Title: Care of the Client with Cranial Surgery
1Care of the Client with Cranial Surgery
- Kathleen Ohman, RN, CCRN, EdD
- Developed in cooperation with Kim Scott, RN, MS
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3Indications for Cranial Surgery
- Intracranial infection (abscess) - usually
staphylococci or streptococci. Cranial surgery
performed to open and drain abscess - Epilepsy - Cranial surgery to remove the
epileptic focus for patients whose epilepsy
cannot be controlled by drug therapy - Skull fractures - for depressed fracture or
fracture with loose fragments. Cranial surgery
necessary to elevate depressed bone and/or remove
fragments
4Indications for Cranial Surgery Brain Tumors
- Steriotactical techniques used to perform biopsy
and/or remove small tumors - Location and type determines if surgical removal
possible - Tumors located in deep central areas of brain
inoperable - Cranial surgery performed if tumor is removable
5Brain Tumors (cont.)
- Primary tumors - arise from tissues in the brain
- Secondary tumors - result from metatastisis from
malignant neoplasm elsewhere in body - Gliomas account for 65 of primary tumors
(malignant) - Astrocytoma- most common glioma
- Oligodendroglioma-often localized frontally
- Glioblastoma multiforme highly malignant and
invasive - Meningioma and Pituitary tumors
- Benign
- Tend to recur
- Unless treated, all tumors cause death from
increased tumor volume leading to increased ICP
6MRI showing a meningioma crossing the tentorium
on left
7Indications for Cranial Surgery Intracranial
bleeding
8Indications for Cranial Surgery Hydrocephalus
- Overproduction, malabsorption, or accumulation of
CSF. Shunting procedure performed to drain CSF.
9Hydrocephalus (cont.)
10AVM (Arteriovenous malformation)
11Aneurysm Repair
- A clip is placed across the neck of the aneurysm
which originates from the carotid artery - Â Â
12Preoperative nursing management
- Preoperative teaching to patient and family
- Explain preop labs, tests, procedures
- Explain anesthesia, estimated length of
procedure, how long in recovery and where will go
after recovery (ICU) - Explain how pt. will look after surgery
- Explain what to expect postoperatively re
dressings, catheter, ET tube, Foley, IVs, IS,
pain management -
13Preoperative nursing management (cont.)
- Nearest relative may need to sign consent
- Scalp prep - hair shaved (save hair) to reduce
risk of infection and provide better exposure - Baseline neuro assessment
- Family anxious re potential physical and
emotional deficits related to surgery -
compassionate preoperative nursing care
14Types of Cranial SurgeryBurr Hole-to remove
blood/fluid or in preparation for a craniotomy
15Types of Cranial Surgery Craniotomy
16Craniotomy (cont.)
After the dura has been stitched closed, the
piece of bone is replaced and sutured into
place. An ICP monitoring device may then be
implanted.
17Craniotomy (cont.)
18Types of Cranial Surgery Craniectomy
19Shunt Procedures
While the patient is deep asleep and
pain-free (using general anesthesia), a flap is
cut into the scalp, and a small hole is drilled
in the skull.
20Shunt Procedures (cont.)
A small catheter is passed into a ventricle of
the brain. A pump is attached to the catheter to
keep the fluid away from the brain. Another
catheter is attached to the pump and tunneled
under the skin, behind the ear, down the neck
and chest, and into the peritoneal cavity
(abdominal cavity). The CSF is absorbed in the
peritoneal cavity.
21Minimally Invasive Cranial Surgery
- A preoperative cerebral arteriogram (A) shows a
basilar tip aneurysm. Â A postoperative
arteriogram, after aneurysm clipping via a
superolateral orbital craniotomy, confirms
successful clipping (B). A patient with a healed
superolateral orbital craniotomy incision line
(C) (arrows).
22 - Steriotaxis
- Advantages
- non-invasive
- less risky than crani-
- otomy
- decreased cost
- decreased length of
- stay, recovery
"stereotactic radio surgery- removing tumors
with radiation to a specific target, without
radiating the entire brain
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24Nursing Management after Cranial Surgery
- Primary Goal of Care - prevention of increased
ICP - Ventriculostomy
- Drains CSF
- Allows for intraventricular drug administration
- Measures pressure within vessels
-
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27Monitor ICP and CPP Pressure Waves
- A waves (plateau waves)
- - associated with ICPgt20
- - indicates exhausted intracranial spatial
compensation - - associated with increased cerebral volume
and - decreased cerebral blood flow, cerebral
ischemia and brain damage -
28B waves - rhythmic oscillations approx. q min -
associated with fluctuating breathing
pattern C waves - associated with normal
changes in systemic art. pressure
B waves in raised ICP
29Nursing management after cranial surgery (cont.)
- Frequent assessment of neurological status (every
30 minutes, then hourly) for the first 24-48
hours - Frequent vital signs
- Limit care activities that increase ICP
- DO NOT cluster cares!
30Nursing management Positioning
- Elevate HOB 30 to 45 degrees for supratentorial
surgery - Keep patient flat or slightly elevated if
incision in posterior fossa (infratentorial)
31Nursing management after cranial surgery (cont.)
- Assess for pain and provide pain relief
measures-narcotics mask LOC - Check drains for placement, patency - strict
sterile technique - Check dressing for drainage, CSF leak - strict
sterile technique - Suctionlimit to lt 15 seconds preoxygenate
- Turn q 2 hrs (slow, gentle movements)
- ROM exercises
32Nursing management after cranial surgery (cont.)
- Assess effect of ill family member on family
- Teach family to provide care to ill family member
- Facilitate family communication and planning
- Provide accurate information to family regarding
patients condition - Initiate referrals as needed, i.e. speech
therapy, physical therapy
33Postoperative Medications
- Anticonvulsants
- Corticosteroids
- Histamine blockers
- Analgesics
- Antibiotics
34Postoperative Complications
- Increased intracranial pressure (ICP)
- Hematomas
- Subdural hematoma
- Epidural hematoma
- Subarachnoid hemorrhage
35Postoperative complications (cont.)
- Hypovolemic shock
- Hydrocephalus
- Respiratory Complications
- Atelectasis
- Hypoxia
- Pneumonia
- Neurogenic pulmonary edema
36Postoperative Complications (cont.)
- Infection
- Meningitis
- Fluid and electrolyte imbalances
- Dehydration
- Hyponatremia
- Hypernatremia
37Postoperative Complications (cont.)
- Seizures
- Cerebrospinal fluid (CSF) leak
- Cerebral edema
38Summary
- Neuro care complex
- Encompasses science and art of nursing
- Requires technical expertise
- Requires collaboration, communication, compassion