NURSING PROCESS: THE PATIENT UNDERGOING INTRACRANIAL SURGERY
After surgery, the frequency of postoperative monitoring is based on the patient’s clinical status. Assessing respiratory function is essential because even a small degree of hypoxia can increase cere-bral ischemia. The respiratory rate and pattern are monitored, and arterial blood gas values are assessed frequently. Fluctuations in vital signs are carefully monitored and documented because they indicate increased ICP. The patient’s temperature is mea-sured at intervals to assess for hyperthermia secondary to damage to the hypothalamus. Neurologic checks are made frequently to detect increased ICP resulting from cerebral edema or bleeding. A change in LOC or response to stimuli may be the first sign of increasing ICP.
The surgical dressing is inspected for evidence of bleeding and CSF drainage. The nurse must be alert to the development of com-plications; all assessments are carried out with these problems in mind. Chart 61-2 provides an overview of the nursing management of the patient after intracranial surgery. Seizures are a potential com-plication, and any seizure activity is carefully recorded and reported. Restlessness may occur as the patient becomes more responsive or may be due to pain, confusion, hypoxia, or other stimuli.
Based on the assessment data, the patient’s major nursing diag-noses after intracranial surgery may include the following:
· Ineffective cerebral tissue perfusion related to cerebral edema
· Potential for ineffective thermoregulation related to dam-age to the hypothalamus, dehydration, and infection
· Potential for impaired gas exchange related to hypoventila-tion, aspiration, and immobility
· Disturbed sensory perception related to periorbital edema, head dressing, endotracheal tube, and effects of ICP
· Body image disturbance related to change in appearance or physical disabilities
Other nursing diagnoses may include impaired communica-tion (aphasia) related to insult to brain tissue and high risk for impaired skin integrity related to immobility, pressure, and in-continence. There may be impaired physical mobility related to a neurologic deficit secondary to the neurosurgical procedure or to the underlying disorder.
Potential complications include:
· Increased ICP
· Bleeding and hypovolemic shock
· Fluid and electrolyte disturbances
The major goals for the patient include neurologic homeostasis to improve cerebral tissue perfusion, adequate thermoregulation, normal ventilation and gas exchange, ability to cope with sensory deprivation, adaptation to changes in body image, and absence of complications.
Attention to the patient’s respiratory status is essential because even slight decreases in the oxygen level (hypoxia) can cause cere-bral ischemia and can affect the clinical course and outcome. The endotracheal tube is left in place until the patient shows signs of awakening and has adequate spontaneous ventilation, as evalu-ated clinically and by arterial blood gas analysis. Secondary brain damage can result from impaired cerebral oxygenation.
Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. The control of cerebral edema is discussed in the earlier section on management of increased ICP. Nursing strategies used to control factors that may raise ICP are found earlier in Nursing Process: The Patient With Increased ICP. Intra-ventricular drainage is carefully monitored, using strict asepsis when any part of the system is handled.
Vital signs and neurologic status (LOC and responsiveness, pupillary and motor responses) are assessed every 15 minutes to every 1 hour. Extreme head rotation is avoided because this raises ICP. After supratentorial surgery, the patient is placed on his or her back or side (unoperated side if a large lesion was removed) with one pillow under the head. The head of the bed may be elevated 30 degrees, depending on the level of the ICP and the neurosurgeon’s preference. After posterior fossa (infratentorial) surgery, the patient is kept flat on one side (off the back) with the head on a small, firm pillow. The patient may be turned on either side, keeping the neck in a neutral position. When the patient is being turned, the body should be turned as a unit to prevent plac-ing strain on the incision and possibly tearing the sutures. The head of the bed may be elevated slowly as tolerated by the patient.
The patient’s position is changed every 2 hours, and skin care is given frequently. During position changes, care is taken to pre-vent disrupting the ICP monitoring system. A turning sheet placed under the head to the midthigh makes it easier to move and turn the patient safely.
Moderate temperature elevation can be expected after intracra-nial surgery because of the reaction to blood at the operative site or in the subarachnoid space. Injury to the hypothalamic centers that regulate body temperature can occur during surgery. High fever is treated vigorously to combat the effect of an elevated tem-perature on brain metabolism and function.
Nursing interventions include monitoring the patient’s tem-perature and using the following measures to reduce body tem-perature: removing blankets, applying ice bags to axilla and groin areas, using a hypothermia blanket as prescribed, and adminis-tering prescribed medications to reduce fever.
Conversely, hypothermia may be seen after lengthy neurosur-gical procedures. Therefore, frequent measurements of rectal temperature are necessary. Rewarming should occur slowly to prevent shivering, which increases cellular oxygen demands.
The patient undergoing neurosurgery is at risk for impaired gas ex-change and pulmonary infections because of immobility, immuno-suppression, decreased LOC, and fluid restriction. Immobility compromises the respiratory system by causing pooling and sta-sis of secretions in dependent areas and the development of at-electasis. The patient whose fluid intake is restricted may be more vulnerable to atelectasis as a result of inability to expectorate thickened secretions. Pneumonia is frequently seen in neuro-surgical patients, possibly related to aspiration and restricted mobility.
The nurse assesses the patient for signs of respiratory infection, which include temperature elevation, increased pulse rate, and changes in respirations, and auscultates the lungs for decreased breath sounds and adventitious sounds.
Repositioning the patient every 2 hours will help to mobilize pulmonary secretions and prevent stasis. When the patient regains consciousness, additional measures to expand collapsed alveoli can be instituted, such as yawning, sighing, deep breathing, incentive spirometry, and coughing (unless contraindicated). If necessary, the oropharynx and trachea are suctioned to remove secretions that cannot be raised by coughing; however, coughing and suctioning increase ICP. Therefore, suctioning should be used cautiously. In-creasing the humidity in the oxygen delivery system may help to loosen secretions. The nurse and the respiratory therapist work to-gether to monitor the effects of chest physical therapy.
Periorbital edema is a common consequence of intracranial surgery because fluid drains into the dependent periorbital areas when the patient has been positioned in a prone position during surgery. A hematoma may form under the scalp and spread down to the orbit, producing an area of ecchymosis (black eye).
Before surgery, the patient and family should be informed that one or both eyes may be edematous temporarily after surgery. After surgery, placing the patient in a head-up position (if not contraindicated) and applying cold compresses over the eyes will help reduce the edema. If periorbital edema increases signifi-cantly, the surgeon is notified because it may indicate that a post-operative clot is developing or that there is increasing ICP and poor venous drainage. Health care personnel should announce their presence when entering the room to avoid startling the pa-tient whose vision is impaired due to periorbital edema or neu-rologic deficits.
Additional factors that can affect sensation include a bulky head dressing, the presence of an endotracheal tube, and effects of increased ICP. The first postoperative dressing change is usu-ally performed by the neurosurgeon. In the absence of bleeding or a CSF leak, every effort is made to minimize the size of the head dressing. If the patient requires an endotracheal tube for mechanical ventilation, every effort is made to extubate the pa-tient as soon as clinical signs indicate it is possible. The patient is monitored closely for the effects of elevated ICP.
The patient is encouraged to verbalize feelings and frustrations about any change in appearance. Nursing support is based on the patient’s reactions and feelings. Factual information may need to be provided if the patient has misconceptions about puffiness about the face, periorbital bruising, and hair loss. Attention to grooming, the use of the patient’s own clothing, and covering the head with a turban (and ultimately a wig until hair growth occurs) are encouraged. Social interaction with close friends, family, and hospital personnel may increase the patient’s sense of self-worth.
As the patient assumes more responsibility for self-care and participates in more activities, a sense of control and personal competence will develop. The family and social support system can be of assistance while the patient recovers from surgery.
Complications that may develop within hours after surgery in-clude increased ICP, bleeding and hypovolemic shock, altered fluid and electrolyte balance (including water intoxication), in-fection, and seizures. These complications require close collabo-ration between the nurse and the surgeon.
Increased ICP and bleeding are life-threatening to the patient who has undergone intracranial neurosurgery. The following must be kept in mind when caring for all patients who undergo such surgery:
· An increase in blood pressure and decrease in pulse with res-piratory failure may indicate increased ICP.
· An accumulation of blood under the bone flap (extradural, subdural, intracerebral) may pose a threat to life. A clot must be suspected in any patient who does not awaken as expected or whose condition deteriorates. An intracranial hematoma is suspected if the patient has any new postoper-ative neurologic deficits (especially a dilated pupil on the operative side). In these events, the patient is returned to the operating room immediately for evacuation of the clot if indicated.
· Cerebral edema, infarction, metabolic disturbances, and hydrocephalus are conditions that may mimic the clinical manifestations of a clot.
The patient is monitored closely for indicators of complica-tions, and early signs and trends in clinical status are reported to the surgeon. Treatments are initiated promptly, and the nurse as-sists in evaluating the response to treatment. The nurse also pro-vides support to the patient and family.
Should signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees, administration of mannitol (an osmotic diuretic), and possible administration of pharmaco-logic paralyzing agents.
Fluid and electrolyte imbalances may occur because of the pa-tient’s underlying condition and its management or as complica-tions of surgery. Fluid and electrolyte disturbances can contribute to the development of cerebral edema.
The postoperative fluid regimen depends on the type of neu-rosurgical procedure and is determined on an individual basis. The volume and composition of fluids are adjusted according to daily serum electrolyte values, along with fluid intake and output.
Sodium retention may occur in the immediate postoperative period. Serum and urine electrolytes, blood urea nitrogen, blood glucose, weight, and clinical status are monitored. Intake and output are measured in view of losses associated with fever, res-piration, and CSF drainage. Fluids may have to be restricted in patients with cerebral edema.
Oral fluids are usually resumed after the first 24 hours (Hickey, 2003). The presence of gag and swallowing reflexes must be checked before initiation of oral fluids. Some patients with pos-terior fossa tumors may have impaired swallowing, so fluids may need to be administered by alternative routes. The patient should be observed for signs and symptoms of nausea and vomiting as the diet is progressed (Hickey, 2003).
Patients undergoing surgery for brain tumors often receive large doses of corticosteroids and thus tend to develop hyper-glycemia. Therefore, serum glucose levels are measured every 4 hours. These patients are prone to gastric ulcers, and therefore histamine-2 receptor antagonists (H2 blockers) are prescribed to suppress the secretion of gastric acid. The patient is monitored for bleeding and assessed for gastric pain.
If the surgical site is near, or causes edema to, the pituitary gland and hypothalamus, the patient may develop symptoms of diabetes insipidus, which is characterized by excessive urinary output. The urine specific gravity is measured hourly, and fluid intake and output are monitored. Fluid replacement must com-pensate for urine output, and serum potassium levels must be monitored.
SIADH, which results in water retention with hyponatremia and serum hypo-osmolality, occurs in a wide variety of central nervous system disorders (brain tumor, head trauma) causing fluid disturbances. Nursing management includes careful intake and output measurements, specific gravity determinations of urine, and monitoring of serum and urine electrolyte studies, while following directives for fluid restriction. SIADH is usually self-limiting.
The patient undergoing neurosurgery is at risk for infection re-lated to the neurosurgical procedure (brain exposure, bone expo-sure, wound hematomas) and the presence of intravenous and arterial lines for fluid administration and monitoring. Risk for in-fection is increased in patients who undergo lengthy intracranial operations and those with external ventricular drains in place longer than 48 to 72 hours.
The incision site is monitored for redness, tenderness, bulging, separation, or foul odor. The dressing is often stained with blood in the immediate postoperative period. It is important to re-inforce the dressing with sterile pads so that contamination and infection are avoided. (Blood is an excellent culture medium for bacteria.) If the dressing is heavily stained or displaced, this should be reported immediately. (A drain is sometimes placed in the craniotomy incision to facilitate drainage.)
After suboccipital surgical procedures, CSF may leak through the incision. This complication is dangerous because of the pos-sibility of meningitis. Any sudden discharge of fluid from a cra-nial incision is reported at once because a massive leak requires direct surgical repair. Attention should be paid to the patient who complains of a salty taste, because this can be due to CSF trick-ling down the throat. The patient is advised to avoid coughing, sneezing, or nose blowing, which may cause CSF leakage by cre-ating pressure on the operative site.
Aseptic technique is used when handling dressings, drainage systems, and intravenous and arterial lines. The patient is moni-tored carefully for signs and symptoms of infection, and cultures are obtained from the patient with suspected infection. Appro-priate antibiotics are administered as prescribed.
Other causes of infection in the patient undergoing intra-cranial surgery are similar to those in other postoperative patients: pneumonia and urinary tract infections.
Seizures and epilepsy may be complications after any intracranial neurosurgical procedure. Preventing seizures is essential to avoid further cerebral edema. Administering the prescribed antiseizure medication before and immediately after surgery may prevent the development of seizures in subsequent months and years. Status epilepticus (prolonged seizures without recovery of consciousnessin the intervals between seizures) may occur after craniotomy and also may be related to the development of complications (hematoma, ischemia).
Other complications may occur during the first 2 weeks or later and may threaten the patient’s recovery. The most important of these are thromboembolic complications (deep vein thrombosis, pulmonary embolism), pulmonary and urinary tract infection, and pressure ulcers (Warbel, Lewicki & Lupica, 1999). Most of these complications may be avoided with frequent changes of position, adequate suctioning of secretions, assessment for pul-monary complications, observation for urinary complications, and skin care.
The recovery at home of a neurosurgical patient depends on the extent of the surgical procedure and its success. The patient’s strengths as well as limitations are explained to the family, along with their part in promoting recovery. Because administration of antiseizure medication is a priority, the patient and family are en-couraged to use a check-off system to ensure that the medication is taken as prescribed.
Usually no dietary restrictions are required unless another health problem requiring a special diet exists. Although taking a shower or tub bath is permitted, the scalp should be kept dry until all the sutures have been removed. A clean scarf or cap may be worn until a wig or hairpiece is purchased. If skull bone has been removed, the neurosurgeon may suggest a protective hel-met. After a craniotomy, the patient may require rehabilitation, depending on the postoperative level of function. The patient may require physical therapy for residual weakness and mobil-ity issues. Occupational therapy is consulted to assist with self-care issues. If the patient is aphasic, speech therapy may be necessary.
Barring complications, patients are discharged from the hospital as soon as possible. Patients with severe motor deficits require ex-tensive physical therapy and rehabilitation. Those with post-operative cognitive and speech impairments require psychological evaluation, speech therapy, and rehabilitation. The nurse works collaboratively with the physician and other health care profes-sionals during hospitalization and home care to achieve as com-plete a rehabilitation as possible.
When tumor, injury, or disease makes the prognosis poor, care is directed toward making the patient as comfortable as possible. With return of the tumor or cerebral compression, the patient becomes less alert and aware. Other possible conse-quences include paralysis, blindness, and seizures. The home care nurse, hospice nurse, and social worker work with the fam-ily to plan for additional home health care or hospice services or placement of the patient in an extended-care facility. The patient and family are encouraged to discuss end-of-life preferences for care; the patient’s end-of-life preferences must be respected.
The nurse involved in home and continuing care of patients following cranial surgery needs to remind patients and family members of the need for health promotion and recommended health screening.
Expected patient outcomes may include:
1) Achieves optimal cerebral tissue perfusion
a) Opens eyes on request; uses recognizable words, pro-gressing to normal speech
b) Obeys commands with appropriate motor responses
2) Attains thermoregulation and normal body temperature
a) Registers normal body temperature
3) Has normal gas exchange
a) Has arterial blood gas values within normal ranges
b) Breathes easily; lung sounds clear without adventitious sounds
c) Takes deep breaths and changes position as directed
4) Copes with sensory deprivation
5) Demonstrates improving self-concept
a) Pays attention to grooming
b) Visits and interacts with others
6) Absence of complications
a) Exhibits ICP within normal range
b) Has minimal bleeding at surgical site; surgical incision is healing without evidence of infection
c) Shows fluid balance and electrolyte levels within desired ranges
d) Exhibits no evidence of seizures
An overview of care of the patient undergoing intracranial surgery is presented in Chart 61-2.