INTRODUCTION

In the past, the earliest evidence of craniotomy is most likely found in the procedure called
trephination, which is basically an antiquated medical intervention in which a hole is drilled or
scraped into the human skull exposing the dura mater in order to treat health problems
concerning intracranial diseases. Cave paintings also indicate that people believed such
practice would cure epileptic seizures, migraines, and mental disorders. It was also suggested
that it was a primitive, if not the oldest, emergency surgery for head wounds (Dangod, 2014).
In modern medicine, it is a treatment used for epidural and subdural hematomas and for
surgical access for certain other neurosurgical procedures, such as intracranial pressure
monitoring. Modern surgeons generally use the term craniotomy for this procedure. The
removed piece of skull is typically replaced as soon as possible. If the bone is not replaced, then
the procedure is considered a craniectomy (Dangod, 2014).
Today, as contemporary era comes in, it has evolved to craniotomy per se, or
considering the words etymology, the surgical cutting of the cranium. A craniotomy is a surgical
operation in which part of the skull, called a bone flap, is removed in order to access the brain.
Craniotomies are often a critical operation performed on patients suffering from brain lesions or
traumatic brain injury (TBI), and can also allow doctors to surgically implant deep brain
stimulators for the treatment of Parkinsons disease, epilepsy, and cerebellar tremor. The
procedure is also widely used in neuroscience for extracellular recording, brain imaging, and for
neurological manipulations such as electrical stimulation and chemical titration.
Because craniotomy is a procedure that is utilized for several conditions and diseases,
statistical information for the procedure itself is not available. However, because craniotomy is
commonly performed to remove a brain tumor, statistics concerning this condition are given.
Approximately 90% of primary brain cancers occur in adults, more commonly in males between
55 na d65 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 100,000).

Current Trends about the Disease Condition

Blunt cerebrovascular injuries can be diagnosed using whole body 16 multi-detector CT
(MDCT); there's no need for an additional neck MDCT angiography examination according to a
recent study conducted by researchers at the University of Maryland Medical Center and R.
Adams Cowley Shock Trauma Center, both in Baltimore, MD. The study showed that whole
body MDCT is just as accurate as neck MDCTA. Blunt cerebrovascular injuries are uncommon

but potentially devastating injuries that can lead to stroke and death. These include dissections,
pseudoaneurysms, and arteriovenous fistulae.
For the study, the researchers identified 108 blunt trauma patients that were examined
with either whole-body MDCT or neck MDCTA followed by angiography over a 23-month period.
From this group, 77 whole body MDCT and 48 neck MDCTA examinations were compared with
the results that were pulled from the reports of correlative angiography.
According to the study, angiography confirmed blunt cerebrovascular injuries in 83
patients with 25 of those showing injury to more than one of the four major arteries (carotid or
vertebral). In the neck, where injuries were most common, each technique showed low
sensitivity for blunt carotid (69% for whole-body MDCT and 64% for MDCTA) and blunt vertebral
artery injuries (74% for whole-body MDCT and 68% for MDCTA), but specificities were high for
both carotid (82% for whole-body MDCT and 94% for MDCTA) and vertebral artery injuries
(91% for whole-body MDCT and 100% for MDCTA). The two techniques diagnosed blunt
cerebrovascular injuries with statistically comparable accuracy. Routine use of whole-body
MDCT would facilitate diagnosis and treatment of asymptomatic blunt cerebrovascular injuries
in

patients

without

typical

risk

factors

for

injuries.

(Accessed

on:

http://www.eurekalert.org/pub_releases/2008-03/arrs-wbm032808.php)

II.

ANATOMY AND PHYSIOLOGY

The brain and spinal cord make up the central nervous system (CNS). The CNS controls
all the functions of the body such as vision, taste, touch, muscle movement, breathing, thought,
behavior, memory, and emotion. Every process in the body is affected by the brain.
What are the different sections of the brain?

A. Gray Matter
A general term for concentrations of nerve cell bodies. A nucleus (such as the red
nucleus or abducens nucleus) is a definable group of cell bodies in the central nervous
system (CNS). The cerebral and cerebellar cortices are layered arrangements of cell
bodies on the surface of the cerebrum and cerebellum. A ganglion is a collection of cell
bodies in the peripheral nervous system (PNS).
B. White Matter
A general term for collections of axons. A tract is a bundle of axons that originates and
terminates within the CNS. Other examples of axonal groupings in the CNS are
funiculus, fasciculus, lemniscus, peduncle, or column. Commissures (anterior, posterior,
corpus callosum) are collections of axons in the CNS that interconnect symmetrical
structures in both halves of the brain. Decussations are axons that cross the midline to
terminate on the contralateral side. Nerves are axons passing between the CNS and
PNS.
C. General Organization

The gross anatomy of the brain is organized by embryonic regions. Each region relates
to neural structures that develop from the walls of the brain vesicles. There are five
regions. The telencephalon, diencephalon and mesencephalon are related to brain
vesicles of the same name. The metencephalon and myelencephalon are regions
related to the rhombencephalic vesicle. Each vesicle develops into a ventricle in the
mature brain. The major structures that develop in each region are listed below.(Fig.
11.3)

II. TELENCEPHALON
A. Cerebral Hemispheres
The two cerebral hemispheres are joined together by the corpus callosum. The
hemispheres have lateral and medial surfaces and frontal, temporal and occipital poles. The
surfaces are enfolded forming gyri (convexities) and sulci and fissures.
1. Lateral surface
The lateral surface of the cerebral hemispheres are divided into lobes by sulci, fissures
and imaginary lines. The principal sulci on the lateral surface of the hemisphere are the
central sulcus, which divides the frontal from the parietal lobes, and the lateral
(Sylvian) fissure which divides the temporal lobe from the fronto-parietal lobes.
Posterior parts of the parietal and temporal lobes are divided from the occipital lobe by
an imaginary line drawn from the preoccipital notch on the basal surface of the
hemisphere to the superior part of the parieto-occipital sulcus on the medial wall of the
hemisphere. A primary functional area is localized in each lobe.
2. Medial surface
The medial surface is made up of the medial extensions of the frontal, parietal, temporal
and occipital lobes. In addition, gyri of the limbic system form a central ring of cortex
bordering the corpus callosum and rostral parts of the brainstem. The cingulate gyrus
lies just above the corpus callosum. It is separated from the frontal lobe and anterior
parts of the parietal lobe by the cingulate sulcus. The parahippocampal gyrus is
located on the ventromedial surface of the temporal lobe. The fornix, a major tract of the
limbic system, can be seen in a medial view of the cerebral hemisphere. The fornix
originates from the hippocampus, limbic cortex buried within the temporal lobe. The
limbic system is associated with emotional behaviors. Two other important sulci seen on
the medial surface are the parieto-occipital sulcus, which forms the border between
these lobes, and the calcarine sulcus which is a landmark for the primary visual cortex.

3. The lobes of the telencephalon

a. Frontal lobe
The precentral gyrus is the location of the primary motor cortex. It is somatotopically
organized (body mapped) in a mediolateral direction (See, Fig. 11.28). Cortical areas
controlling the foot muscles are represented on the medial wall of the hemisphere and
cortical areas controlling face, jaw, tongue and laryngeal muscles (muscles important in
production of speech) are located laterally near the lateral fissure. Anterior to the speech
musculature representation in the primary motor cortex is the speech association cortex
called Broca's speech area.
b. Parietal lobe
The postcentral gyrus is the primary cortical receiving area for somatosensory input from
skin and muscle receptors of the body and head. Like the precentral gyrus, the
postcentral gyrus is somatopically organized in the mediolateral direction, with cells in
the medial portion of the gyrus responding to tactile stimulation of the foot and cells in
the lateral part of the gyrus responding to tactile stimulation of the face, jaw, and tongue.
c. Occipital lobe
The boundary between the parietal and occipital lobes is not clear cut on the gross brain,
but in general it is considered to be a hypothetical line drawn from the parieto-occipital
fissure dorsally to the preoccipital notch ventrally. The neocortex of the occipital lobe
which surrounds the calcarine sulcus is the receives visual input.
d. Temporal lobe
The primary cortical area for auditory input is located on the superior temporal gyrus
buried within the lateral fissure. Note that the temporal lobe has middle and inferior
gyri as well. The cortex at the junction of the temporal and parietal lobes posterior is
known as Wernicke's speech area. In most individuals, Broca's and Wernicke's are
larger on the left side. This asymmetry probably underlies the hemisphere lateralization
of the expressive functions of language. For this reason, the left hemisphere is often
called the dominant hemisphere.
B. Commissures
The two cerebral commissures, the corpus callosum and the anterior commissure,
are sectioned in a midsagittal cut between the two hemispheres. The corpus callosum
interconnects most of the cerebral hemispheres but the anterior interconnects the
anterior temporal lobes and olfactory structures.

C. Internal Capsule
The internal capsule is a large white matter channel of axons projecting to and from the
cerebral cortex. It is divided into two parts, the anterior limb which contains fibers related
to the frontal lobe and posterior limb which contains fibers from the caudal lobes. The
anterior limb divides the caudate and putamen nuclei. The posterior limb passes
between the thalamus and the globus pallidus. Cells in the thalamic nuclei contribute
most of the axons in the internal capsule that terminate in the cerebral cortex.
D. Lateral Ventricles
The lateral ventricles are the C-shaped ventricular cavities in each hemisphere. Each
lateral ventricle is divided into an anterior horn associated with the frontal lobe, a
posterior horn deep to the occipital lobe and an inferior horn in the temporal lobe. The
anterior horns are separated by a thin, non-neural membrane called the septum
pellucidum.

III. DIENCEPHALON
A. Thalamus
The dorsal thalamus is an egg-shaped mass of nuclei that project topographically to the
cerebral cortex. These nuclei relay visual, auditory, somatosensory, motor, and
multimodal information. A thalamus on one side is bordered laterally by the internal
capsule and medially by the third ventricle. A thin layer of ependyma separates the
dorsal part of the thalamus from the lateral ventricle.
B. Hypothalamus
The hypothalamus is a small region containing nuclei associated with limbic and
vegetative functions such as appetite, thirst, temperature regulation, sex, and
aggression. The hypothalamus is located ventral and rostral to the thalamus. The caudal
boundary is marked by the mammillary bodies. The rostral nerve and tract is a derivative
of the diencephalon. The stalk of the pituitary, the infundibulum, arises from the ventral
surface of the hypothalamus and angles rostralward. Hypothalamic neurons exert much
of their influence by neuronal and vascular signals to the pituitary.
C. IIIrd Ventricle

The third ventricle forms a narrow slit between the thalami and hypothalami. It
communicates with the lateral ventricles by the interventricular foramen (of Monro). It
forms two recesses above the optic tract and infundibulum.

IV. MESENCEPHALON (MIDBRAIN)

A. Tectum
The tectum forms the roof of the cerebral aqueduct, the ventricular cavity of the
midbrain. It consists of the superior and inferior colliculi which function in reflexive
movements of the head and eyes to sudden visual and auditory stimuli, respectively.
B. Mesencephalic Tegmentum
The region ventral to the cerebral aqueduct is the tegmentum. It contains cranial nerve
nuclei III, IV, and two important nuclear complexes of the motor system, the red nucleus
and the substantia nigra. In the core of the midbrain tegmentum is the reticular
formation.
C. Cerebral Peduncles
The cerebral peduncles (Basis Pedunculi) are located in the most ventral part of the
midbrain. They contain axons whose cell bodies are located in the precentral gyrus.
V. METENCEPHALON
A. Pons
The pons is composed of the pontine tegmentum and pontine nuclei. The tegmentum is
a continuation of the midbrain tegmentum. It contains both ascending and descending
tracts, several cranial nerve nuclei including those of the V, VII, and VIII nerves, and the
reticular formation. The pontine nuclei are located ventral to the tegmentum. They are
clumps of cells. Longitudinally oriented bundles of axons in the pons are continuous with
axons in the cerebral peduncles. Many of these longitudinal bundles will collect to form
the pyramids of the medulla
B. Cerebellum
The cerebellum consists of a cortex and cerebellar nuclei embedded within the
subcortical white matter. Axons going to a from the cerebellum pass by way of the
cerebellar peduncles. The inferior cerebellar pedunclei carries input from the spinal cord
and vestibular system and output to the brainstem. The middle cerebellar peduncle
carries input from the pontine nuclei and the superior cerebellar pedunclei carries mostly
output from the cerebellar nuclei to the midbrain and thalamus.

VI. MYELENCEPHALON
A. Medulla Oblongata
The myelencephalon is synonymous with the medulla oblongata. The medulla is
continuous with the pontine tegumentum and spinal cord. The medulla can be divided by
its relation to the fourth ventricle and central canal. The rostral, "open" medulla is related
to the fourth ventricle. Cranial nerve nuclei (V, VIII, IX, X, XII) lie ventral to the ventricular
floor. The "closed" medulla surrounds the central canal which continues into the spinal
cord. Some of the same cranial nerve nuclei which appear at rostral levels are found in
dorsal parts of this medullary level. In addition, two somatosensory tracts (gracilis and
cuneatus) and related nuclei form raised tubercles on the dorsal surface. An important
structure on the ventral surface of the medulla is the pyramids, located just lateral to the
midline. A pyramid is a collection of axons which originates from cortical cell bodies.
These axons descend into the internal capusle, cerebral peduncle and pons before they
form the pyramids. At the spino-medullary junction the pyramidal axons decussate to the
contralateral side enroute to all levels of the ventral horn of the spinal cord. The XII
cranial nerve exits between the inferior olive and the pyramid on each side.
The Cardiovascular System
The heart, blood vessels and the
blood make up the cardiovascular system.
The

human

contraction,

heart,
provides

through
the

rhythmic
pressure

necessary to propel blood through the

body. Blood flow is essential to deliver
nutrients to the tissues of the body and to
transport metabolic wastes including heat
to removal sites. The presence of an
arterial pulse, caused by the beating of
the heart, is appropriately designated as a
vital sign.
The heart weighs about 300 grams and is located within the mediastinum. It is coneshaped and tilted forward and to the left. Because of a rotation in orientation during fetal
development, the apex of the heart (tip of the cone) is at its bottom and lies left to the midline.
The base is at the top, where the great vessels enter the heart, and lies posterior to the

sternum. The heart consists of four chambers: two smaller atria at the top (the base) of the heart
and two larger ventricles at the apex. A band of fibrous tissue separates the atria from the
ventricles and seats the four cardiac valves. A muscular septum separates the right from the left
atrium and the right from the left ventricle.
Functionally, the heart is actually two pumps working simultaneously. The right atrium
and right ventricle generate the pressure to propel the oxygen-poor blood through the pulmonic
circulation (right side of the heart pumps blood to the lungs and back to the left side of the
heart); the left atrium and left ventricle propel oxygen-rich blood to the remainder of the body
through the systemic circulation (left side of the heart pumps blood to all other tissues of the
body and back to the right side of the heart).
At rest, each side of the heart pumps
approximately 5000ml (5L) of blood
per minute (cardiac output). This is
accomplished
frequency

by

(heart

contraction

rate)

of

72

beats/minute, with each contraction

ejecting a volume of 70 ml (stroke
volume) into the atrial system. Cardiac
output can increase five-fold during
exercise as a result of increases in
both heart rate and stroke volume.
The functions of the heart are:
1. Generating

blood

pressure.

Contractions of the heart generate

blood pressure, which is required
to force blood through the blood
vessels.
2. Routing
separates

blood.
the

The
pulmonary

heart
and

systemic circulations, which ensures the flow of oxygen-rich blood in the tissues.
3. Ensuring one-way blood flow. The valves of the heart ensure a one-way blood flow through
the heart and the blood vessels.
4. Regulating blood supply. Changes in the rate and force of heart contraction match blood
flow to the changing metabolic needs of the tissues during rest, exercise and changes in
body position.
9

Structure of the Heart

Summary of the Structure and Functions of the Heart
Structure
Function
Pericardium
Two-layered case that encases and protects heart
Atrium
Upper receiving chambers of the heart
>Right Atrium
>Receives deoxygenated systemic blood via superior and inferior
vena cava; passes to the right ventricle
>Left atrium

Ventricles
>Right ventricle

>Receives oxygenated blood from lungs; blood passes to the left

ventricle
Lower, pumping chamber of the heart
>Receives blood from atrium via tricuspid valve; pumps it to the
pulmonary circulation

>Left ventricle

>Receives blood from the atrium via mitral valve; pumps it to the

Cardiac Valves
>Tricuspid and bicuspid

systemic circulation
Prevent backflow of blood
>Prevent backflow from the right ventricle to the right atrium and

(mitral) valves

from the left ventricle to the left atrium, respectively

>Semilunar valves

>Prevent backflow from pulmonary artery to right ventricle

(pulmonary semilunar) and from aorta to left ventricle (aortic

Coronary Arteries
>Right coronary artery

semilunar)
Supply blood to the heart
>Perfuses right atrium, right ventricle, inferior portion of the left
ventricle and posterior septal wall, SA node and AV node

>Left coronary artery

>Supplies blood to anterior wall of left ventricle, anterior ventricular

septum, and apex of the left ventricle

>Left anterior descending

artery

>Supplies blood to left atrium, lateral and posterior surfaces of the

left

ventricle,

occasionally

posterior

interventricular

septum;

sometimes supplies SA and AV nodes

Circumflex artery
>SA node

>pacemaker node; initiates heartbeat by generating an electrical

impulse

10

>AV node

>Normal pathway for impulses originating in atria to be conducted to

AV

ventricles; can be a secondary pacemaker

Rapidly transmit cardiac action potentials to enable synchronous

bundle,

branches,

bundle
Purkinjes

contraction of the ventricles

fibers
Layer of the Heart
The heart consists of three distinct layers
of

tissue:

endocardium,

myocardium

and

epicardium. The endocardium (innermost layer)

consists of thin endothelial tissue lining and the
inner chambers and the heart valves. The
myocardium (middle layer) consists of striated
muscle fibers forming interlaced bundles and is
the actual contracting muscle of the heart. The
epicardium or visceral pericardium covers the
outer surface of the heart. It closely adheres to
the heart and to the first several centimeters of the pulmonary artery and aorta.
The visceral pericardium is encased by the parietal pericardium, a tough, loose-fitting,
fibrous outer membrane that is attached anteriorly to the lower half of the sternum, posteriorly to
the thoracic vertebrae, and inferiorly to the diaphragm. Between the visceral pericardium and
the parietal pericardium is the pericardial space, which holds 5 to 20 ml of pericardial fluid. This
fluid lubricates the pericardial surfaces as they slide over each other when the heart beats.
Excessive fluid accumulation in the pericardial space can diminish the filling of the ventricles
(cardiac tamponade).

Chambers of the Heart

The heart consists of four chambers: two upper collecting chambers (atria) and two
lower pumping chambers (ventricles). A muscular wall (septum) separates the chambers of the
right side from those of the left side. The right atrium receives deoxygenated blood from the
body. The blood moves to the right ventricle, which pump it to the lungs against low resistance.
The left atrium receives oxygenated blood from the lungs. The blood flows into the left ventricle
(the hearts largest, most muscular chamber), which pumps it against high resistance into the
systemic circulation.

11

Cardiac Valves
The cardiac valves are delicate, flexible structures that consist of fibrous tissue covered
by endothelium. They permit only unidirectional blood flow through the heart. The valves open
and close passively, determined by pressure gradients between the cardiac chambers. Leaky
valves that do not seal when closed are caller regurgitant or insufficient. Stiff valves that
cannot open completely are called stenotic.
Cardiac valves are of two

tyoes:

1.

Atrioventricular

(AV);

and

2.

Semilunar.Atrioventricular valves lie between the atria and the ventricles. The tricuspid valve on
the right side, is composed of three leaflets. The mitral valve (biscuspid), on the left, is
composed of two. Attached to the edges of the AV valves are strong fibrous filaments called
chordae tendinae, which arise from papillary muscles on the ventricular walls. The papillary
muscles and chordae tendinae work together to prevent the AV valves from bulging back into
the atria during ventricular contraction (systole).
The semilunar valves consists of three cup-like cusps that open during ventricular
contraction and close to prevent backflow of blood into the ventricles during relaxation
(diastole). Unlike the AV valves, the semilunar valves open during ventricular contraction. The
pulmonic semilunar valve (right ventricle to pulmonary artery) and the aortic semilunar valve (left
ventricle to aorta) do not have papillary muscles.
Cardiac Blood Supply
The heart muscle requires a rich oxygen supply to meet its own metabolic needs. The
coronary arteries (right and left) branch off the aorta just above the aortic valve, encircle the
heart, and penetrate the myocardium.

12

Contraction of the muscle of the left ventricle generates enough extravascular pressure
to occlude the coronary blood vessels and prevent the backflow to the muscle of the heart
during ventricular systole. Thus 75% of the coronary artery blood occurs during diastole, when
the heart is relaxed and resistance is low.For adequate blood flow through the coronary arteries,
the diastolic blood pressure must be at least 60 mm Hg. Coronary blood flow increases with
increased heart workload (e.g., exercise). The coronary veins return blood from most of the
myocardium ti the coronary sinus of the right atrium. Some areas, particularly on the right side
of the heart, drain directly into the cardiac chambers.
Functions of the Heart
Electrophysiologic Properties
The

electrophysiologic

properties of cardiac muscles regulate

the heart rate and rhythm. These
properties

include

automaticity,

excitability,
contractility,

refractoriness and conductivity.

Excitability
The ability of cardiac muscle
cells to depolarize in response to a
stimulusexcitabilityis influenced by
hormones,

electrolytes,

nutrition,

oxygen supply, medications, infection

and autonomic nerve activity.
In myocardial cells, as
in other types of muscle and neurons, differences in intracellular and extracellular ion
concentrations create electrical and concentration gradients for ionic movement across the
semipermeable cell membrane. At rest, the inside of the myocardial cell is more negative than
the outside. The resting membrane potential results primarily from the differences in
concentrations of potassium and sodium ions. Although both positive ions are present on either
side of the cell membrane, potassium has greater intracellular concentration and sodium has a
greater extracellular concentration. Selective channels can increase membrane permeability for
specific ions, allowing the ion to move down the electrochemical gradient and to alter the resting
membrane potential.

13

When the cardiac cell is stimulated to a certain threshold, a sequence of ion permeability
changes cause a dramatic change in the transmembrane potential; this is known as the action
potential. The action potential consists of depolarization and repolarization phase. The
electrocardiogram

(ECG)

reflects

currents

generated

during

the

depolarization

and

repolarization of regions of the heart.

Depolarization is caused by an increase in cell membrane permeability to sodium. The
cell returns to its resting (relaxed) state during repolarization. Sodium permeability drops
sharply, and potassium permeability increases, returning the membrane to the negative resting
potential. In the process of depolarization and repolarization, small amounts of sodium leak into
the cell and potassium leaks outward. The cell compensates for this by actively pumping sodium
back out and potassium inward (using the enzyme NA, K-ATPase).
Other ions, such as calcium and chloride, also play a role in the action potential and the
contraction it causes. For the heart, calcium is especially important because it initiates
contraction. During depolarization, myocardial cell membrane permeability to calcium increases
and calcium moves into the cell. The inward Ca++ flux triggers the release of more calcium
stored in the sarcoplasmic reticulum. As the intracellular concentration of calcium increases,
calcium reacts with contractile proteins and myocardial muscle fibers contact.
Automaticity (Rhythmicity)
The ability of cardiac pacemaker cells to initiate an impulse spontaneously and
repetitively, without external neurohormonal control, is known as automaticity, or rhythmicity.
Given the proper conditions, the heart can continue to beat outside the body. In contrast,
skeletal muscle must be stimulated by a nerve to depolarize and contract. The sinoatrial (SA)
node pacemaker cells have the highest rate of automaticity of all cardiac cells, and thus govern
the heart rate.
The conduction tissue area with the highest automaticity, or rate of spontaneous
depolarization, assumes the role of the pacemaker. SA node automaticity is due to the changes
in ionic permeability of membrane. Even at rest, a decreasing potassium permeability and
increasing slow channel permeability (for NA+ and Ca++ ions) move the cell membrane
potential more positively toward threshold voltage. When threshold is reached, the cell initiates
an all-or-non action potential. Norepinephrine and acetylcholine cause heart rate to increase
and decreases, respectively. The rate of spontaneous depolarization can also be affected by
other hormones, body temperature, drugs, and disease.
Contractility
The heart muscle is composed of long, narrow cells or fibers. Cardiac muscle fibers, like
striated skeletal muscle, contain myofibrils, Z bands, sarcomeres, sarcolemmas, sarcoplasm,

14

and sarcoplasmic reticulum. Contraction results from the same sliding filament mechanism
described for skeletal muscle.
The action potential initiates the muscle contraction by releasing calcium through the T
tubules of the cell membrane. The calcium reaches the sarcoplasmic reticulum, causing
additional calcium release. The intracellular calcium diffuses to myofibrils, where it binds with
troponin. When the actin filaments become activated by calcium, the heads of the cross-bridges
from the myosin filaments immediately become attracted to the active sites of the actin.
Contraction then occurs by power stroke repetition. After contraction, free calcium ions are
actively pushed back into the sarcoplasmic reticulum, and muscle relaxation begins.
One important difference between cardiac and skeletal muscle is that cardiac muscle
needs extracellular calcium. All the calcium involved in skeletal muscle comes from the
sarcoplasmic reticulum. In cardiac muscle, however, extracellular calcium enters through the T
tubules and triggers the release of more calcium from the sarcoplasmic reticulum. Because of
this, calcium-channel blockers can alter contraction of the heart, but not the contraction of
skeletal muscle.
Refractoriness
Refractoriness is the hearts inability to respond to a new stimulus while still in a state of
depolarization from an earlier stimulus. Refractoriness develops when sodium channels of the
cardiac cell membrane become inactivated and unexcitable during an action potential. Thus the
heart muscle does not respond to restimulation, preventing the possibility of tetanic contractions
that are seen in skeletal muscle.
Refractoriness occurs in two periods. The absolute refractory period occurs during
depolarization and the first part of repolarization. During this period, cardiac cells do not respond
to any stimuli, however strong. The relative refractory period occurs in the final stages of
repolarization; refractoriness diminishes and a stronger-than-normal stimulus can excite the
heart muscle to contract. At the end of the refractory period, there is a transient hyperexcitability
(vulnerable period). The sodium channels are reset and the cardiac cells can again conduct
action potentials. The refractory period is the time when the heart chambers are filling with blood
for the next beat.
Normally, the ventricles have an absolute refractory period of 0.25 to 0.3 second, which
approximates the duration of action potential. The relative refractory period for the ventricles
lasts about 0.05 second. The atria have a refractory period of about 0.15 second, and they can
therefore contract rhythmically much more quickly than the ventricles. The durations of the
action potential and the refractory period are not fixed; however, both can shorten as heart rate
increases.

15

Conductivity
Conductivity is the ability of heart muscle fibers to propagate electrical impulses along
and across cell membranes. The heart muscle must conduct the action potential from its origin
throughout the heart both rapidly and smoothly so that the atria and ventricles contract as a unit.
Intercalated disks join adjacent myocardial cells, allowing the action potential to travel over or
entire the muscle mass through gap junctions. The fibrous band of tissue that separates the
atria and ventricles lacks intercalated disks. Therefore, the atria are isolated electrically from the
ventricles except for the normal conduction pathway, including the antrioventricular node.
Cardiac conduction is a sequential depolarization of the following:
Sinoatrial (SA) node
AV node
Bundle of His and bundle branches
Purkinje fibers
Ventricular myocardium
The SA node, or pacemaker, is located at the junction of the superior vena cava and
right atrium. Under normal circumstances, the SA node initiates electrical impulses (heartbeat)
approximately 60 to 100 times per minute, but it can adjust its rate. Three internodal and one
interatrial tract carry the wave of depolarization through the right atrium to the AV node and to
the left atrium, respectively. The sympathetic and parasympathetic nervous systems regulate
the SA node. Any myocardial tissue that generates impulse at a higher rate than the SA node
can become an abnormal, ectopic, pacemaker.
The AV node or AV junction, is located in the lower aspect of the atrial septum. The AV
node can be a secondary pacemaker, but it normally receives electrical impulses from the SA
node and is the only pathway for conduction impulses from the atria to the ventricles. Within the
AV node, the impulse is delayed 0.07 second while the atria contract. This delay enables atrial
contraction to be completed before the ventricles contract.
The common bundle of His in the interventricular septum is relatively short, branching
into right and left segments. The right bundle branch (RBB) courses down the right side of the
interventricular system. The left bundle branch (LBB) bifurcates into anterior and posterior
fascicles, both of which extend into the left ventricle. The right and left bundle branches
terminate in Purkinje fibers.
Purkinje fibers are a diffuse network of conducting strands beneath the ventricular
endocardium; they rapidly spread the wave of depolarization through the ventricles. Activation of
the ventricles begins in the septum and then moves from the apex of the heart upward. Within

16

the ventricular walls, depolarization proceeds from endocardium to epicardium. Repolarization

occurs in each cell and does not involve the conduction system. Repolarization occurs in
reverse order, so that the last cells to depolarize are the first to repolarize. The action potentials
of the Purkinje fibers have the longer duration, and their repolarization is occasionally seen as a
U wave of the electrocardiogram (ECG).
Cardiac Output and Cardiac Index
Cardiac Output (CO) is the volume of blood ejected per minute by rhythmic ventricular
contraction. At the end of ventricular diastole, each ventricle contains approximately 140 ml of
blood (end-diastolic volume [EVD]). Normally, during systole, the heart ejects approximately half
of this volume. The volume ejected with each contraction (heartbeat) of the ventricle is the
stroke volume and ejection fraction. Cardiac output can be calculated as follows:

CO=[ EDV ESV ] x HR

where ESV is the end-systolic volume and HR is the heart rate.
Cardiac output averages between 4 and 8 L/min in adults. For a normal 150-pound (70
kg) adult at rest, cardiac output is 5 to 6 L/min. Adjustments in either stroke volume or heart rate
can compensate the fluctuations in the other, or both can rise or fall to maintain cardiac output.
Cardiac output is commonly measured by thermodilution with the use of a pulmonary
artery (Swan-Ganz) catheter. Several other approaches can also be used, such as obtaining the
heart rate from an ECG and stroke volume through ventricular imaging techniques.
Clinicians compute the cardiac index (CI) from the cardiac output to compensate for
individual differences in the body size:

CI =

Cardiac Output
body Surface Area

The normal cardiac index is 2.5 to 4 L/min/m2.

Stroke volume has a major influence on cardiac output and is determined by (1)
preload, (2) afterload and (3) the contractile state of the heart.
Preload
Preload is the myocardial fiber length of the left ventricle at end diastole. It is determined
by the EDV. The Frank-Starling Law of the heart states that the greater the resting myocardial
fiber length, or stretch, the greater the force of its contraction. Preload therefore increases when
increased EDV (e.g., from increased venous return) subjects myocardial fibers to greater
stretch. The ventricles respond with a greater force of contraction, producing a larger stroke
volume and increased cardiac output. This phenomenon, however, has limits, such as the
greatly distended ventricles characteristic of heart failure.
Afterload
Afterload is the resistance to left ventricle ejection. More specifically, it is the amount of
pressure required by the left ventricle to open the aortic valve during systole and to eject blood.

17

Afterload directly relates to arterial blood pressure and the characteristics of the valve. If arterial
blood pressure is high, the heart must work harder to pump blood into the circulation. Stroke
volume is inversely related to afterload. For example, if afterload increases because of
peripheral vasoconstriction (which increases arterial blood pressure), myocardial fiber
shortening is reduced and ejections are less effective. Then the ventricles cannot eject a normal
stroke volume.

Contractile State
The contractile (inotropic) state refers to the vigor of contraction generated by the
myocardium regardless of its blood volume (preload). Unlike skeletal muscle, the myocardium
can alter contractile velocity and therefore force. The rate of cross-bridge cycling in the
myocardium is calcium dependent, and agents that increase intracellular calcium level thus
increase contractile force. For example, sympathetic stimulation increases myocardial
contractility and ventricular pressure, thereby ejecting blood more rapidly and increasing stroke
volume. Metabolic abnormalities (e.g., hypoxemia) and metabolic acidosis decrease myocardial
contractility, therefore reducing stroke volume.
Cardiac Pressures
With the use of a pulmonary artery pressure (Swan-Ganz) catheter, pressures in the
right atrium, right ventricle, and pulmonary artery can be measured. Inflation of a balloon at the
catheter tip allows measurement of pulmonary capillary wedge pressure (PCWP), an estimate
of left atrial pressure. Assuming normal aortic valve function, arterial systolic pressure reflects
the left ventricular systolic pressur. These pressures are useful in determining factors that
characterize cardiac performance, such as preload, afterload, volume, filling pressures, and
resistance.
Heart Rate
The normal heart rate is 60 to 100 beats/min. Sinus tachycardia is a rate more than 100
beats/min; sinus bradycardia is a rate fewer than 60 beats/min. (The sinus in these terms
indicates that the impulse arose in the sinoatrial node, the normal pacemaker region of the
heart). The intrinsic heart rate is 90 beats/min. At rest the heart rate of 70 beats/min reflects the
dominant control by the parasympathetic nervous system. Variations in heartbeat can be
caused by exercise, the size of the client, age, hormones, temperature, blood pressure, anxiety,
stress and pain.
Arterial Pressure

18

Arterial pressure is the pressure of blood against arterial walls. Systolic pressure is the
maximum pressure of the blood exerted against the artery walls when the heart contracts
(normally 100 to 140 mm Hg). Diastolic pressure is the force of blood exerted against the artery
walls during the hearts relaxation (or filling) phase (normally 60 to 90 mm Hg). Blood pressure
is expressed as systolic pressure/diastolic pressure (e.g., 120/80 mm Hg). Cardiac output is a
key determinant of arterial pressure.
Baroreceptors, Stretch Receptors and Chemoreceptors
Changes in the sympathetic and parasympathetic activity occurs in response to
messages sent from sensory receptors in various parts of the body. Important receptors in
cardiovascular reflexes includes (1) arterial baroreceptors; (2) stretch-sensitive cardiopulmonary
receptors of the atria and veins, and (3) chemoreceptors.
Baroreceptors (pressoreceptors) are stretch-sensitive nerve endings affected by
changes in arterial blood pressure. They are located in the walls of the aortic arch and carotid
sinuses. Increases in arterial pressure stimulate baroreceptors, which send impulses to the
medulla, resulting in heart rate and
arterial pressure decreases (the vagal
response).

When

arterial

pressure

decreases, baroreceptors receive less

stretch and thus send fewer impulses
to the medulla. Then sympatheticmediated increase in heart rate and
vasoconstriction occurs.
Cardiopulmonary

stretch

receptors are located in the terminal

sections of the vena cava and the
atria. These receptors respond to the
length

changes,

which

reflect

circulatory volume status. When blood

pressure decreases in the vena cava and right atrium (e.g., hypovolemia), stretch receptors
send fewer impulses that usual to the central nervous system (CNS). This process results in a
sympathetic response, particularly to the kidney, to enhance salt and water retention over hours
to days. The changes also stimulate the release of antidiuretic hormone (ADH) from the
posterior pituitary. Hypervolemia produces the opposite effects.
Chemoreceptors, found in the aortic arch and carotid bodies, are primarily sensitive to
increased carbon dioxide levels and decreased arterial pH (academia) and secondarily sensitive

19

to hypoxemia. When these changes occur, chemoreceptors transmit impulses to the CNS to
increase heart rate.

20

21

Synthesis of the Disease

A stroke is caused by a blocked or bleeding artery in the brain. Most strokes are due to
blocked arteries that supply blood to the brain and are called ischemic strokes. Strokes due to
bursting of brain blood vessels are called hemorrhagic strokes. Intracerebral hemorrhage is
caused by bleeding into the brain itself, while subarachnoid hemorrhage is due to bleeding
around the base of the brain. A TIA (transient ischemic attack) is caused by a temporary
blockage of blood flow to a blood vessel to the brain lasting less than 24 hours. Another, rarer,
form of stroke can occur when a vein (that drains blood out of the brain) is blocked. This is
called a venous stroke. Ischemic Stroke This type of stroke is caused by blockage of a blood
vessel (artery) supplying the brain. Brain tissue that no longer receives its blood supply can die
within a few hours unless something is done to stop the damage. The blockage of arteries can
occur in large arteries in the neck or the base of the brain, or in small arteries inside the brain
itself. A blood clot can form in the brain or it can form elsewhere and be carried to the brain by
an artery and after having an ischemic stroke and the majority of survivors have some long-term
disability. There are many conditions that increase a persons risk of ischemic stroke. These
include high blood pressure, smoking, heart diseases, diabetes, narrowing of arteries supplying
the brain, high cholesterol and an unhealthy lifestyle. Treating these conditions can decrease
stroke risk.Intracerebral Hemorrhage This type of stroke is caused by the bleeding of a blood
vessel within the brain. As a result of the bleeding a blood clot forms in the brain, which puts
pressure on the brain and damages it. Although intracerebral hemorrhage is less common than
ischemic stroke and it is more serious. The most common cause of intracerebral hemorrhage is
high blood pressure. Another cause, especially in younger people with intracerebral
hemorrhages, is abnormally formed blood vessels in the brain (vascular malformations or
aneurysms). Subarachnoid Hemorrhage Subarachnoid hemorrhage results from the bleeding of
an artery around the base of the brain. It is the least common stroke type, accounting for about
5%of all strokes. The most frequent cause of subarachnoid hemorrhage is bleeding from an
aneurysm. An aneurysm is a weakening and ballooning of a short portion of an artery (similar to
a bubble on the side of an old hose). The factors that can increase a persons risk of this type of
stroke include high blood pressure, smoking, and a family history of burst aneurysms. TIA
(Transient Ischemic Attack) A TIA is like a temporary ischemic stroke. An artery is temporarily
blocked, preventing blood from reaching a part of the brain. This lack of blood flow causes that
part of the brain to stop functioning. The symptoms of a TIA are the same as symptoms of an
ischemic stroke. In a TIA, the blood vessel opens up again, before any permanent injury to the
brain occurs and the patient recovers completely. Most TIA symptoms last less than 30 minutes.
22

People who suffer TIAs are at HIGH RISK OF STROKE soon thereafter. A TIA should lead to
immediate medical evaluation to determine its cause and a treatment plan to prevent a stroke
from following soon after. Venous Stroke Venous stroke is caused by a blood clot blocking the
veins that allow blood to drain out of the brain. (All other strokes are caused by abnormalities of
arteries carrying blood to the brain). Venous stroke causes a back pressure effect that leads to
the stroke. These strokes can be either ischemic or hemorrhagic. Some causes of venous
stroke include severe dehydration, severe infection in the sinuses of the head and medical or
genetic conditions that increase a persons tendency to form blood clots.

NON- PRECIPITATING FACTORS

AGE

Advancing age is one of the most significant risk factors for CVA (stroke). And the
incidence increases if > 55 years old for both males and females. (Joyce Black, 2008)

SEX

The incidence of stroke in men is slightly higher than women; Stroke is uncommon in
women of childbearing age. (Joyce Black, 2008)

FAMILY HISTORY

Family history of stroke increases ones risk for stroke. (Joyce Black, 2008); Stroke risk
can cluster in families because genes that predispose someone to develop major risk
factors (such as diabetes, high blood pressure and high cholesterol) run in families. In
addition, families often share unhealthy habits such as smoking, lack of exercise and
poor diet. (Heart Healthy Women, 2013).

RACE

Stroke is more prevalent in African Americans than in whites or Hispanics. This

difference is probably related to the increase incidence of hypertension and diabetes
mellitus in this group. (Joyce Black, 2008)

PRECIPITATING FACTORS

23

HYPERTENSION

HPN is the most important modifiable factor for both ischemic and hemorrhagic stroke.
Adequate blood pressure control associated with 38% reduction in stroke incidence
(Black, 2008)

CARDIOVASCULAR DISEASE

Is associated with an increased risk of stroke (Black, 2008)

ATRIAL FIBRILLATION

Is associated with an increased risk of stroke (Black, 2008)

HYPERLIPIDEMIA

Elevated low-density lipoprotein (LDL) cholesterol is an important risk factor for ischemic
heart disease. Small additional risk, mainly for individuals younger than the age of 55
(Black, 2008)

DIABETES MELLITUS

DM increases the risk of stroke and morbidity and mortality after stroke. (Joyce Black,
2008); People with Diabetes Mellitus are up to 4 times more likely to have a stroke than
someone who does not have the disease, mainly because many people with diabetes
have health problems that are also stroke risk factors (National Stroke Association,
2012)

CAROTID STENOSIS & HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIAs)

Prior stroke, TIAs are considered modifiable factors for stroke. Reduction in the risk
factors for initial stroke may prevent stroke recurrence. Early recognition of carotid
stenosis and treatment of TIAs with antiplatelet agents reduce the risk of stroke. (Joyce
Black, 2008)

24

VICES

Current research suggests that although heavy alcohol consumption increases ones risk
of a stroke, light or moderate alcohol consumption may protect against ischemic stroke.
(Joyce Black, 2008)

b.3 Signs & Symptoms (Book-based)

Some strokes have early warning signs, called transient ischemic attacks (TIAs).
Manifestations of impending ischemic stroke include transient hemiparesis, loss of speech, and
hemisensory loss. Manifestations of a thrombotic stroke develop over minutes to hours to days.
The slow onset is because the thrombus is still increasing in size. First there is partial, and then
complete, occlusion of the affected vessel. In contracts, manifestations of embolic strokes occur
suddenly and without warning.
Hemorrhagic stroke also occurs rapidly, with manifestations developing over minuets to
hours. Common manifestations include sever occipital or nuchal headaches, vertigo, syncope,
paresthesias, transient paralysis, epistaxis and retinal hemorrhages.
Manifestations of deficit must persist longer than 24 hours to be diagnostic of stroke.
TIAs are focal neurologic deficits lasting less than 24 hours. Stroke manifestations can be
correlated with the cause of Thrombosis, Embolism, Hemorrhage and with the area of the brain
in which perfusion is impaired. The middle cerebral artery is the most common site of ischemic
stroke. The clients deficit also varies according to whether the dominant or the nondominant
side of the brain is affected. The degree of deficit can also vary from little impairment to serious
functional loss.
HEMIPARESIS and HEMIPLEGIA

Hemiplegia is paralysis of one side of the body. Hemiparesis is weakness of one side of
the body and is less severe than hemiplegia. Both are a common side effect of stroke or
cerebrovascular accident. One may wonder how only one side of the body can become
paralyzed or weak after a stroke. One sided paralysis or weakness occurs when a stroke
affects the corticospinal tract of one side of the brain. The right side of the brain controls
the motor function of the left side of the body. The left side of the brain controls the motor
function of the right side of the body. Thus when one side of the brain is damaged, it
causes only one side of the body to be affected.

25

APHASIA

Aphasia is a language disorder that results from damage to portions of the brain that are
responsible for language. For most people, these are parts of the left side (hemisphere)
of the brain. Aphasia usually occurs suddenly, often as the result of a stroke or head
injury, but it may also develop slowly, as in the case of a brain tumor. The disorder
impairs both the expression and understanding of language as well as reading and
writing. Aphasia may co-occur with speech disorders such as dysarthria or apraxia of
speech, which also result from brain damage

DYSARTHRIA
Is a motor speech disorder. It results from impaired movement of the muscles used for
speech production, including the lips, tongue, vocal folds, and/or diaphragm. The type
and severity of dysarthria depend on which area of the nervous system is affected. In
addition to speaking problems, clients with dysarthria often have difficulty chewing and
swallowing because of poor muscle control.
DYSPHAGIA
Swallowing is a complex process that requires the function of several cranial nerves.
The mouth must open (CN V), the lips must close (CN VII), and the tongue must move
(CN XII). The mouth must sense the quantity and quality of the food bolus ( CN V and
VII) and must send messages to the swallowing center (CN V and IX). During the
swallowing, the tongue moves the food bolus toward the oropharynx. The pharynx
elevates and the glottis closes. Contraction of the pharyngeal muscles transports food
from the pharynx to the esophagus. Peristalsis moves food to the stomach. A stroke in
the territory of the vertebrobasilar system causes dysphagia.
VISUAL CHANGES
Vision is a complex process controlled by several areas in the brain. Parietal and
temporal lobe strokes may interrupt visual fibers of the optic tract enroute to the occipital
cortex and impair visual acuity.
HOMONYMOUS HEMIANOPIA.
Is a visual loss in the same half of the visual field of each eye, so the client has only half
of the visual field of each eye, so the client has only half of normal vision. For example,
the client may see clearly on one side of the midline but see nothing on the other side.
And they cannot see the past midline without turning the head toward that side.

26

HOMER SYNDROME
Is a paralysis of the sympathetic nerves to the eye, causing sinking of the eyeball, ptosis
of the upper eyelid, slight elevation of the lower lid, constriction of the pupil, and lack of
tearing in the eye.
AGNOSIA

Is a disturbance in the ability to recognize familiar objects through the senses. The most
common types are visual and auditory. Agnosia may result from an occlusion of the
middle or posterior cerebral arteries supplying the temporal or occipital lobes.

UNILATERAL NEGLECT

Is the ability of a person to respond a stimulus on the contralateral side of a cerebral

infarction. Clients with injury to the temporoparietal lobe, inferior parietal lobe, lateral
frontal lobe, cingulate gyrus, thalamus, and striatum as a result of a middle cerebral
artery occlusion most commonly develop neglect.

SENSORY DEFICITS

Several types of sensory changes can result from a stroke in the sensory strip of the
parietal lobe supplied by the anterior or middle cerebral artery. The deficit is on the
contralateral side of the body and is frequently accompanied by hemiplegia or
hemiparesis. Hemisensory loss (a loss of sensation on one side of the body) is generally
incomplete and may not be noticed by the client. The superficial sensations of touch,
pressure, and temperature are affected in varying degrees. Paresthesia is described as
persistent, burning pain; feeling of heaviness, numbness, tingling, or prickling.
Proprioception (the ability to perceive relationship of body parts to the external
environment) and postural sense disturbances may occur with loss od muscle-joint
sense. This may seriously interfere with the clients ability to ambulate because of a lack
of balance control and inappropriate movements causing risk of falling.

BEHAVIORAL CHANGES

Various portions of the brain assist with control of behavior and emotions. The cerebral
cortex interprets stimuli. The temporal and limbic areas modulate emotional responses
to stimuli. The hypothalamus and pituitary glands coordinate the motor cortex and
27

language areas. The brain can be seen as a modulator of emotions and when the brain
is not fully functional, emotional reactions and responses lack this modulation.
INCONTINENCE

Stroke may cause bowel and bladder dysfunction. One type of neurogenic bladder, an
uninhibited bladder, sometimes occurs after stroke. Nerves send the message of thr
bladder filling to the brain, but the brain does not correctly interpret the message and
does not transmit message not to urinate to the bladder. This results to frequency,
urgency, and incontinence. Sometimes client with a type of neurogenic bowel seem
fixated on having a bowel movement. Other causes emotional factors, inability to
communicate, impaired physical mobility, and infection. The duration and severity of the
dysfunction depend on the extent and location of the infarction.

IV. Clinical Intervention

1.1. Description of prescribed surgical treatment performed.
Craniotomy is a cut that opens the cranium. During this surgical procedure, a section of
the skull, called a bone flap, is removed to access the brain underneath. The bone flap is
usually replaced after the procedure with tiny plates and screws.
A craniotomy may be small or large depending on the problem. It may be performed during
surgery for various neurological diseases, injuries, or conditions such as brain tumors,
hematomas (blood clots), aneurysms or AVMs, and skull fractures. Other reasons for a
craniotomy may include foreign objects (bullets), swelling of the brain, or infection. Depending
on the reason for the craniotomy, this surgery requires a hospital stay that ranges from a few
days to a few weeks.
What is a craniotomy?
Craniotomy is any bony opening that is cut into the skull. A section of skull, called a bone
flap, is removed to access the brain underneath. There are many types of craniotomies, which
are named according to the area of skull to be removed (Fig. 1). Typically the bone flap is
replaced. If the bone flap is not replaced, the procedure is called a craniectomy.

28

Figure 1. Craniotomies are often named for the bone being removed. Some common
craniotomies include frontotemporal, parietal, temporal, and sub occipital.
Craniotomies are also named according to their size and complexity. Small dime-sized
craniotomies are called burr holes or keyhole craniotomies. Sometimes stereotactic frames,
image-guided computer systems, or endoscopes are used to precisely direct instruments
through these small holes. Burr holes or keyhole craniotomies are used for minimally invasive
procedures to:

insert a shunt into the ventricles to drain cerebrospinal fluid (hydrocephalus)

insert a deep brain stimulator to treat Parkinson Disease

insert an intracranial pressure (ICP) monitor

remove a small sample of abnormal tissue (needle biopsy)

drain a blood clot (stereotactic hematoma aspiration)

insert an endoscope to remove small tumors and clip aneurysms

Large or complex craniotomies are often called skull base surgery. These craniotomies
involve the removal of a portion of the skull that supports the bottom of the brain where delicate
cranial nerves, arteries, and veins exit the skull. Reconstruction of the skull base is often
necessary and may require the additional expertise of head-and-neck, otologic, or plastic
surgeons. Surgeons often use sophisticated computers to plan these craniotomies and locate
the lesion. Skull base craniotomies can be used to:

29

remove or treat large brain tumors, aneurysms, or AVMs

treat the brain following a skull fracture or injury (e.g., gunshot wound)

remove tumors that invade the bony skull

Illustrations
Step 1: Prepare the patient
No food or drink is permitted past midnight the night before surgery. Patients are
admitted to the hospital the morning of the craniotomy. With an intravenous (IV) line placed in
your arm, general anesthesia is administered while you lie on the operating table. Once asleep,
your head is placed in a 3-pin skull fixation device, which attaches to the table and holds your
head in position during the procedure (Fig. 2). Insertion of a lumbar drain in your lower back
helps remove cerebrospinal fluid (CSF), thus allowing the brain to relax during surgery. A brainrelaxing drug called mannitol may be given.

Figure 2. The patients head is placed in a

three-pin Mayfield skull clamp. The clamp
attaches to the operative table and holds
the head absolutely still during delicate
brain
the hairline

surgery. The skin incision is usually made behind

(dashed line).

Step 2: Make a skin Incision

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

30

Step 3: Perform a craniotomy, open the skull

The skin and muscles are lifted off the bone and folded back. Next, one or more small
burr holes are made in the skull with a drill. Inserting a special saw through the burr holes, the
surgeon uses this craniotome to cut the outline of a bone flap (Fig. 4). The cut bone flap is lifted
and removed to expose the protective covering of the brain called the dura. The bone flap is
safely stored until it is replaced at the end of the procedure.

Figure 4. A craniotomy is cut with a special saw called a craniotome. The bone flap is
removed to reveal the protective covering of the brain called the dura.

31

Step 4: Exposure of the brain

After opening the dura with surgical scissors, the surgeon folds it back to expose the
brain (Fig. 5). Retractors placed on the brain gently open a corridor to the area needing repair or
removal. Neurosurgeons use special magnification glasses, called loupes, or an operating
microscope to see the delicate nerves and vessels.

Figure 5. The dura is opened and folded back to expose the brain.
Step 5: Correct the problem
Because the brain is tightly enclosed inside the bony skull, tissues cannot be easily
moved aside to access and repair problems. Neurosurgeons use a variety of very small tools
and instruments to work deep inside the brain. These include long-handled scissors, dissectors
and drills, lasers, ultrasonic aspirators (uses a fine jet of water to break up tumors and suction
up the pieces), and computer image-guidance systems. In some cases, evoked potential
monitoring is used to stimulate specific cranial nerves while the response is monitored in the
brain. This is done to preserve function of the nerve and make sure it is not further damaged
during surgery.

Step 6: Close the craniotomy

With the problem removed or repaired, the retractors holding the brain are removed and
the dura is closed with sutures. The bone flap is replaced back in its original position and
secured to the skull with titanium plates and screws (Fig. 6). The plates and screws remain
permanently to support the area; these can sometimes be felt under your skin. In some cases, a
drain may be placed under the skin for a couple of days to remove blood or fluid from the
surgical area. The muscles and skin are sutured back together. A turban-like or soft adhesive
dressing is placed over the incision.

32

Figure 6. The bone flap is replaced and secured to the skull with tiny plates and screws.

1.2. Indication of prescribed surgical treatment.

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

Brain tumors
o

An abnormal growth of cells within the brain or inside the skull, which can be
cancerous or non-cancerous.

Bleeding (hemorrhage)
o

A loss of blood in the circulatory system

Blood clots (hematomas)

o

A collection of blood outside the blood vessels generally the result of

hemorrhage, or more specifically, internal bleeding. It is named based on the site
of injury. Examples of which is subdural hematoma (between the dura mater and
arachnoid mater) and epidural hematoma (between the dura mater and the
skull).

Weaknesses in blood vessels (cerebral aneurysms)

o

A localized, blood-filled dilation (balloon-like bulge) of a blood vessel caused by

disease or weakening of the vessel wall. As the size of an aneurysm increases,

33

there is an increased risk of rupture, which can result in severe hemorrhage or

other complications including sudden death.

Relief from increased intracranial pressure

Damage to tissues covering the brain (dura)

Pockets of infection in the brain (brain abscesses)

o

Abscess caused by inflammation and collection of infected material coming from

local (ear infection, dental abscess, infection of paranasal sinuses, infection of
the mastoid air cells of the temporal bone, epidural abscess) or remote (lung,
heart, kidney etc.) infectious sources within the brain tissue. The infection may
also be introduced through a skull fracture following a head trauma or surgical
procedures. Brain abscess is usually associated with congenital heart disease in
young children. It may occur at any age but is most frequent in the third decade
of life.

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

o

A neuropathic disorder of the trigeminal nerve that causes episodes of intense

pain in the eyes, lips, nose, scalp, forehead, and jaw.

Epilepsy
o

A common chronic neurological disorder characterized by recurrent unprovoked

seizures

Chiari malformations
o

A malformation of the brain. It consists of a downward displacement of the

cerebellar tonsils and the medulla through the foramen magnum, sometimes
causing hydrocephalus as a result of obstruction of cerebrospinal fluid (CSF)
outflow. The cerebrospinal fluid outflow being caused by phase difference in
outflow and influx of blood in the vasculature of the brain

34

BENEFITS VERSUS RISKS:

Benefits of craniotomy include removal of brain tumors for return of motor or sensory
impairment and relief from seizure attacks, control of bleeding to prevent death especially from
ruptured aneurysm, evacuation of blood clots to decrease ICP, drainage of brain abscesses to
manage infection, and alleviation of pain from neuropathic disorders and for modality in skull
fractures. This would lead to an improved quality of life and more time for the patient to live.
All operations carry some risks. Brain surgery carries more than most. Any operation can
be complicated by heart trouble, chest infection, blood clots in the leg (thrombosis) and wound
infection. The chances of these complications are greater in elderly or unhealthy patients and, in
particular, those who smoke or drink heavily. The major specific complications of brain surgery
are damage to the brain at the time of surgery and bleeding within the head after the operation.
Meningitis and epilepsy occasionally follow craniotomy. When bleeding is suspected, you would
have to return to operating room within a few hours of the operation for a reopening of the
wound. Sometimes deterioration is due to brain swelling and the bone flap is left out, being
stored frozen in antibiotic solution. It may then be replaced at a later date when the swelling has
settled down.
Consequently, damage to normal brain tissue may cause injury to an area and
subsequent loss of brain function. Loss of function in specific areas can cause memory
impairment. Some other examples of potential harm that may result from this procedure include
deafness, double vision, numbness, paralysis, blindness, or loss of the sense of smell.

Risks:
All operations carry some risks. Brain surgery carries more than most. Any operation can
be complicated by heart trouble, chest infection, blood clots in the leg (thrombosis) and wound
infection. Consequently, damage to normal brain tissue may cause injury to an area and
subsequent loss of brain function. Loss of function in specific areas can cause memory
impairment. Some other examples of potential harm that may result from this procedure include
deafness, double vision, numbness, paralysis, blindness, or loss of the sense of smell.
General complications of any surgery include bleeding, infection, blood clots, and
reactions to anesthesia. Specific complications related to a craniotomy may include:

1. Infections - Infection constitutes an unwanted effect related to brain surgery. If bacteria gain
access to the brain during the procedure, chances of brain infection are high. For example,

35

infection due to Staphylococcus Aureus can lead to meningeal inflammation. As a small hole is
made in the skull, the patient stands a fair chance of acquiring a skull infection. A proper
antibiotic regime is started immediately to prevent such after effects.
2. Bleeding - There is a possibility of post-operative intracranial bleeding in cases in which
surgical eradication of a malignant or benign tumor has been carried out. This bleeding is known
as a hemorrhage and it causes an increase in pressure. This spike in pressure either within or
on the brain as well as the surrounding structures has the potential to reach alarmingly high
levels, leading to either unconsciousness or death.
Some symptoms that suggest intracerebral bleeding include: nausea, sudden headache,
vomiting and loss of sensation leading to numbness. Weakness is another important symptom.
One must call for a doctors help immediately on noticing these symptoms.
3. Seizure- Seizures are caused by unusual electrical activity within the brain. Post
neurosurgery, seizures are quite common and may occur either immediately, after a few months
or even many years after the day of operation. If the seizure does occur soon after the
completion of surgery, it is regarded as a provoked seizure. Some seizures are classified as
unprovoked if they continue to occur for a long time after the surgery. Patients belonging to the
latter category are diagnosed as epileptic.
Seizures occur because after the removal of damaged or infected tissue, the brain makes new
but different connections with the nerves. Such abnormal connections lead to unprovoked
seizures which range in frequency. The good news is that many such seizures are treatable via
effective anti-convulsant drugs.
4. Stroke- A stroke is defined as an emergency medical situation in which the blood flow in the
brain experiences a sudden interruption. Blocked vessels may be a cause of stroke, especially
after brain tumor removal surgery.
In such a condition, brain cells of that particular region die due to the lack of oxygen. Irreversible
brain damage can occur in those affected areas that may be involved with functions such as
speech, movement or vision. Such patients experience weakness or even paralysis.
5. Coma- Coma is another side effect either during or post surgery. In this state, the affected
patient is unconscious and fails move or respond.
6. Brain damage- Removal of damaged tissue in the brain sometimes leads to removal of some
unaffected tissue as well. The possibility of damage to the normal tissues also exists. Brain
damage can be either temporary or permanent. Symptoms gradually fade out in temporary
cases, but the ones with permanent damage of tissue require rehabilitation. Such damage can
also alter personality.
7. Brain swelling- Accumulation of the cerebrospinal fluid (CSF) or swelling of the brain can
lead to increased intracranial pressure. Such elevated pressure leads to feeling of lethargy,
vomiting or headache. In such cases, certain changes in behavioral pattern may be noticed.

36

Steroids are recommended to bring the pressure down. In cases of elevated intracranial
pressure another intervention is required when CSF is increasing.
Benefits:
Benefits of craniotomy include removal of brain tumors for return of motor or sensory
impairment and relief from seizure attacks, control of bleeding to prevent death especially from
ruptured aneurysm, evacuation of blood clots to decrease ICP, drainage of brain abscesses to
manage infection, and alleviation of pain from neuropathic disorders and for modality in skull
fractures. This would lead to an improved quality of life and more time for the patient to live.

1.3 Required instruments, devices, supplies, equipment, and facilities

Scalpel Handle for Blades No 10

thru 15

7in Metzenbaum Scissors,

Curved

Stille-Luer Duckbill Rongeurs,

Angled to Side

Backhaus Towel Clamps, 5-1/4 in

Qty: 8

Jansen Retractor, 3x3 Prongs,

10mm 4-1/2in, Blunt

Crown-Kerrison Cervical
Rongeur

Cushing Pituitary Rongeur

Schlesinger Pituiary Rongeur

This rongeur is straight, and features a 6

Schlesinger Cervical Rongeurs

Gigli Saw Handle, Loop Style,

37

Set of 2

8.5in Love Nerve Root Retractor

Adson Hemostats, Straight 7 in

Adson Hemostats, Curved 7 in

Gigli Saw 20in, Standard Twisted

Wire Type

Mayo Dissecting Scissors,

Straight 5-1/2 in

Mayo Dissecting Scissors,

Curved 5-1/2 in

3.25in Backhaus Towel Clamps

Potts-Smith Operating Scissors

Halsted Mosquito Forceps,

Straight, Extra Delicate 5in

Halstead-Mosquito Forceps,
Curved, Delicate 5 in

38

Frazier Dura Separator, 6in

Adson Periosteal Elevator,

Blunt, Curved

Dandy Kolodney Scalp Hemostat

Zaufel-Jansen Rongeur, 7in, D/A,

Curved, 5mm Bite

Langenbeck Elevator, Broad, 7in

Hudson Cerabellar Extension

Murphy Retractor, 4 Prongs,

Foerster Sponge Forceps,

Sharp, 7-1/2 in

Straight, Smooth, 9-1/2 in

Allis Tissue Forceps, 4x5 Teeth,

6 in

Senn Miller Retractor, Sharp, 61/4 in

39

Luer Rongeurs, 7in, Straight Jaw

8mm Bite

Rochester-Pean Hemostats,
Straight, 6-1/4 in

Kelly Scissors Straight

Sharp/Points

6.75in Cushing Spatula Spoon

DeBakey Type Needle Holders, 7

in

Rochester-Pean Hemostats,
Straight, 7-1/4 in

Cushing Perforator
This is a perforator for the hudson brace.

11mm Michel Wound Clips

40

Dandy Nerve Hook, Straight

Tissue Forceps, 2 x 3 Teeth, 6 in

Adson Dressing Forceps, Serrated,

4-3/4 in

Frazier Suction Tube, Angled, 7

Fr, 5 in

Frazier Suction Tube, Angled, 9

Fr, 5 in

Frazier Hook, Sharp, Delicate

Prong, 5 in

Roger Wire Scissors, 4-3/4 in,

Angled to Side

Crile-Wood Needle Holder 6 in

w/ Tungsten Carbide

41

Beckman-Adson Retractor 12-1/2 in,

Freer Septum Elevator, 7-1/2in

Hinged, Sharp, 3/4in x 1in

8in Adson Dura Hook, Sharp

Bailey-Gigli Saw Guide, 12in,

Flexible

Gruenwald Nasal Forceps, 8 in

4.75in Adson Tissue Forceps

8.5in Love Nerve Retractor, Straight

8.5in Love Nerve Retractor,

Angled

42

The OR should contain anesthetic equipment, overhead lights, electro diathermy equipment,
and suctioning systems. A standard craniotomy tray is usually sufficient for a craniotomy.

1.4 Perioperative task and responsibilities of the nurse. Emphasize and outline critical
tasks and responsibilities of both scrub and circulator roles pre-operatively, intraoperatively, and post-operatively
Pre-operative responsibilities:
Both the circulating nurse and the scrub nurse set up the operating room and
position the equipment appropriately. As a team, both should check the case cart and
the equipment to be used during the operation. The circulating nurse attends to the client
while the scrub nurse continues to prepare the room. By the time the client arrives, the
following should have been already done:
1. Ensure that the following are cleaned and ready for use:

OR table linen

Lift linen

Armboard covers

Safety straps

43

Headcover for the client

Rolls or pads necessary to avoid pressure on bony prominences

2. Check for the effectiveness and safety of the following:

Monitoring equipment

Spotlight fixture of the OR

Suction apparatus should function at maximum vacuum. Connect the machine to

the cannesters

Electrocautery machine with ground pad

3. Prepare the folloqing protective devices for use when necessary:

X-ray protective devices

Eyewear

Plastic apron

4. Prepare the case table. Collect the needed supplies for surgery, such as:

Sterile drapes pack

Sterile gowns

Specific instruments needed for the surgery

Basins where sterile NSS is poured

Sterile gloves in the sizes of the sterile team members. Provide extra gloves

Suctions, specimen bottles

Establish the sterile field by draping the table with a sterile drape.

Duties of a scrub nurse:

Prepares the sterile field

Counts sponges, sharps, and other instruments

44

Assist the surgeon and assistant after scrubbing

Assist the sterile team during operation such us passing instruments

Counts sponges, sharps, and other instruments

Dresses wounds\performs aftercare of the client

Removes spoiled gown and gloves at the end of the operation

Duties of a Circulating nurse:

Fastens the back of the scrub nurses gown and the surgeons gown

Opens sterile packages

Serves the sterile package to the scrub nurse

Moves surgical instruments with the use of ovum forceps

Pours solutions

Patient- Centered preparation:

1. Verify clients first, middle and last name, and the birth date. This can be done
verbally or by referring to the ID band
2. Verify the surgical procedure, name of the surgeon, laterality of the operation, and
date of operation verbally with the client and/or his/her family.
3. Review the clients chart for completeness of the following:

Medical history and physical examination

Laboratory reports

Informed consent

Preoperative medications, if the drug was given 30-35 minutes prior to admission
to the OR

Maintenance of NPO
45

Changing of the client into the hospital gown

Documentation of pre-surgery vital signs

Removal of body hair on the surgical site

Administration of IVF to the client

Intra-operative responsibilities:
1. Scrub Nurse a nurse or surgical technician who prepares the surgical set-up,
maintains surgical asepsis while draping and handling instruments, and assists the
surgeon by passing instruments, sutures, and supplies.
2. Circulating Nurse respond to request from the surgeon, anesthesiologist or
anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the
nursing care plan.

Post-operative responsibilities:

Immediately after the surgery, nurses count everything from sponges to surgical
tools to ensure that everything is accounted for. If they find a discrepancy, they
must determine what happened to the missing items.

They also sterilize and clear away surgical tools, and remove the drapes that
covered the patient. In addition, they dispose of medical waste and may prepare
samples taken from the patient for testing.

They also clean the operating room and restock supplies so the room is ready for
the next surgical team.

Nurses continue to monitor patients after they awaken from anesthesia. They
evaluate the incision site to ensure that the sutures are holding and the wound is
healing.

They also identify possible infection and administer antibiotics if complications

arise.

Because patients are more vulnerable to illness after a surgical procedure,

nurses must watch for signs of pneumonia or easily transmitted ailments, such as
staph infections.

46

They also regularly assess the patients vital signs, including heart rate, pulse,
respiration and temperature. They monitor the patients IV line and urinary
catheter.

Prior to operation:

A careful history and physical examination are performed

Intravenous

fluids

are

given

to

correct

volume

depletion

and

any

electrolyteimbalances are measured and corrected. Monitor and regulate IVFs

The nurse instructs the patient about the need to avoid smoking to
enhancepulmonary recovery postoperatively and avoid respiratory complications.
It isalso important to instruct the patient to avoid the use of aspirin and
other agents that can alter coagulation and other biochemical process

On of the most important responsibility of the nurse is to let the patient signan
informed consent regarding the surgery.

The patient is given anaesthesia prior to surgery and the patient is under NPO.

During the operation:

Monitoring the vital signs of the patient is one of the responsibilities of thenurse
during the surgery.

Assisting the anesthesia care provider during induction of general anesthesia

Ensuring adequate oxygenation and hydration

After the operation:

After recovery, the nurse places the patient in the low fowlers position. IVfluids
may be given. Water and other fluids are given in about 24hours, andsoft diet is
started when bowel sounds returned

1.5 expected outcomes of surgical treatment performed

Trouble with walking.

If you're having a stroke, you may stumble or have sudden dizziness, loss of balance or
loss of coordination.

Trouble with speaking.

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

47

Paralysis or numbness on one side of the body.

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

Trouble with seeing.

If you're having a stroke, you may suddenly have blurred or blackened vision or may see
double.

Headache

A sudden, severe "bolt out of the blue" headache or an unusual headache, which may
be accompanied by a stiff neck, facial pain, pain between your eyes, vomiting or altered
consciousness, sometimes indicates you're having a stroke. Since there would be the
elimination of the signs and symptoms such as pain, there would be a better quality of
life for the patient which could increase productivity and minimize hospital or clinic visits,
upon discharge clients maybe given information regarding:

Discomfort
1. After surgery, headache pain is managed with narcotic medication. Because narcotic pain
pills are addictive, they are used for a limited period (2 to 4 weeks).Their regular use may also
cause constipation, so drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax)
2. A medicine (anticonvulsant) may be prescribed temporarily to prevent
seizures. Common anticonvulsants include Dilantin (phenytoin), Tegretol
(carbamazepine), and Neurontin (gabapentin). Some patients develop sideeffects (e.g., drowsin
ess, balance problems, rashes) caused by theseanticonvulsants; in these cases, blood samples
are taken to monitor the drug levels and manage the side effects.
Restrictions
1. Do not drive after surgery until discussed with your surgeon and avoid sitting for long periods
of time.
2. Do not lift anything heavier than 5 pounds (e.g., 2-liter bottle of soda),including children.
3. Housework and yard work are not permitted until the first follow-up office visit. This includes
gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or
dryer.

48

4. Do not drink alcoholic beverages.

Activity
1. Gradually return to your normal activities. Fatigue is common.
2. An early exercise program to gently stretch the neck and back may be advised

1.6 Medical management of physiologic outcomes. May include fluid therapy,

pharmacologic therapy, etc.
Goal is to reduce pressure on the brain

Circulation support (intravenous fluids and medications to maintain blood

pressure)

Respiratory support (oxygen and mechanical ventilation if necessary)

Dexamethasone (a corticosteroid medication) may be used to decrease the

inflammation of the brain

Mannitol (a diuretic) may be used to decrease the swelling of the brain

Dilantin (a seizure medication) may be used to prevent or control Seizures

Reversal of blood thinning agents such as Warfarin or Hepari

Nursing Diagnosis
A. Pre-Operative Problems
1. Altered cerebral tissue perfusion r/t vascular occlusion
2. Impaired physical mobility r/t neuromuscular and musculoskeletal impairment
3. Activity intolerance r/t immobility
4. Risk for aspiration
5. Risk for injury
B. Post-Operative Problems
1. Acute pain
2. Impaired verbal and/or written communication r/t impaired cerebral circulation
3. Self care deficit: bathing/hygiene
4. Unilateral neglect r/t damage to the right hemisphere secondary to CVA
49

5. Risk for infection

50

Nursing Management of Physiologic, Physical, and Psychosocial Outcomes

Pre-Operative Problems:

PROBLEM #1: ALTERED CEREBRAL TISSUE PERFUSION RT VASCULAR OCCLUSION

ASSESSMENT
S=

O= The patient

NURSING
DIAGNOSIS
Impaired cerebral

SCIENTIFIC
EXPLANATION

PLANNING
Short term

INTERVENTIONS
Monitor Vital signs

RATIONALE

EXPECTED

> To identify any

OUTCOME
Short term

tissue perfusion r/t

objective:

other deviations

objective:

vascular occlusion

After 5hrs. of

from normal.

After 5hrs. of Nursing

may also manifest

Nursing

intervention, the pt.

the ff:

intervention, the pt.

shall demonstrate

>Change in

will demonstrate

>Assist pt. in

>To aid with proper

increased perfusion

pupillary reactions

increased perfusion

assuming

perfusion or flow of

as individually

>Change in Mental

as individually

semifowlers

blood (circulation or

appropriate

Status

appropriate

position w/ head

venous drainage).

midline.

>Behavioral
Changes

Long Term

Long Term

>Capillary refill

Objective:

Objective:

longer than 3 secs.

After 2-3 days of

>Encourage quiet

>To conserve

After 2-3 days of

>Restlessness

Nursing

and restful

energy which could

Nursing Intervention,

>Extremity

Intervention, the pt.

atmosphere.

aid in lowering the

the pt. shall

weakness

will be able o

O2 tissue demand.

demonstrate

>Narrowed Pulse

demonstrate

behaviors which may

Pressure

behaviors which

improve proper

>Decreased in Hct

may improve proper

circulation such as

and Hgb

circulation such as

compliance to health

>Icteric Conjunctiva

compliance to

>Exercise caution

>The t issues may

management &

health management

in using hot or cold

have decreased

therapies provided.

& therapies

pads.

sensitivity due to

provided.

ischemia.
>Administer
medications as
ordered such as

>To probably

antihypertensive or

decrease cardiac

diuretics.

workload and in
maximizing tissue

>Discuss to the

perfusion

patients SO the
importance of care
of dependent limbs,

>To promote

body hygiene, and

wellness

foot care when

circulation is
impaired.

PROBLEM #2: IMPAIRED PHYSICAL MOBILITY RT NEUROMASCULAR AND MUSCULOSKELETAL IMPAIRMENT

ASSESSMENT
S=

NURSING
DIAGNOSIS
Impaired physical

SCIENTIFIC

PLANNING

EXPLANATION

Short Term

EXPECTED

INTERVENTIONS

RATIONALE

>Monitor Vital signs

>To identify any

OUTCOME
Short Term

mobility

Objective:

other deviations

Objective:

O = The patient

neuromuscular and

After 4 hrs. Of

from normal.

After 4 hrs. Of Nursing

may also manifest

musculoskeletal

Nursing Intervention,

he following:

impairment

the pt. will be able to

>Assess patient

>To determine any

shall maintained

maintained position

condition

other underlying

position and function

Intervention, the pt.

>Slowed movement

and function and

cause of

and skin integrity as

>Limited motor skills

skin integrity as

manifestations

evidenced by absence

>Postural instability

evidenced by

during performance

absence of

>Provide adequate

> To prevent further

foortdrop, decubitus,

of ADLs

contractures,

rest periods as well

stress & fatigue

and so forth

>Movement induced

foortdrop, decubitus,

as comfort & safety

shortness of breath

and so forth

measures

of contractures,

Long Term
Objective:

Long Term

>Turn pt. slowly

> To provide proper

After 2-3 days of

Objective:

from side to side

circulation of blood

nursing intervention,

flow on both sides

the pt. shall maintain

After 2-3 days of

nursing intervention,

or increased strength

the pt. will be able to

>Determine pt.

>To assess

and function of

increased strength

level of mobility

functional ability

affected and/or

and function of

compensatory body

affected and/or

>Assist pt. in his

>To promote

compensatory body

activities

optimal level of

part

function

part

>Encourage

>Promotes well-

adequate intake of

being and

fluids & Nutritious

maximizes energy

foods

production.
>To assist in

>Involve clients

learning ways of

SO in care

managing problems
of immobility.

PROBLEM 3: UNILATERAL NEGLECT RT DAMAGE TO THE RIGHT HEMISPHERE SECONDARY TO CVA

ASSESSMENT
S=

O = The patient
may manifest the

NURSING

SCIENTIFIC

PLANNING

INTERVENTIONS

RATIONALE

EXPECTED

DIAGNOSIS
Unilateral neglect rt

EXPLANATION
An ischemic stroke,

Short Term:

>Monitored Vital

> To identify any

OUTCOME
Short Term:

damge to the right

cerebrovascular accident

After 2 hrs. Of

signs

other deviations

After 2 hrs. Of Nursing

hemisphere

(CVA), or brain attack is

Nursing

from normal.

Intervention, the pt.

secondarty to CVA

a sudden loss of function

Intervention, the pt.

resulting from disruption

will be able to

shall be able to
>Assessed patient

>To determine any

participate in the

following:
>Irritability
>Right hemiplegia
>Need assistance
in performing ADLs
>Decrease attention
to the affected side

of the blood supply to a

participate in the

part of the brain. In an

other underlying

performance of range

performance of

cause of

of motion exercises on

ischemic brain attack,

range of motion

manifestations

the extremities

there is disruption of the

exercises on the

cerebral blood flow due to

extremities

obstruction of a

condition

>Performed AM

> To enhanced well

care

being & provide

bloodvessel. This can

comfort

Long Term:

cause a wide variety of

Long Term:

After 2-3 days of

neurologic deficits

After 2-3 days of

>Observe clients

>To determine the

nursing intervention,

depending on the location

nursing

behavior

extent of damage

the pt. shall be able to

of the lesion with which

intervention, the pt.

vessels are obstructed. A

will be able to

>Remove excess

>To reduced

of the affected

stroke is an upper motor

increase the

stimuli from the

distractions

extremities with due

neuron lesion and results

utilization of the

environment when

assistance from the

in loss of voluntary control

affected extremities

working with the

S.O

over motor movements.

with due assistance

client

Because the upper motor

from the S.O

increase the utilization

neurons decussate
(cross), a disturbance of
voluntary motor control on

>Encourage client

>To compensate

one side of the body may

to turn head and

for visual field loss

reflect damage to the

eyes in full rotation

upper motor neurons on

and scan the

the opposite side of the

environment

brain.The most common

motor dysfunction is

>Orient to

>To improve

hemiplegia (paralysis on

environment as

clients

one side of the body).

often as needed

interpretation of

and ensure

environmental

adequate lightning

stimuli

in the environment
>Collaborate with

>Focuses on

physical and

functional

occupational

adaptation

therapist in
promoting task
specific activities

PROBLEM #4: HYPERTHERMIA

ASSESSMENT

SCIENTIFIC
EXPLANATION
Hyperthermia or

Short Term:

>Monitor and

commonly known as fever

After 2 hr of nursing

Record Vital Signs.

O = The patient

is present when the body

intervention the pt

may manifest

temperature is higher than

will be able to

the following:

37C. It occurs when the

maintain core

>Poor skin turgor

body is invaded by some

temperature within

>Flushed skin

bacteria, viruses, or

normal range

>Dry mucous

parasites. This could occur

membrane

due to the prolonged use

S=

NURSING
DIAGNOSIS
Hyperthermia

PLANNING

INTERVENTIONS

RATIONALE
>Baseline data

EXPECTED
OUTCOME
Short Term:
The patient shall
maintain core

>Enhance heat loss

temperature within

>Provide tepid

by evaporation and

normal range

sponge bath.

conduction.

>Encourage SO to

>Increase

>Skin warm to

of the Foley catheter

Long Term:

touch

without changing it or the

>Sensory loss

metabolic rate and

Long Term:

After 2 days of

replace the fluid

The patient shall be

insertion of unsterile

nursing

loss

free of seizure activity

>Muscle

tubing. This could also

intervention, the pt

weakness

occur due systemic

will be able to be

>Blurred vision

problem.

free of seizure

>Unconciousnes

activity

increase fluids

>Instruct SO to
loosen clothing

>For comfort
measures

s
>Fatigue
>Headache

>Monitor laboratory
results

>Dizziness

>Indicative of
infections

>Abnormal blood
profile

>Monitor IVF
ordered by the
physician

>Raise side rails of

the bed

>Administer
antipyretic as
ordered by the
physician

>To prevent
dehydration

>To ensure safety

of the patient

>To Reduce fever.

PROBLEM #5: RISK FOR IMPAIRED SWALLOWING

ASSESSMENT
S=

NURSING
DIAGNOSIS
Risk for Aspiration

SCIENTIFIC
EXPLANATION
When there is a blockage

PLANNING

INTERVENTIONS

RATIONALE

Short term:

>Note level of

>To assess if there

EXPECTED
OUTCOME
Short term:

of vertebrobasilar artery

After 5hrs. of

consciousness of

is gag reflex or

The patient shall have

O = The patient

there will be Cranial

Nursing

surroundings, and

difficulty of

demonstrated

may also manifest

nerves affectations. CN V,

intervention, the pt.

cognitive

swallowing.

techniques to prevent

the ff:

VII, IX, XII blockage may

will be able to

impairment.

>Dysphagia

result to dysphagia or

demonstrate

>Impaired

difficulty of swallowing

techniques to

swallowing

which thereby having high

prevent aspiration.

>Depressed gag

risk for aspiration.

aspiration.
>To clear

>Suction as needed

secretions

>Give semisolid

>To prevent

reflex.

Long Term:

foods; avoid pureed

aspiration and to

Long Term:

>Reduced level of

After 1-2 days of

that may increase

aid swallowing

The patient shall have

consciousness

Nursing

risk of aspiration.

Intervention, the pt.

experienced no
>This activates

aspiration aeb

will experience no

>Provide very warm

temperature

noiseless respirations,

aspiration aeb

or cold liquids

receptors in the

and clear breath

noiseless

mouth that help to

respirations, and

stimulate

clear breath

swallowing.

sounds.

sounds.
>To strengthen
>Refer to speech

muscles and

therapist

techniques to
enhance
swallowing.

S=

Risk for Aspiration

When there is a blockage

Short term:

>Note level of

>To assess if there

Short term:

of vertebrobasilar artery

After 5hrs. of

consciousness of

is gag reflex or

The patient shall have

O = The patient

there will be Cranial

Nursing

surroundings, and

difficulty of

demonstrated

may also manifest

nerves affectations. CN V,

intervention, the pt.

cognitive

swallowing.

techniques to prevent

the ff:

VII, IX, XII blockage may

will be able to

impairment.

>Dysphagia

result to dysphagia or

demonstrate

>Impaired

difficulty of swallowing

techniques to

swallowing

which thereby having high

prevent aspiration.

>Depressed gag

risk for aspiration.

aspiration.
>To clear

>Suction as needed

secretions

>Give semisolid

>To prevent

reflex.

Long Term:

foods; avoid pureed

aspiration and to

Long Term:

>Reduced level of

After 1-2 days of

that may increase

aid swallowing

The patient shall have

consciousness

Nursing

risk of aspiration.

Intervention, the pt.

experienced no
>This activates

aspiration aeb

will experience no

>Provide very warm

temperature

noiseless respirations,

aspiration aeb

or cold liquids

receptors in the

and clear breath

mouth that help to

sounds.

noiseless

respirations, and

stimulate

clear breath

swallowing.

sounds.
>To strengthen
>Refer to speech

muscles and

therapist

techniques to
enhance
swallowing.

PROBLEM #6: RISK FOR INJURY

ASSESSMENT
S=

NURSING
DIAGNOSIS
Risk for Injury

SCIENTIFIC
EXPLANATION
Because of limited range

Short Term:

of

After 2 hr of nursing

motion

and

slightly

PLANNING

INTERVENTIONS
>Monitor v/s

RATIONALE
>To obtain baseline

EXPECTED
OUTCOME
Short Term:

data

The patient shall

O = The patient

paralyze body the patient

intervention the pt

may manifest the

is

will be able to

>Assess pts

>To note for the

following:

properly which maybe a

modify environment

general condition

etiology or

>Limited range of

risk for injury.

to enhance safety

unable

to

mobilize

modify environment to

precipitating factors

motion.

that can lead to

>Contralateral

fever.

hemiparesis

Long Term:

>Sensory loss

After 2 days of

enhance safety

Long Term:
>Assess mood,

>That may result in

The patient shall have

>Muscle weakness

nursing

coping abilities,

carelessness and

>Blurred vision

intervention, the pt

personality styles

increased risk

>Fatigue

will be able to be

taking without

>Headache

free of injury

considerations of

>Dizziness

consequences

>Abnormal blood
profile

>Identify

>To promote safe

interventions and

physical

safety devices

environment and
individual safety

>Raise the side

>To promote safe

rails of the bed

physical
environment and
individual safety

>Frequent skin

> To assess if there

inspection

is presence of
pressure ulcers.

>Keep things into

>To prevent injury

right premises and

and promote safety.

clear the way

be free of injury

Post-Operative Problems:

PROBLEM #1: IMPAIRED SKIN INTEGRITY

ASSESSMEN
T
S=
O = The
patient may
manifest the
following:
> Disruption of
skin surface
and layers
> invasion of
body structures
> presence of
edema
> altered

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLANATION

Impaired skin

Surgical incision of the

integrity related

abdominal wall

to presence of

secondary to

surgical

craniotomy brings

incision

about the disruption of

secondary to

the skin layers,

craniotomy

altering its normal

structure making it
vulnerable to pain
upon any untoward
movement and
possible entry of

OBJECTIVES
Short term:

NURSING
INTERVENTIONS
>Establish rapport

RATIONALE
>To gain clients
active participation

After 2-3 hours of

and trust

nursing
interventions,

timely healing of
skin lesions,

>To know the

>Assess patients

condition of the

condition

patient

without
complication

The patient shall display

timely healing of skin
pressure sores without
complication
Long term:
The patient shall maintain

wounds, or
pressure sores

Short term:

lesions, wounds, or

patient will be
able to display

EXPECTED OUTCOME

>Monitor and record

>To obtain baseline

VS

data

optimal nutrition and

physical well-being

circulation
> altered
sensation

foreign microorganism
Long term:
After 1-2 days of
nursing

>Observe skin,

>Developing jaundice

sclera and urine for

may indicate

change in color

obstruction of bile
flow

interventions, the
patient will be
able to maintain
optimal nutrition

>Encourage patient

and physical well-

to increase intake of

>For proper hydration

being

fluid and Vitamin C

and hasten wound

healing

>Change dressings
as ordered

>To prevent infection,

skin irritation and
reduce risk of
contamination

>Encourage early

>To promote

ambulation

circulation and
improve the healing
process

PROBLEM #2: ACUTE PAIN

ASSESSMEN
T
S=
O = The
patient may
manifest the
following:
> Irritability
> Facial
Grimaces

NURSING
DIAGNOSIS
Acute pain

SCIENTIFIC
EXPLANATION
Pain is a most
common response of
clients after a surgery.
Pain is an unpleasant
sensory and emotional
experience arising
from actual tissue
damage. Described in
such damage after an
craniotomy, after the

> Guarding

effect of anesthesia

Behavior

fades off the normal

>Restlessness

response of the body

to an injury is the

> Appears

feeling of pain, as a

weak

result of irritation of

>Sweating

the visceral lining of

the abdomen, thus

OBJECTIVES
Short Term:
After 4 hours of
nursing

NURSING
INTERVENTIONS

RATIONALE

>Note presence

>To plan for pain

location, intensity,

management to

and duration of pain

alleviate anxiety it is
useful in identifying

interventions, the

edema involved

patient will be

extremities

able to verbalize

EXPECTED OUTCOME
Short Term:
After 4 hours of nursing
interventions, the patient
shall verbalize relief of
pain AEB a
reduced/controlled facial

relief of pain AEB

> Promote client

> To prevent further

grimaces, irritability and

safety such as

injury

restlessness with a pain

reduced/controlle

raising side rails.

scale ranging from 6/10

d facial grimaces,

to 3/10.
>To reduce metabolic

irritability and
restlessness with

> Maintain bed rest.

After 8 hrs. of nursing

ranging from 6/10

> If touch is
culturally
Long Term:

Long Term:

consumption.

a pain scale
to 3/10.

demands/ oxygen

>To promote comfort

interventions, the patient

and reduce pain.

shall manifest absence of

appropriate, it can

irritability, facial grimaces,

be used

guarding behavior,

> Stiff Posture

sending impulses to

After 8 hrs. of

the pain receptor, to

nursing

the thalamus, and

interventions, the

interpretation of pain

patient will

in the cerebral cortex,

manifest absence

>With a pain

thereby the pt. may

of irritability, facial

scale of 6/10

manifest irritability,

grimaces,

facial grimaces,

guarding

guarding behavior,

behavior,

restlessness, appears

restlessness,

weak, sweating, stiff

appears weak,

posture, unstable RR,

sweating, stiff

Temp., PR and BP,

posture, unstable

and with a pain scale

RR, Temp., PR

of 6/10.

and BP, and with

> Unstable RR,

Temp., PR and
BP

>With mild
sharp pain felt
regularly on the
abdomen
radiating to the
back
accompanied
with palpation,
aggravated
upon
movement.

restlessness, appears
weak, sweating, stiff

>Provide comfort
measures

>Provide diversional

posture, unstable RR,

>To provide non-

Temp., PR and BP, and

pharmacologic pain

with a pain scale ranging

management.

from 6/10 to 0.

activities
>To reduce pain
> Administer pain
relievers such as
Acetaminophen as

>To decrease pain.

ordered.

a pain scale

> Administer

ranging from 6/10

replacement fluids

to 0.

and electrolytes.

>To assist with

measures to reduce
pain by supporting
circulating volume
and tissue perfusion.

> Provide
supplemental
Oxygen.

>To offset increased

oxygen demands and
consumption.

PROBLEM #3: ALTERED TISSUE PERFUSION RELATED TO EXCESSIVE BLOOD LOSS

ASSESSMENT
S=
O = The patient
may manifest the
following:

NURSING

SCIENTIFIC

DIAGNOSIS
Altered tissue

EXPLANATION
Altered tissue perfusion

perfusion related to

is a condition wherein

excessive blood

there is decrease in

loss

Oxygen resulting in the

failure to nourish the

>Restlessness

tissues at the capillary

>Extremity
weakness

level because of

>Narrowed Pulse
Pressure

the hearts ability to

>Decreased in Hct
and Hgb

compensates with what

>Altered mental
status
>Icteric Conjunctiva

excessive blood loss

PLANNING
Short term:

INTERVENTIONS
>Establish rapport

> To promote
cooperation and

After 2-30 of nursing

gain trust

interventions the pt.

will be able to
verbalize
understanding on the
condition and therapy
regimen

> To obtain baseline

> Assess patient

data.

condition
> To have a baseline

Long term:

EXPECTED
OUTCOME
Short term:
After 2-30 of nursing
interventions the pt.
shall verbalize

pump blood
is left with the body to

RATIONALE

> Monitor and

for a need of further

record v/s

evaluation.

understanding on the
condition and therapy
regimen

Long term:
After 8 hours of N.I.

utilize, therefore

After 8 hours of N.I.

the pt. shall

decrease in cardiac

the pt. will be able to

demonstrate

output then results to

demonstrate

increased perfusion

decrease pulse rate,

increased perfusion

decrease respiratory

as individually

rate, increased blood

appropriate AEB pts

>Identify changes r/t

pressure and increased

skin warm and

system in and or

temperature; thus, the

peripheral pulses

peripheral alteration

present. V/s within

lumina of the blood

present. V/s within

and circulation

normal range,

>To assess
causative or
contributing factors

as individually
appropriate AEB pts
skin warm and
peripheral pulses

vessels become

normal range,

oriented, balance I

narrowed, there is a

oriented, balance I

and O, free of pain

decrease in the amount

and O, free of pain

and discomfort.

of oxygen circulating

and discomfort.

>Measure

the body, leading to

circumference of

ineffective tissue

extremities as

perfusion.

indication

>To determine
severity of
decreased perfusion

> Measure capillary

refill, palpate for
presence or

>To prevent further

absence and quality

com plications due

of pulses

to infection

>Observe for sign of

>To check for tissue

shock or sepsis to

ischemia

note for presence of

bleeding

>Exercise caution of
hot water bottles or

>To increase

heating pads

gravitational blood
flow

PROBLEM #4: IMPAIRED VERBAL AND/OR WRITTEN COMMUNICATION RT IMPAIRED CEREBRAL CIRCULATION
ASSESSMENT

NURSING

SCIENTIFIC

PLANNING

INTERVENTIONS

RATIONALE

EXPECTED

DIAGNOSIS
Impaired verbal

EXPLANATION
There is an affectation

Short Term:

and/or written

of

After 3 hrs of nsg int.

communication r/t

lobes that caused by

the pt will be able to

impaired cerebral

impaired

cerebral

verbalize or indicate

>Assess pts

>To note for the

shall verbalize ir

circulation

circulation that affects

understanding of the

general condition

etiology or

indicate

>Headache

its proper functions that

communication

precipitating factors

understanding of

>Dyspnea

leads

difficulty and plans for

that can lead to

communication

>Unable to speak

delayed

ways of handling.

fever.

difficulty and plans for

>Discomfort

ability

>Irritability

process, transmit and

>Note results of

>To assess

>Low self esteem

use

neurological testing

causative/contributin

>Difficulty in

symbols

Long Term:

such as

g factors

expressing needs

communicating

After 3 days of

EEG/CTscan and

After the nursing

>Weakness

resulting

nursing intervention

the likes

intervention the pt

>Slurred speech

verbal communication.

S=
O = The patient
may manifest the
following:

the

certain

to

decreased,
or

to
a

brain

absent

>Monitor v/s

>To obtain baseline

OUTCOME
Short Term:

data

After the nrsing

intervention the pt

receive,
system

o
in

in

ways of handling

impaired

the pt will establish

Long Term:

shall establish

method of

>Assess

>To assess

methods of

communication in

environment factors

causative/contributin

communication in

which needs can be

that may affect

g factors

which can be

expressed.

ability to

To assist client to

communicate

establish a means of
communication to
express needs,
wants, ideas and
questions

>Establish

>Individuals may

relationship with the

talk more easily

client , listening

when they are

carefully and

rested and relaxed

attending to clients
verbal/nonverbal
expressions
>Maintain a calm,

>To attend pts

unhurried manner,

needs immediately

provide sufficient
time for the client to
responds
Anticipate needs
until effective
communication is
reestablished
>Administer due

>For pts recovery

meds

and to treat

expressed.

underlying
conditions

PROBLEM #5: SELF CARE DEFICIT: BATHING/HYGIENE

ASSESSMENT

NURSING

SCIENTIFIC

EXPECTED

> To identify any

OUTCOME
Short Term:

possible because of the

After 4 hrs. Of

signs

other deviations

After 4 hrs. Of Nursing

musculoskeletal

movement

Nursing

from normal.

Intervention, the pt.

impairment

elicited by such stimuli,

Intervention, the pt.

may manifest the

which

will be able to

>Assessed patient

>To determine any

identify personal

following:

through our nerves going

identify personal

condition

other underlying

resources, which can

to our neurons, which are

resources, which

cause of

help in providing

then interpreted, by our

can help in

manifestations

assistance.

brain.

providing

>Inability to get bath

supplies
>Inability to wash
body parts
>Inability to pick
appropriate clothing
>Inability to replace
articles or clothing
on own
>Inability to
maintain

neuromuscular,

EXPLANATION
movements are

RATIONALE

>Monitored Vital

O = The patient

Body

INTERVENTIONS

Short Term:

S=

DIAGNOSIS
Self Care deficit r/t

PLANNING

Neurons

of

impulses

then

passes

Nerves

and

serve

as

assistance.

shall be able to

>Provided

> To prevent further

messengers. If these are

adequate rest

stress & fatigue

impaired, the affectation to

periods as well as

Long Term:

the brain function would

Long Term:

comfort & safety

After 2-3 days of

be

After 2-3 days of

measures

nursing intervention,

decreased

function,

which may later on cause

nursing

impairment also to other

intervention, the pt.

structures of the body and

will be able to

> To provide proper

the pt. shall be able to

>Turned pt. slowly

circulation of blood

demonstrate

from side to side

flow on both sides

techniques or changes

appearance at a

this

could

affect

satisfactory level

performance of ADLs. An

techniques or

example

changes to meet

of

that

the
is

Impaired ability to perform

bathing/hygiene, dressing

demonstrate

self care needs.

of he body

to meet self care

needs.

>To assess degree

>Determined pt.

of disability

strengths and skills

or grooming.
>To promote
>Assisted pt. in his

optimal level of

activities

function
>Promotes well

>Encouraged

being and

adequate intake of

maximizes energy

fluids & Nutritious

production.

foods
>To assist with the
>Provided time for

patients current

listening to patient

disability or

and SO, and

condition.

provided privacy
during personal
care activities.
>Involved clients
SO in care
>To assist in
> Provided health

learning ways of

teachings and

managing

support o the SO

problems of

for care options

immobility and for

providing
appropriate nursing
care.

PROBLEM 6: RISK FOR INFECTION

ASSESSMENT
S=
O = The patient may
manifest the
following:
>Hyperthermia
>Erythema
>Chills
>Swelling

NURSING

SCIENTIFIC

DIAGNOSIS

EXPLANATION

Risk for infection

The skin as the first line

of defense is very
important in the
development of infection,
skin when intact cannot
be penetrated and has
nearly infalliable
protective abilities. When
a pt.s. skin is incised, the
first line of defense is
destroyed; despite of the

>Body malaise

sterile equipments and

>Increased WBC

meticulous techniques of
the surgical team,

OBJECTIVES
Short term:
After 2-3 hours of

NURSING
INTERVENTIONS

RATIONALE

> Assess patient

> To obtain

condition

baseline data.

nursing
interventions the pt.
will be able to
identify individual

EXPECTED
OUTCOME
Short term:
After 2-3 hours of
nursing interventions

> Monitor and

> To have a

record v/s

baseline for a need

of further

risk factor and

evaluation.

intervention to

the pt. shall identify

individual risk factor
and intervention to
reduce potential
infection

reduce potential
infection

> Adhere to facility

infection control,
sterilization and

Long term:

infection remains as ever

After 8 hours of

possible with a break in

nursing

the skin it is a good portal

intervention, the pt.

of entry for

will be able to

aseptic policies

>To assess
causative or
contributing factors

Long term:
After 8 hours of
nursing intervention,
the pt. shall achieve

>Stress proper
handwashing

>To prevent cross

timely wound healing

contamination of

and be free of purulent

microbes and

drainage, erythema

microorganisms to start

achieve timely

technique by all

prevent infection

the cause of infection;

wound healing and

caregivers between

thus the a post-op. pt. is

be free of purulent

therapies and pt.

at a high risk for infection.

drainage, erythema

>To prevent and

and be afebrile.

control infection
>Change dressings
as
indicated/needed

>To inform the pt.

and SO(s) and
prevent infection

> Discuss the

correct way of
wound cleaning

> To address the

condition and
continue course of

>Administer
medication caution
as ordered

tx.

and be afebrile.

CONCLUSION
Stroke is a term used to describe the neurologic changes caused by an interruption in
the blood supply to a part of the brain. The incidence of stroke and stroke mortalities has
gradually declined in many industrialized countries in recent years as a result of increased
recognition and treatment of risk factors, which may include modifiable risk factors such as
hypertension
Public education is focused on prevention, recognition of manifestations and early
treatment of brain attack. As they say prevention is better than cure. Therefore it is important for
each and every one of us to avoid these modifiable risk factors and change sedentary lifestyles
to healthy lifestyles. Cholesterol levels should be brought to a normal level; diabetes should be
controlled and reducing heavy alcohol consumption. The best intervention is to stop smoking
cigarettes.
As nursing students, this study showed us the importance of early detection of diseases
such as stroke since it may lead to more serious conditions if it is not properly managed or
treated. Knowledge of the risk factors and preventive measures can help in reducing the
incidence of stroke. Prompt recognition, which allows for early treatment of stroke, is
recommended to lessen residual deficits and decreased disability. Through this study, may we
be able to help others to understand and know more about stroke and ways to prevent and treat
its signs and symptoms.
With this case report, the researchers realized that

psychological

and

physical

implications nvolved in this procedure. Medically, the procedure may be life-saving at its best.
However, social stigma often pinned down the person as terminally ill. This would definitely
affect the persons self- concept and hope over his disease condition. As aspiring nurses, they
should always consider better patient outcomes so as to provide efficient and effective care
delivery.
In this study the group was able to be familiarized to surgical managements and its
benefits and side effect to patient during surgery.

LEARNING DERIVED

As a student nurse, making a case report about craniotomy is very interesting and
fulfilling not only because it is rare, but also it has a very extensive and complex procedure in
order to accomplish it. Allot of bodily systems is affected when a case like this happens. We get
to learn more about the risk factors and benefits of it and how to provide appropriate care for the
patient.
-Donado, JustinWhen we took the case, I knew that it will be a fun and learning experience for me and
for the group. At first we were having second thoughts on taking up the case diagnosis, but we
decided to challenge ourselves although we know that it is a bit complex compared to other
operations. We established rapport with our new sub-group mates to make this case report
possible by working and communicating with each other.
-Malit, JemicahI was always enthusiastic about unique operations such as this because it has many
knowledge. I was so interested not only because I wanted to be a surgeon, but I also want to
expand my knowledge about the theories involved in the operation and also discover new
instruments that are being used in the operation. As we are working together, I realized that the
key is teamwork and camaraderie among my group mates in order to accomplish the case.
-Maglanoc, ErickaI am privileged to handle such case because of the knowledge I can gain from the case
report. It was the first time that I encountered such case that is why I am looking forward to do a
case report for it. Me and my group mates talked and discussed on how are we going to handle
the case. At first we were overwhelmed because we might not handle it properly. But we
decided to take it in order for us to expand our experience and knowledge.
- Ocampo, Kim Persia-

As to with this activity for our related learning experience, I really learned a lot. This
activity really inspired us to be at our best in everything that we do, as well as to practice the

discipline that is really needed for us to achieved excellent results in terms of learnings
regarding the nursing profession. Another thing that I have learned is that I have built my
confidence in terms of performing surgical procedures, of course, through the guidance that our
clinical instructor have laid upon us.
-Vega, Danica-

VII. BIBLIOGRAPHY

Jones and Barlett (2011). Nurse's Handbook of IV Drugs. Third Edition. Malloy, Inc.
Joyce M. Black & Jane Hokanson Hawks. Medical Surgical Nursing, Clinical Management for
Positive Outcomes, vol. 1 & 2, 7th edition. ELSEVIER (SINGAPORE) PTE LTD. (2005).
Joyce Young Hokanson. Brunner & Suddarths Textbook of Medical Surgical Nursing,

10th

Edition. Lippincott Williams & Wilkins, 2004.

Kee, J.L (2011) Laboratory and Diagnostic Test with Nursing Implication: Pearson Education, Inc
Mosby. Mosbys Nursing PDQ. ELSEVIER (SINGAPORE) PTE LTD. (2004)
Saunders. (2014). Saunders Nursing Drug Handbook 2014. Philadelphia, PA: Elsevier, Inc

http://www.enotes.com/nursing-encyclopedia/cerebrovascular-accident
http://www.emedicinehealth.com/anatomy_of_the_central_nervous_system/page2_em.
htm
http://www.mayoclinic.com/health/transient-ischemic-attack/DS00220
http://www.mayoclinic.com/health/stroke/DS00150/DSECTION=symptoms
http://www.mayoclinic.com/health/type-2-diabetes/DS00585
http://www.mayoclinic.com/health/high-blood-pressure/DS00100