Intracranial Surgery

  1. Types
    1. Craniotomy: surgical opening of skull to gain access to intracranial structures; used to remove a tumor, evacuate blood clot, control hemorrhage, relieve increased ICP
    2. Craniectomy: excision of a portion of the skull; sometimes used for decompression
    3. Cranioplasty: repair of a cranial defect with a metal or plastic plate
  2. Nursing interventions: preoperative
    1. Routine pre-op care (see Perioperative Nursing).
    2. Provide emotional support; explain post-op procedures and that client's head will be shaved, there will be a large bandage on head, possibly temporary swelling and discoloration around the eye on the affected side, and possible headache.
    3. Shampoo the scalp and check for signs of infection.
    4. Shave hair.
    5. Evaluate and record baseline vital signs and neuro checks.
    6. Avoid enemas unless directed (straining increases ICP).
    7. Give pre-op steroids as ordered to decrease brain swelling.
    8. Insert Foley catheter as ordered.
  3. Nursing interventions: postoperative
    1. Provide nursing care for the unconscious client (see Care of the Unconscious Client).
    2. Maintain a patent airway and adequate ventilation.
      1. Supratentorial incision: elevate head of bed 15°-45° as ordered; position on back (if intubated or conscious) or on unaffected side; turn every 2 hours to facilitate breathing and venous return.
      2. Infratentorial incision: keep head of bed flat or elevate 20°-30° as ordered; do not flex head on chest; turn side to side every 2 hours using a turning sheet; check respirations closely and report any signs of respiratory distress.
      3. Instruct the conscious client to breathe deeply but not to cough; avoid vigorous suctioning.
    3. Check vital signs and neuro checks frequently; observe for decreasing LOC, increased ICP, seizures, hyperthermia.
    4. Monitor fluid and electrolyte status.
      1. Maintain accurate I&O.
      2. Restrict fluids to 1500 ml/day or as ordered to decrease cerebral edema.
      3. Avoid overly rapid infusions.
      4. Watch for signs of diabetes insipidus (severe thirst, polyuria, dehydration) and inappropriate ADH secretion (decreased urine output, hunger, thirst, irritability, decreased LOC, muscle weakness).
      5. For infratentorial surgery: may be NPO for 24 hours due to possible impaired swallowing and gag reflexes.
    5. Assess dressings frequently and report any abnormalities.
      1. Reinforce as needed with sterile dressings.
      2. Check dressings for excessive drainage, CSF, infection, displacement and report to physician.
      3. If surgical drain is in place, note color, amount, and odor of drainage.
    6. Administer medications as ordered.
      1. Corticosteroids: to decrease cerebral edema
      2. Anticonvulsants: to prevent seizures
      3. Stool softeners: to prevent straining
      4. Mild analgesics
    7. Apply ice to swollen eyelids; lubricate lids and areas around eyes with petrolatum jelly.
    8. Refer client for rehabilitation for residual deficits.