Care of the Client with Cranial Surgery

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Care of the Client with Cranial Surgery

• Kathleen Ohman, RN, CCRN, EdD
• Developed in cooperation with Kim Scott, RN, MS

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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 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

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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 SurgeryBurr 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 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.
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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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• 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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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 ICPgt20
• - 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 - 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
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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
• Suctionlimit to lt 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
  patients 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 hematoma
• Epidural hematoma
• Subarachnoid hemorrhage

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Postoperative complications (cont.)

• Hypovolemic shock
• Hydrocephalus
• Respiratory Complications
• Atelectasis
• Hypoxia
• Pneumonia
• Neurogenic 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.)

• Seizures
• Cerebrospinal fluid (CSF) leak
• Cerebral edema

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Summary

• Neuro care complex
• Encompasses science and art of nursing
• Requires technical expertise
• Requires collaboration, communication, compassion