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Transcript of cranial-surgery-care-nursing
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Care of the Client with Cranial Surgery
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Indications 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
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Indications 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
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Brain 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
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MRI showing a meningioma crossing the tentorium on left
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Indications for Cranial Surgery Intracranial bleeding
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Indications for Cranial Surgery Hydrocephalus
Overproduction, malabsorption, or accumulation of CSF. Shunting procedure performed to drain CSF.
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Hydrocephalus (cont.)
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AVM (Arteriovenous malformation)
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Aneurysm Repair
A clip is placed across the neck of the aneurysm which originates from the carotid artery
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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, IV’s, IS, pain management
Preoperative nursing management
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Preoperative 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
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Types of Cranial Surgery:Burr Hole
-to remove blood/fluid or in preparation for a craniotomy
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Types of Cranial Surgery: Craniotomy
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Craniotomy (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.
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Craniotomy (cont.)
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Types of Cranial Surgery: Craniectomy
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Shunt 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.
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Shunt Procedures (cont.)
A small catheter is passed into a ventricle of the brain. A pump is attachedto the catheter to keep the fluid away from the brain. Another catheter isattached 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.
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Minimally Invasive Cranial Surgery
A preoperative cerebral arteriogram (A) shows a basilar tip aneurysm. 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).
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SteriotaxisAdvantages:• 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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Nursing 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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Monitor ICP and CPP Pressure Waves
A waves (plateau waves)- associated with ICP>20
- indicates exhausted intracranial spatial compensation
- associated with increased cerebral volume and decreased cerebral blood flow, cerebral ischemia
and brain damage
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B waves in raised ICP
B waves- rhythmic oscillations approx. q min- associated with fluctuating breathing pattern
C waves- associated with normal changes in systemic art. pressure
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Nursing 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!
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Nursing management: Positioning
Elevate HOB 30 to 45 degrees for supratentorial surgery
Keep patient flat or slightly elevated if incision in posterior fossa (infratentorial)
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Nursing 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
Suction—limit to < 15 seconds; preoxygenate Turn q 2 hrs (slow, gentle movements) ROM exercises
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Nursing 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
patient’s condition Initiate referrals as needed, i.e. speech therapy,
physical therapy
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Postoperative Medications
Anticonvulsants Corticosteroids Histamine blockers Analgesics Antibiotics
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Postoperative Complications
Increased intracranial pressure (ICP) Hematomas
Subdural hematomaEpidural hematomaSubarachnoid hemorrhage
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Postoperative complications (cont.)
Hypovolemic shock Hydrocephalus Respiratory Complications
AtelectasisHypoxiaPneumoniaNeurogenic pulmonary edema
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Postoperative Complications (cont.)
Infection Meningitis Fluid and electrolyte imbalances
• Dehydration• Hyponatremia• Hypernatremia
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Postoperative Complications (cont.)
SeizuresCerebrospinal fluid (CSF) leakCerebral edema
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Summary
Neuro care complex Encompasses science and art of nursing Requires technical expertise Requires collaboration, communication,
compassion