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 brains 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), 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 weakness and decreasing levels of consciuosness including disorientation, loss of memory, hallucinations, psychotic behavior and comma;

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 patients 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 ones 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 rubberindustry 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 the of consciousness, also confusion, bulging dizziness, fontanels, nausea, lack of coordination, or numbness. A high pitch cry is a late sign of increased ICP. Typically, infant displays 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 Alzheimers 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 Alzheimers 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 bodys 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 Cushings 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 patients 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 patients 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 23 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 710 days after surgery in the doctors 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 complications related to a craniotomy may include:

to anesthesia. Specific

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 S> O > the patient may manifest: > guarded/protect ive behavior > sleep disturbance > irritability > restlessness

Nursing Diagnosis Acute pain

Scientific Explanation 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 longermore than 6 hours and often more than

Objectives Short Term: After 4 hours of NI, the patient will report relief from pain

Nursing

Rationale

Expected Outcome Short Term: The patient

Interventions >Establish rapport > to gain patients trust >Assess pt. general condition >observe patients non verbal cues such as facial > to have a baseline data > indicates need for further evaluation

should have demonstrated report relief from pain Long Term: The patient should have

Long Term: After 2 days of NI, the patient will be able to demonstrate actions of pain

expression >monitor vital signs

> usually altered been able to in acute pain >to provide nonactions of pain relieved.

12 hours. The >facial grimace 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

relieved.

>provide comfort measures such as back rubs providing diversional activities, and massages

pharmacologic pain management

>To assess contributing >Perform comprehensive assessment to pain. >To rule out worsening of condition. >Perform pain assessment each time pain occurs, note changes from previous >Help in factors to pain

the lower part of the right shoulder blade or to the back.

reports

alleviating anxiety and relieve pain.

>Make time to listen and maintain frequent contact with patient. >Provide adequate rest periods. >To prevent dehydration & promote wound healing >Encourage and instruct to increase fluid intake. >To increase the bodys resistance against possible complication. >To prevent fatigue that will worsen the pain

>Encourage and instruct patient to eat nutritious foods.

>Sufficient rest is necessary to limit the pain.

>Suggest patient to assume position of comfort while in bed. Promote bedrest as indicated. >To facilitate >Encourage diversional activities pain tolerance. >To distract the patient & reduce pain

>Administer analgesics as

ordered.

Cues S> O > the patient may manifest: >lack of cooperation >irritability during Nis >avoidance

Nursing Diagnosis Fear r/t unfamiliarity to environmental experiences (medications and nursing interventions)

Scientific Explanation Fear is characterized by significant anxiety induced by exposure to certain social or performance situations, often resulting in avoidance.

Objectives Short Term: After 4 hours of NI, the patient will display appropriate range of feelings and lessened fear.

Nursing Interventions >Assess patients general condition > monitor vital signs

Rationale >to have a baseline data

Expected Outcome Short Term: The patient should have displayed

>to have a >provide comfort measures > to provide nonpharmacologic pain baseline data

appropriate range of feelings and lessened fear.

Long Term: After 2 days of NI, the patient will be able to lessened her fear

Long Term: The patient should have

>encourage adequate rest period

management

>to prevent >compare verbal & nonverbal responses >to note congruencies or >stay with the patient misperceptions of situations >sense of abandonment can exacerbate >provide fear fatigue

been able to lessened he fear.

Cues S> O > the patient may manifest the following: > inappropri ate or exaggerat ed behavior > unfamiliari ty to

Nursing Diagnosis Deficient Knowledge r/t unfamiliarity with information resources

Scientific Explanation Deificient Knowledge is the absence or deficiency of cognitive information necessary for the make informed choices regarding the condition, treatment or lifestyle

Objectives Short Term: After 3 hours of nursing interventions , the pt. will be able to Exhibit increased me responsibility for own learning and begin to look for information and ask

Interventions Monitor, Assess and Record the Vital Signs of the patient.

Rationale To become aware of any abnormalities and irregularities of the patients vital signs

Expected Outcome Short Term: The pt. shall have exhibited increased interest/assu me responsibility for own learning and begin to look for information and ask question.

Ascertain level of knowledge, including anticipatory needs. To know what is the level of understanding of the person to know what information should be reinforced. Determine clients ability Right timing is

client/SOs to interest/assu

changes. disease condition > inaccurate follow through of instruction The patient may manifest: > incomplian ce to the treatment regimen

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

important in giving information, knowing the clients ability gives the nurse idea on what way will he/she present the information. The pt. shall have initiated necessary lifestyle changes and participate in treatment Personal Factors are important in learning, because learning is regimen. Long Term:

Noted personal factors

Determine Barriers to learning

individualized To make some techniques to

avoid being affected by Identify motivating factors for the individual Provide information relevant to the situation Determine patients most urgent need Knowing to prioritize the Recognize level of achievement, patients learning needs increases the To let the client know about the present situation. This will help the individual to learn those barriers

time factors, and short term and long term goals

effectivity of the teaching plan To know what are the purpose of the patient teaching

Cues S>

Nursing Diagnosis Risk for

Scientific Explanation 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.

Objectives

Nursing Interventions

Rationale

Expected Outcome

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

>to obtain baseline data

Short term: The pt. shall have identified

O> patient may manifest: >afebrile >pale palpebral conjunctiva >pale oral mucosa >good skin turgor >good capillary

Infection related to inadequate primary defense

>a first line defense against nosocomial infections/cross contamination

interventions to reduce/prevent risk of infections

>cleanse sites daily and prn with povidone iodine or other

>to prevent

Long Term: The pt. shall have demonstrated techniques,

insertion/incision infection

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 >to avoid bladder distention

lifestyle changes to promote safe environment.

>change dressings daily and prn >encourage

>to prevent soiling

>to prevent

early ambulation pressure ulcers >instruct client in techniques to protect the integrity of the skin, care for lesions, and >to have knowledge of the continuity of care and for the client to be

>poor skin turgor

prevention of spread of infection. >emphasize necessity of

dependent from care

>premature of treatment when client begins to feel well may result in return of infection

taking antibiotics discontinuation

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/c7a615f059259110Vgn VCM1000005220720a____ http://findarticles.com/p/articles/mi_m0FSL/is_6_85/ai_n19312267/? tag=content;col1 http://www.thinknursing.com/nursing_midwifery/pathways/perioperative