THEORITICAL BACKGROUND

CRANIOTOMY

Compiled By:
Khairan Adiyani

INTERNATIONAL CALASS OF NURSING DIPLOMA PROGRAM

FACULTY OF NURSING AND HEALTH SCIENCE
UNIVERSITY OF MUHAMMADIYAH BANJARMASIN

2018/2019 ACADEMIC YEAR

A. Concept of Disease
1. Anatomical Physiology

1. Duramater (outer layer)

Hard membrane covering the brain from thick and strong connective tissue .
2. Arakhnoida (middle layer)
The thin membrane that separates the dura mater from the pamater forms a balloon filled
with brain fluid which covers the entire central nervous system.
3. Piamater (inner layer)
The thin membrane found on the surface of brain tissue, the pyramid is related to
arakhnoid through connective tissue structures called tubercles.
Parts of the brain:
1. cerebrum (cerebrum)
is the widest and largest part of the brain, egg-shaped filling the front of the cavity in the
cerebrum found lobes, namely:
a. Frontal lobe is the front of the cerebrum located in front of the central sulcus. The
Frontal lobe of the cerebral cortex mainly controls motor skills (eg writing, playing a
musical instrument or tying a shoelace) the frontal lobe also regulates facial
expressions and hand signals.
b. The Parietal lobe, below the lateral cerebral fissure and in front of the occipital lobe.
The parental lobe of the cerebral cortex combines the impression of the shape of the
texture and weight into the general perception, the mathematical and linguistic
abilities originating from this area, also helping to position the surrounding space and
positioning the body parts.
c. The temporal lobe, below the lateral cerebral fissure and in front of the occipital lobe.
The temporal lobe processes events that have just occurred to remember them as
 long-term memory, also understands sounds and images, stores memory and
remembers it and produces emotional pathways.
d. The Oksipitalis lobe, which fills the back of the cerebrum.
2. Brain Trunk (cerebral trunk)
Disensepalon upward associated with cerebrum and medulla oblongata downward with
spinal cord. The cerebrum enters the brain stem in the medulla oblongata, pons varoli
and mensesep Serebrum
3. (cerebellum)
Located at the bottom and back of the skull separated by the cerebrum by the transversal
fissure behind the varoli pons and above the medulla oblongata. This person receives a
lot of sensory afferent fibers which is the center of coordination and intelligence.

2. DEFINITION
Craniotomy is an operation to open the skull (cranium) with the intention of
knowing and repairing brain damage. (Brown, 2009).
Craniotomy is the surgical opening of the skull to increase access to the
intracranial structure. This procedure is performed to remove tumors, reduce ICT,
evacuate blood clots and control hemorrhage. (Brunner and Suddarth, 2005).
Epidural hematoma is bleeding in the epidural space between the skull and the
dura mater, usually: it involves a temporoparietal fracture which results in laceration of
the medial meningeal artery (Susan M, Tucker, Dkk. 1998)

Classification of Craniotomy
a. Epidural Hematoma (EDH)is a bleeding that occurs between the bone and the dura
mater.
b. Subdural hematoma (SDH) is a bleeding contained in the cavity between the layers
of the dura mater with araknoidea
3. Indications Craniotomy
Indications action craniotomyor intracranial surgery is as follows:
a. The removal of abnormal tissue either tumor or cancer.
b. Reducing intracranial pressure.
c. Evacuate blood clots.
d. Controlling blood clots,
e. Improving intracranial organs,
f. Brain tumors,
g. Bleeding (hemorrage),
h. Weakness in blood vessels (cerebral aneurysms)
i. Inflammation in the brain
 j. Trauma to the skull.

4. Etiology of craniotomy
a. by sharp
b. objects Blunt objects
c. Blows sharp objects
d. Traffic
e. Falling
f. accidentswork accidents

5. Clinical manifestations of craniotomy

1. CLINICAL MANIFESTATIONS
According to Brunner and Suddarth (2000) symptoms caused to clients with
craniotomy include:
a. Decreased consciousness, severe headaches, and dizziness
b. If the hematoma is more widespread, symptoms of deserebration and disturbance
of vital signs and respiratory function will arise.
c. An increase in ICT after surgery is characterized by projectile vomiting, dizziness
and increased vital signs.

6. Diagnostic Examination
Craniotomy Preoperative diagnostic procedures can include: (Sjamsuhidajat, R. Wim
de Jong. 2012)
a. Computer tomography (CT scanning)
To show lesions and show the degree of surrounding brain edema, ventricular
size, and changes in position / shift in brain tissue, hemorrhagic.
Note: Repeated examinations may be needed because the ischemia / infarction may not be
detected within 24-72 hours after trauma.
b. Magnetic resonance imaging (MRI)
Same as CT, with the added advantage of examining lesions in other pieces.
c. X-rays
Detect changes in bone structure (fracture), shifting structure from the midline
(due to bleeding, edema), the presence offragments
d. Brain Auditory Evoked Response (BAER): determine the function of the cortex and
brain stem
e. Lumbar function, CSS: can predict the possibilitysubarachnoid hemorrhage
f. Artery Blood Gas(GDA): aware of the problem of ventilation or oxygenation would
improve ICT
7. Pathway
Craniotomy

Less of Pre operatif Intra Operatif Post Operatif

Knowledge
Impaired of
Incision wound
Anxiety skin tissue
Anesthetic effect

Bleeding
Impaired of
skin integrity Pressing the nerve Urinary system System G.I.
Impaired center
tissue
perfussion Decreased of Medullary
Decreased Decreased work of
kidney function stimulation
blood volume respiratory organs

Nerve endings Decreased of lung Decreased of Reflex of vomiting

Lack of blood expansion urinary reflex
volume
Pain receptors
Decreased O2 supply Nausea, vomitis
inkontinensia
Acute pain
Ineffective Nutritional disorders,
breathing pattern Change in pattern less than body’s
of urine needs
elimination
Accumulation of secretion Ineffective air way
clerance
8. Medical Management
a. preoperative
in containment procedures preoperative intracranial surgery patients treated with
anticonvulsant medications (phenytoin) to reduce the risk of postoperative seizures.
Before surgery, steroids (dexamethasone) can be given to reduce cerebral edema.
Fluid can be limited. Hyperosmotic agents (mannitol) and diuretics (furosemide) can
be administered intravenously immediately before and sometimes during surgery if
patients tend to hold water, which occurs in individuals who experience intracranial
dysfunction. The urinary catheter is fixed before the patient is taken to the operating
room to drain the bladder during administration of diuretics and to allow urinary
output to be monitored. Patients can be given antibiotics if the cerebral is
contaminated or deazepam at preoperative to eliminate anxiety.
The scalp is shaved immediately before surgery (usually in the operating room)
so that all superficial abrasions do not all get infected.
b. Postoperative
Arterial pathways and central venous pressure pathways (CVP) can be installed
to monitor blood pressure and measure CVP. The patient may or may not be
intubated and receive additional oxygen therapy.
Reducing Cerebral Edema: Medicationtherapy to reduce cerebral edema
includes administration of mannitol, which increases serum osmolality and draws
free water from the brain area (with a whole blood-brain barrier). This liquid is then
excreted through osmotic diuresis. Dexamethasone can be given intravenously every
6 hours for 24 to 72 hours; then the dose is gradually reduced.
Relieves Pain and Prevents Seizures:Acetaminophen isusually given as long as
the temperature is above 37.50C and for pain. Often patients will experience
headaches after craniotomy, usually as a result of the nerves of the scalp being
stretched and irritated during surgery.Codeine,given via parenteral, is usually
sufficient to relieve headaches.Anticonvulsant medication(phenytoin, deazepam) is
prescribed for patients who have undergone supratentorial craniotomy, because of
the high risk of epilepsy after a neuro supratentorial surgical procedure. Serum levels
were monitored to maintain medication within the therapeutic range.
Monitoring Intracranial Pressure: Theventricular catheter,or some type of
drainage, is often installed in patients undergoing surgery for posterior fossa tumors.
The catheter is connected to an external drainage system. Catheter compliance is
observed through fluid pulses in the hose. ICT can be assessed by arranging the
system with a stopper connection to the pressure hose and transducer. ICTs are
monitored by turning the stopper. Care is needed to ensure that the system is tight at
 all connections and that the stopper is in the right position to avoid drainage of
cerebrospinal fluid, which can result in ventricular collapse if too much fluid is
removed. The catheter is removed when ventricular pressure is normal and stable.
Neuro surgeons are told whenever a catheter is not blocked.
Ventricular shunts are sometimes performed before certain surgical procedures to
control intracranial hypertension, especially in posterior fossa tumor patients.

B. NURSING PLANNING PLAN

1. Assessment
1. Primary Assessment
a. Airway
There is obstruction / airway obstruction by the presence of secretions due to the
weakness of cough reflexes
b. Breathing
Weakness / coughing / protecting the airway, difficult and / or irregular breathing,
breathing sounds ronchi / aspiration
c. Circulation
TD can be normal or increased, hypotension occurs at an advanced stage,
tachycardia, normal heart sounds at an early stage, dysrhythmias, pale, cold skin
and mucous membranes, cyanosis in the later stages
2. Secondary Assessment
a. Pattern of perception of health and maintenance and health
● Family history with tumors
● Exposure to excessive radiation.
● A history of visual problems-loss of visual acuity and diplopia.
● Alcohol addiction, heavy smokers.
● An abnormal feeling occurs.
● Personality disorders / hallucinations
b. Pattern of metabolic nutrition
● History of epilepsy
● Appetite is lost
● The presence of nausea, vomiting during the acute phase
● Loss of sensation on the tongue, cheeks and throat
● Difficulty swallowing (disturbance in the reflex of the palate and pharyngeal)
c. Pattern of elimination
● Changes in urination and bowel movements (Incontinence)
● Negative bowel sounds
d. Pattern of activity and exercise
 ● Muscle tone disorders of muscle weakness, impaired level of consciousness
● Risk of trauma due toepilepsy
● Hamiparase, ataxia
● Vision impairment
● Feeling tired easily, loss of sensation (Hemiplegia)
e. Pattern of sleep and rest
● It is difficult to rest and or sleep easily
f. Pattern of cognitive perception and sensory
● dizziness
● Headache
● Weakness
● Tinnitus
● Motor aphasia
● Loss of contralateral sensory stimulation Disturbing
● taste, smell and vision
● Memory reduction, problem solving
● loses ability to enter visual stimuli
● Decreased consciousness to coma
● Not able to record images
● Not able to distinguish right / left
g. Patterns of perception and self-concept
● Feelings of helplessness and hopelessness
● Unstable emotions and difficulties in expressing
h. Patterns of roles and relationships with others
● Talking problems
● Inability to communicate (losing verbal communication / talking pelo)
i. Reproduction and sexuality
● The existence of sexuality disorders and sexuality deviations
● Influence / relationship of diseases to sexuality
j. The pattern of coping and tolerance mechanisms for stress
● The feeling of anxiety, fear, impatience or anger
● The coping mechanism commonly used
● Feelings of helplessness, hopelessness
● The emotional response of the client to the current status
● People who help in solving problems Are
● easily offended
k. Thebelief system
● religiousadopted, is the activity of worship disrupted
2. NURSING DIAGNOSIS
1. Disorders of comfortable feeling of pain associated with incision wounds.
2. Damage to the integrity of the skin associated with incision wounds.
3. High risk of infection associated with bad wound gygiene
4. Disorders of tissue perfusion associated with bleeding
5. Lack of fluid volume associated with postoperative bleeding.

3. NURSING INTERVENTION
Nursing Criteria Results / Intervention
No Rationalization
Diagnosis Objectives Silence
1. Disorders of Objective: 1. Assess pain, note 1. Useful in
comfortable After nursing action, the location, monitoring the
feeling pain can be overcome characteristics, effectiveness of the
associated or handled properly. scale (0-10). drug, progress in
with incision Criteria results: Investigate and healing. Changes in
wounds · Report the pain is report pain the characteristics
gone or controlled. changes of pain indicate
· Reveal the method appropriately. abscesses.
of giving pain relief. 2. Maintain the 2. Reducing
· Demonstrating the semi fowler rest abdominal tension
use of relaxation position. which increases
techniques and with supine
entertainment position.
activities as a pain 3. Encourage early 3. Increases the
reliever ambulation normalization of
organ function, for
example stimulating
peristaltic and
smooth flatus, and
decreasing
abdominal
discomfort.
4. Give an ice bag 4. Eliminate and
to the abdomen reduce pain through
nerve endings
note: do not do hot
compresses because
it can cause tissue
congestion.
5 Give analgesics 5. Relieving pain
as indicated facilitates
cooperation with
other therapeutic
interventions.
2. Damage to Objective: After the 1. Assess and 1. Identify
the integrity action is given the record the size, complications.
of the skin patient does not color, condition of
associated experience skin the wound, and the
with incision integrity problems. condition around
wounds Criteria results: the wound.
· Demonstrate healing 2. Do wet and cool 2. Is a protective
of wounds on time. compresses or action that can
· Patients show apply slime. reduce pain.
behavior to improve
healing and prevent 3. Perform wound 3. Allows patients to
complications. care and hygiene move more freely
after bathing, then and improve patient
dry the skin comfort.
carefully.
4. Give priority to 4. Accelerate the
improve patient process of healing
comfort. and rehabilitation
of patients,
3. High risk of Objective: 1. Monitor vital 1. Early detection of
infection After nursing action is signs, pay attention infection.
associated taken. Patients are to fever, chills,
with poor expected not to get an sweating and
wound infection. Criteria for mental changes and
hygiene results: increased
· Does not indicate abdominal pain.
any sign of infection. 2. Look at the 2. Providing early
· No infection. incisions and detection of the
bandages. Note the infection process.
characteristics,
wound drainage.
3. Do good hand 3. Reducing the
washing and do spread of bacteria
aseptic wound care.
4. Give antibiotics 4. It may be given in
as indicated. a profile to reduce
the number of
organisms, and to
reduce the spread
and growth.
4. Disorders of Objective: 1. Observation of 1. Long bed rest can
tissue · After treatment there is extremities of trigger venous static
perfusion no disruption of tissue swelling, and and increase the risk
associated perfusion. Criteria erythema. of thrombosis
with results: formation.
bleeding ● Vital signs are 2. Evaluate mental 2. Indications that
stable. status. Note the show systemic
● Client's skin is occurrence of colonization of the
warm and dry. hemaparalis, brain
● Peripheral pulse is aphasia, seizures,
strong and strong. vomiting and
● Balanced input or increased BP
output

5. Lack of fluid Objectives: 1. Keep an eye on 1. Provide

volume · After nursing action the the liquid intake information about
associated patient shows and outflow. replacing organ
with adequate fluid balance needs and functions.
postoperative ● Stable vital signs.
bleeding. ● Moist mucosa 2 Monitor TTV, 2. Adequate
● Skin turgor / good examine mucous indicator of
capillary filling. membranes, skin circulation /
● Good urine output. turgor, mucous perfusion volume.
membrane,
peripheral pulse
and capillary
filling.
3. Monitor 3. Provides
laboratory tests. information about
circulation volume,
fluid and electrolyte
balance.
4. Give IV fluids or 4. Maintain
blood products as circulation volume
indicated.
 Bibliography
Brunner & Suddarth. 2005. Keperawatan Medikal Bedah.(edisi 8). Jakarta : EGC
Carpenito, Lynda Juall. 2006.Buku Saku Diagnosa Keperawatan. Jakarta :EGC
Brown CV, Weng J, Oh D, et al. 2009. Does routine serial computed tomography of the head
influence management of traumatic brain injury. A prospective evaluation. Trauma.
Sjamsuhidajat, R. Wim de Jong , Buku Ajar Ilmu Bedah. EGC, Jakarta. 2012.
Tucker, Susan Martin, 1998, Standart Perawatan Pasien, Proses Keperawatan Diagnosa dan
Evaluasi. Volume 3, Edisi 5, Penerbit Buku Kedoktera, EGC, Jakarta.