Nursing Case Analysis

Burr-Hole Craniotomy for Evacuation of Chronic Subdural Hematoma

 Contents

I. Assessment

A. Demographic Profile

B. History

i. History of Past Illness

ii. History of Present Illness

iii. Nursing History

C. Assessment (PCR)

D. Laboratory and Diagnostic Examinations

E. Nurse’s Notes

II. Anatomy and Physiology

III. Pathophysiology

IV. OR Procedure

V. Drug Analysis

VI. Nursing Care Plans

A. Pre-operative

B. Intraoperative

C. Post-operative

VII. References
I. Assessment

A. Demographic Data

Name of Patient: Gascon, Dominador R. Room no.: 313 I Hospital no.: 09600302

Date of Admission: 7/12/09 Chief Complaint: Decreased level of consciousness

Diagnosis: Left Frontoparietal Chronic Subdural Hematoma

Surgery: Emergency Left Frontoparietal Burr-hole Craniostomy for Evacuation of Chronic

Subdural Hematoma

Date of surgery: 7/12/09 Time Started/ Ended: 6:42PM to 7:50PM

Age: 81 Sex: Male Citizenship: Filipino Religion: United Methodist

Birth date: April 30, 1928 Civil Status: Married Occupation: Farmer

Address: Brgy. Centro East Ballesteros, Cagayan

B. History

i. History of Past Illness

• (+) Prostate, enlargement, 2004

o Medical treatment

• (+) Arthritis

o Voltaren as medication

• (-) Allergies

ii. History of Present Illness

• 4 months prior to admission, patient sustained a fall on his head, no consult done, no
medicines taken, no accompanying signs and symptoms.

• 2 weeks PTA, patient had flight of ideas and claimed to have pain on the head with
no other accompanying symptoms. Patient was given Mefenamic Acid and
Amoxicillin which provided slight relief of symptoms.
 • 6 days PTA, patient was admitted to St. Paul Hospital in Tuguegarao. CT Scan done
showed subdural hematoma. Medicines given were unrecalled.

• 4 days PTA, patient was discharged against medical advice because relatives
thought that there was no more chance for the patient.

• 2 days PTA, patient was brought to local clinic where he was given Mannitol,
Dexamethasone, Citicholine, Levoflaxin. Patient was then referred to our institution,
hence admission.

iii. Nursing History

Date taken: 7/16/09 Information Obtained from: Patient’s Daughter

Comfort, Rest and Sleep

Patient was not experiencing pain on surgical site (head) as verbalized by the patient’s
daughter. Prior to admission, patient complained of pain on the head and was given Mefenamic
acid and Amoxicillin to relieve the pain. Patient was relieved of the pain after taking the
medicines. Patient was experiencing pain on his knees due to his arthritis. Patient had also
experienced joint pains before admission and was taking Voltaren as medication. Patient also
has fever with temperature at 38.5 0C.

According to informant, patient has not verbalized difficulty in sleeping except when he
experiences joint pains.

Safety

Patient is bedbound and is partially assisted. Patient has slight difficulty in seeing and
hearing but is not wearing any assistive device.

Fluids and Nutrition

Patient is on modified diet (1800 Kcal/day 0.8g CHON 60% MBV divided into 3 meals
and 2 snacks). Patient drinks 2-3 glasses of water a day and is on IVF (PNSS). Patient has no
problem in the diet except with risk for aspiration. Patient is wearing dentures. Patient’s weight
is normal.

Elimination

Patient is with indwelling catheter to hospicare bag. Patient experienced dysuria before
insertion of IC due to patient’s enlargement of prostate. Patient’s urine output is about 500-
600cc per day. Patient’s urine is yellow and slightly turbid. Patient has not moved his bowel for 8
days according to informant.
D. Laboratory and Diagnostic Examinations

CBC (7/12/09)

Result Reference
value

Hgb 108 120-170

HCT 0.31 0.37-0.54

Patient’s WBC count is elevated
RBC 3.34 4.0-6.0 which accounts for the patient’s febrile state.
Patient’s haemoglobin, RBC and hematocrit
WBC 10.50 4.5- 10.0
are decreased which may be indicative of
neutrophils 0.76 0.50-0.20 hemorrhage.

Blood Chemistry (7/12/09)

Value Reference Value Patient has decreased levels of

sodium and potassium. This results to fluid
Na 136 137-147 shift which can lead to water retention that
causes edema which is manifested in the
K 3.7 3.8-5
patient’s lower extremities. The decrease in
NA may be brought about by hemorrhage
and intake of diuretics (Mannitol)

Coagulation Assay (7/12/09)

results Reference
values
Normal Control 126s
Prothrombin time 13.1 s 10.3-14.1s
Prothrombin ratio 1.1

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

C. Nurse’s Notes

7/12 5pm > Received patient from ward accompanied by

daughter brought to OR per stretcher. Transferred to OR
bed secured with body strap. Patient has the following
contraptions PNSS 1L @ 20 gtts/min from ER with
500mL more to infuse. Foley catheter fr.16 drain to
urine bag. Draining yellowish color urine. Patient was
hooked on monitors. Initial VS are as follows: PR-72; RR-
20; BP- 130/80; SPO2- 96%. Cautery pad placed on left
leg. Initial count of needles, sponges and instruments
5:40pm
done.
5:45pm > A line was inserted by Dr. Gonzaga using abocath
g20
> Anesthesia given by Dr. Gonzaga assisted by Dr. Tan
6:00pm
and Galvan per GETA using ET8 level 20 using
sevoflurane as anesthetic agent. Another line was
inserted on brachial arm using g.16 needle. Shaving
6:42pm
done by Dr. Pagcu followed by prepping. Prepping agent
used was Betadine antiseptic and cleanser.Infiltration
done using sensorcaine 10mL diluted with .05
epinephrine.
7:54pm
> Operation started done by Dr. Pagcu assisted by IIC
and CIC. Initial and final count of cottonoids, needles,

II. Anatomy and Physiology

Anatomy of the Brain

The Cerebrum

The cerebrum is the largest part of the brain and controls voluntary actions, speech,
senses, thought, and memory.

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

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

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

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

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

• The occipital lobes are located at the back of the brain. They receive and process
visual information.

The cortex, also called gray matter, is the most external layer of the brain and
predominantly contains neuronal bodies (the part of the neurons where the DNA-containing cell
nucleus is located). The gray matter participates actively in the storage and processing of
information. An isolated clump of nerve cell bodies in the gray matter is termed a nucleus (to be
differentiated from a cell nucleus). The cells in the gray matter extend their projections, called
axons, to other areas of the brain.

Fibers that leave the cortex to conduct impulses toward other areas are termed efferent
fibers, and fibers that approach the cortex from other areas of the nervous system are termed
afferent (nerves or pathways). Fibers that go from the motor cortex to the brainstem (for
example, the pons) or the spinal cord receive a name that generally reflects the connections
(that is, corticopontine tract for the former and corticospinal tract for the latter). Axons are
surrounded in their course outside the gray matter by myelin, which has a glistening whitish
appearance and thus gives rise to the term white matter.

Cortical areas receive their names according to their general function or lobe name. If in
charge of motor function, the area is called the motor cortex. If in charge of sensory function, the
area is called a sensory or somesthetic cortex. The calcarine or visual cortex is located in the
occipital lobe (also termed occipital cortex) and receives visual input. The auditory cortex,
localized in the temporal lobe, processes sounds or verbal input. Knowledge of the anatomical
projection of fibers of the different tracts and the relative representation of body regions in the
cortex often enables doctors to correctly locate an injury and its relative size, sometimes with
great precision.

Central Structures of the Brain

The central structures of the brain include the thalamus, hypothalamus, and pituitary gland.
The hippocampus is located in the temporal lobe but participates in the processing of memory
and emotions and is interconnected with central structures. Other structures are the basal
ganglia, which are made up of gray matter and include the amygdala (localized in the temporal
lobe), the caudate nucleus, and the lenticular nucleus (putamen and globus pallidus). Because
the caudate and putamen are structurally similar, neuropathologists have coined for them the
collective term striatum.

• The thalamus integrates and relays sensory information to the cortex of the parietal,
temporal, and occipital lobes. The thalamus is located in the lower central part of the
brain (that is, upper part of the brainstem) and is located medially to the basal ganglia.
The brain hemispheres lie on the thalamus. Other roles of the thalamus include motor
and memory control.

• The hypothalamus, located below the thalamus, regulates automatic functions such as
appetite, thirst, and body temperature. It also secretes hormones that stimulate or
suppress the release of hormones (for example, growth hormones) in the pituitary gland.

• The pituitary gland is located at the base of the brain. The pituitary gland produces
hormones that control many functions of other endocrine glands. It regulates the
production of many hormones that have a role in growth, metabolism, sexual response,
fluid and mineral balance, and the stress response.
 • The ventricles are cerebrospinal fluid-filled cavities in the interior of the cerebral
hemispheres.

The Base of the Brain

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

• Traditionally, the cerebellum has been known to control equilibrium and coordination
and contributes to the generation of muscle tone. It has more recently become evident,
however, that the cerebellum plays more diverse roles such as participating in some
types of memory and exerting a complex influence on musical and mathematical skills.

• The brainstem connects the brain with the spinal cord. It includes the midbrain, the
pons, and the medulla oblongata. It is a compact structure in which multiple pathways
traverse from the brain to the spinal cord and vice versa. For instance, nerves that arise
from cranial nerve nuclei are involved with eye movements and exit the brainstem at
several levels. Damage to the brainstem can therefore affect a number of bodily
functions. For instance, if the corticospinal tract is injured, a loss of motor function
(paralysis) occurs, and it may be accompanied by other neurologic deficits, such as eye
movement abnormalities, which are reflective of injury to cranial nerves or their
pathways in the brainstem.

o The midbrain is located below the hypothalamus. Some cranial nerves that are
also responsible for eye muscle control exit the midbrain.

o The pons serves as a bridge between the midbrain and the medulla
oblongata. The pons also contains the nuclei and fibers of nerves that serve eye
muscle control, facial muscle strength, and other functions.

o The medulla oblongata is the lowest part of the brainstem and is interconnected
with the cervical spinal cord. The medulla oblongata also helps control
involuntary actions, including vital processes, such as heart rate, blood pressure,
and respiration, and it carries the corticospinal (that is, motor function) tract
toward the spinal cord.

Meninges

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

Chronic Subdural Hematoma

A subdural hematoma is a collection of blood between the brain and its outer lining (the
Risk factors: Causes (injuries):
agedura mater).Subdural
older than 60 yearshematomas typically develop when trauma to the head causes
Sports the tiny
injuries
veins abuse
alcohol that connect the brain to the dura mater (known as bridging veins) toVehicular
tear and leak blood.
accidents
use of anticoagulant drugs Falls
SYMPTOMS
bleeding disorders Objects fall on head
male gender Blow on head
With a chronic subdural hematoma, bleeding develops much more slowly--usually over weeks
or months. Symptoms are similar to those of acute subdural hematoma but tend to be milder
and subtler and can include:
TRAUMA
• Headache;
• Memory loss;
• Primary
BalanceDamage
or vision problems;
(direct) and Secondary Damage
• Personality changes.

Skull Contusio Brain

fractur n motion
e

Tissue Tissue Rotation Additional Bleeding

compress lacerated of brain counterco
ed by by bone and up injury Inflammation and Edema
bone fragment shearing
Hematoma
of tissue
Possible Infection

Tissue Edema and Tissue

damage minor damage
and bleeding and
bleeding bleeding

Increased Intracranial Pressure

Compress brain stem Compress blood vessel

Loss of Vital Functions Ischemia and

Respiratory and cardiovascular Necrosis
controls
IV. OR Procedure

Emergency Left Frontoparietal Burr-hole Craniostomy

For Evacuation of Chronic Subdural Hematoma

The first illustration shows the pre-operative condition in a left lateral view of the brain,
indicating an acute left fronto-parietal subdural hematoma. The second illustration
shows the hemorrhage in a cut-away view of the brain from above. The third illustration
shows the first step in the procedure, including the creation of two 5 cm incisions into
the left side of the head. The fourth illustration is an enlargement of the surgical area,
showing the drilling of a hole through the skull at each incision site. The fifth illustration
shows the evacuation of the blood from the surface of the brain.

Procedure description
A burr hole for subdural hematoma is performed to remove a hemorrhage (blood clot)
from around the surface of the brain. The location of the blood clot is beneath the firm covering
of the brain known as the dura mater, and is therefore called subdural hematoma. Generally,
when a blood clot is moderately old (at least two to three weeks), it may be drained through a
small hole in the skull, and a large craniotomy flap (opening in the skull) might be avoided.
 The patient will be taken to the operating room and put to sleep under general
anesthesia. The head will be partially shaved, to expose the area of operation. The head may
simply rest on towels, or it may be placed in three fixation points (Mayfield head pins). The
area where surgery is to be performed is then "prepped and draped" using an antibiotic
solution. Next, the surgeon will make an incision, and reflect the scalp over the area of the
hematoma. Then, an air powered drill is used to make a hole in the skull. The dura mater
(tough covering of the brain) is then opened. The hematoma (blood clot) is now seen, and the
surgeon will irrigate some of it out, and may pass a drain around the brain to provide post-
operative drainage. The surgeon will then close the scalp.

Procedure Risks
A. Risks related to the operative site:

Surgical Exposure: The patient is placed in a supine position (on their back). There is risk
of non healing of the scalp post operatively. Although very uncommon, there can be injury to
or tearing of the scalp from the pins on the Mayfield clamp.

Brain injury: The surgery involves exposure of the surface of the brain. There is the
possibility that there may be injury to the brain. If so, this could result in weakness, seizures,
stroke, paralysis, coma or death. There may be residual fluid or blood, requiring additional
surgery in the future. If the fluid around the brain is loculated in pockets separated by
membranes, then the surgery will be unlikely to remove all the fluid, and may in fact only
remove a small portion. This would necessitate additional surgery, possibly a larger
craniotomy to remove the membranes and blood.

General Risks: These include such general difficulties, such as bleeding, infection, stroke,
paralysis, coma and death. Incisions on the low back generally heal well, but if could be
tender, or may heal in an unpleasant manner. There is also the possibility that the surgery
may not relieve the symptoms for which the procedure was performed. The problem for
which the surgery was performed may recur, requiring additional surgery in the future. In
addition, although every attempt is made to protect all areas of the body from pressure on
nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

B. Risks of Anesthesia:
Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion,
if it given.

Anesthesia
Agent: sevorane Method:GETA
OR Technique
1. Induction of anesthesia
2. Asepsis and Anti-sepsis
3. Linear incision over Left Frontoparietal area down to periosteum
4. Burr-hole craniotomy
5. Cruciate dural opening
6. Evacuation of chronic subdural hematoma
7. Irrigation of normal saline
8. Homeostasis
9. Placement of Jackson Pratt
10. Closure layer by layer
MS- skin
Vicryl- periosteum
Suture technique: interrupted
11. Site dressing

Instruments

Knife handle #3 2 Adsons 2

Knife handle #7 1 Uretrals 2
Tissue forceps 2 Weitlaner ST 2
Thumb forceps 1 Hudson with 9 burrs
Mosquito 28 Needles:
Allis 18 Round
Towel clip 16 Cutting
Kidney basin 1 Intestinal
Medicine cup 2 Suture:
Needle holder 4 MS 2-0
Mayo scissors 1 MS 4-0
Metzembaum 1 Vicryl 2-0
Straight mayo scissors 1 Others:
Cautery tip P 1 Asepto syringe
Freer 1 Jackson Pratt
Periosteal elevator 3 Stapler
Curette 1 Bonewax
Gooseneck 1 OS (2/3’s and 24’s)
Razor
VII. REFERENCES:

o Nursing 2008 Drug Handbook

o Pathophysiology of the Systems
o Nursing Care Plans by Doenges
o Essentials of Anatomy and Physiology by Seeley, Stephens, Tate
o http://www.neurosurgerypa.com/procedures/Burrhole.html
o http://www.ubneurosurgery.com/handler.cfm?event=practice,template&cpid=1706
o www.scribd.com
o www.nursingcrib.com
o http://www.doereport.com