Care of the Client with Cranial Surgery

Kathleen Ohman, RN, CCRN, EdDDeveloped 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 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

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 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.

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).

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

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 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

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 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

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 hematomaEpidural hematomaSubarachnoid hemorrhage

Postoperative complications (cont.)

Hypovolemic shock Hydrocephalus Respiratory Complications

AtelectasisHypoxiaPneumoniaNeurogenic pulmonary edema

Postoperative Complications (cont.)

Infection Meningitis Fluid and electrolyte imbalances

• Dehydration• Hyponatremia• Hypernatremia

Postoperative Complications (cont.)

SeizuresCerebrospinal fluid (CSF) leakCerebral edema

Summary

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

compassion