injury to or tearing of the scalp from the pins on the Mayfield clamp. Brain injury: The surgery involves exposure of the surface of the brain. There is the possibility that there may be injury to the brain. If so, this could result in weakness, seizures, stroke, paralysis, coma or death. There may be residual fluid or blood, requiring additional surgery in the future. If the fluid around the brain is loculated in pockets separated by membranes, then the surgery will be unlikely to remove all the fluid, and may in fact only remove a small portion. This would necessitate additional surgery, possibly a larger craniotomy to remove the membranes and blood. General Risks: These include such general difficulties, such as bleeding, infection, stroke, paralysis, coma and death. Incisions on the low back generally heal well, but if could be tender, or may heal in an unpleasant manner. There is also the possibility that the surgery may not relieve the symptoms for which the procedure was performed. The problem for which the surgery was performed may recur, requiring additional surgery in the future. In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases. B. Risks of Anesthesia: Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if it given.

Anesthesia Agent: sevorane


OR Technique 1. Induction of anesthesia 2. Asepsis and Anti-sepsis 3. Linear incision over Left Frontoparietal area down to periosteum 4. Burr-hole craniotomy 5. Cruciate dural opening 6. Evacuation of chronic subdural hematoma 7. Irrigation of normal saline 8. Homeostasis 9. Placement of Jackson Pratt 10. Closure layer by layer MS- skin Vicryl- periosteum Suture technique: interrupted 11. Site dressing Instruments Knife handle #3 Knife handle #7 Tissue forceps Thumb forceps Mosquito Allis Towel clip Kidney basin Medicine cup Needle holder Mayo scissors Metzembaum Straight mayo scissors Cautery tip P Freer Periosteal elevator Curette Gooseneck 2 1 2 1 28 18 16 1 2 4 1 1 1 1 1 3 1 1 Adsons Uretrals Weitlaner ST Hudson with 9 burrs Needles: Round Cutting Intestinal Suture: MS 2-0 MS 4-0 Vicryl 2-0 Others: Asepto syringe Jackson Pratt Stapler Bonewax OS (2/3’s and 24’s) Razor 2 2 2

VII. REFERENCES: Nursing 2008 Drug Handbook Pathophysiology of the Systems Nursing Care Plans by Doenges Essentials of Anatomy and Physiology by Seeley, Stephens, Tate,template&cpid=1706

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