Transcript Care of the Client with Altered Cerebral Perfusion

Care of the Client with
Cranial Surgery
Kathleen Ohman, RN, CCRN, EdD
Developed in cooperation with Kim Scott, RN, MS
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
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
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
MRI showing a meningioma crossing the tentorium on left
Indications for Cranial Surgery
Intracranial bleeding
Indications for Cranial Surgery
Hydrocephalus

Overproduction, malabsorption, or accumulation
of CSF. Shunting procedure performed to drain
CSF.
Hydrocephalus (cont.)
AVM (Arteriovenous
malformation)
Aneurysm Repair
A clip is placed across the neck of the aneurysm which
originates from the carotid artery
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, IV’s, IS, pain management
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

Types of Cranial Surgery:
Burr Hole
-to remove blood/fluid or in
preparation for a craniotomy
Types of Cranial Surgery:
Craniotomy
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.
Craniotomy (cont.)
Types of Cranial Surgery:
Craniectomy
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.
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.
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).
Steriotaxis
Advantages:
•
•
•
•
non-invasive
less risky than craniotomy
decreased cost
decreased length of
stay, recovery
"stereotactic radio surgery”- removing tumors with radiation to a
specific target, without radiating the entire brain
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



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
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
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!
Nursing management: Positioning

Elevate HOB 30 to 45 degrees for supratentorial
surgery

Keep patient flat or slightly elevated if incision
in posterior fossa (infratentorial)
Nursing management after
cranial surgery (cont.)






Assess for pain and provide pain relief measuresnarcotics 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
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
Postoperative Medications





Anticonvulsants
Corticosteroids
Histamine blockers
Analgesics
Antibiotics
Postoperative Complications
 Increased
intracranial pressure (ICP)
 Hematomas
Subdural hematoma
Epidural hematoma
Subarachnoid hemorrhage
Postoperative complications
(cont.)
Hypovolemic shock
 Hydrocephalus
 Respiratory Complications
Atelectasis
Hypoxia
Pneumonia
Neurogenic pulmonary edema

Postoperative Complications
(cont.)



Infection
Meningitis
Fluid and electrolyte imbalances
Dehydration
• Hyponatremia
• Hypernatremia
•
Postoperative Complications
(cont.)
 Seizures
 Cerebrospinal
fluid (CSF) leak
 Cerebral edema
Summary
 Neuro
care complex
 Encompasses science and art of nursing
 Requires technical expertise
 Requires collaboration, communication,
compassion