head injuries, etc 2012

8/2/2019 Head Injuries, Etc 2012

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Neurological

Lewis Chapter 57 pg. 1439

Head Injury any trauma to the scalp, skull, or brain

o HEAD TRAUMA- craniocerebral trauma altered

consciousness- most common cause of death from trauma in

United States

o Est. 1.1 million persons are treated and released for traumatic

brain injury- 235,000 hospitalized and 22% of these die

decreased number of fatalities

Males are more likely- almost twice as likely; ages 15-21 more common

Causes- falls, motor vehicle collisions, fire-arms, sports-related

injuries, recreational injuries Prevention is key- steps to prevent falls, coaches- educate, headgear;

obey traffic laws (DUIs), caution against riding in the back of trucks,

wearing helmets

High potential for poor outcome-look for: presence of intracranial

hemorrhage, increasing age of patient, abnormal motor responses,

impaired or absent eye movements or pupillary light reflexes, early

sustained hypotension, hypoxemia or hypercapnia, ICP levels higher

than 20 mm Hg. (normal 0-15) Any bleeding in brain will cause ICP to

increase-may cause actual displacement of braino Most deaths occur within a few hours after the head injury

IT IS CRITICAL TO RECOGNIZE CHANGES IN NEURO

STATUS AND RAPIDLY INTERVENE

Primary Injury- initial damage to brain resulting from traumatic event

Secondary Injury- evolves- unchecked cerebral edema; ischemia

1. Scalp lacerations-

External- abrasion, contusion, laceration, hematoma

Profuse bleeding (very vascular)

Major complications: blood loss and infection- avulsion (tearingaway)

Irrigate wound before suturing (remove organisms)

2. skull fractures- break in continuity of skull caused by functional

trauma

head trauma


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type depends on velocity, momentum, direction of injuring

agent, and site of impact

descriptions- Table 57-6 pg. 1481

o simple- linear (break in continuity of bone without

alteration of relationship of parts) or depressed(inward indentation of skull-fragments get embedded

into brain, possibly)

o simple (linear or depressed skull fracture without

fragmentation or communicating lacerations),

comminuted- splintered (multiple linear fractures with

fragmentation of bone into many pieces), or compound

(depressed skull fracture and scalp laceration with

communicating pathway to intracranial cavity)

o

closed or open- depends on presence of scalp lacerationor extension of fracture into air sinuses or dura;open

increases risk of infection

symptoms will depend on location of fracture- Table 57-7 pg.

1439- must know: RHINORRHEA( CSF leakage from the nose),

OTORRHEA (CSF leakage from ear), BATTLES SIGN

(postauricular ecchymosis), and PERIORBITAL ECCHYMOSIS

(raccoon eyes)

o frontal fracture- exposure of brain to contaminants

through frontal air sinus, possible association with air in

forehead tissue, CSF rhinorrhea, or pneumocranium

o orbital fracture-periorbital ecchymosis (raccoon eyes),

optic nerve injury

o temporal fracture- boggy temporal muscle because of

extravasation of blood, oval-shaped bruise behind ear in

mastoid region (Battles sign), CSF otorrhea, middle

meningeal artery disruption, epidural hematoma

o parietal fracture- deafness, CSF or brain otorrhea,

bulging of tympanic membrane caused by blood or CSF,

facial paralysis, loss of taste, Battles sign

o posterior fossa fracture- occipital bruising resulting in

cortical blindness, visual field defects, rare appearance

of ataxia or other cerebellar signs

o basilar skull fracture (base of skull)- CSF or brain

otorrhea, bulging of tympanic membrane caused by


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blood or CSF, Battles sign, tinnitus or hearing

difficulty, rhinorrhea, facial paralysis, conjugate

deviation of gaze, vertico

Testing of fluid to determine if CSF: test fluid with Dextrostix or Tes-Tape strip-

looking for glucose- if positive, CSF

if present in blood, glucose will be unreliable- look

for HALO OR RING test- allow fluid to drip on

4x4- blood coalesces to center- will see yellowish

ring around blood if CSF is present

presence of CSF indicates the potential of a

meningeal infection

bloody CSF indicates brain laceration or contusionNote color, appearance, and amount

Major complications of skull fractures: intracranial infections and

hematomas meningeal and brain tissue damage esp. with basilar fracture

(tend to be open; increases chance of meningeal infection)

Treatment of skull fractures- usually conservative- may need craniotomy if

there are loose bone fragments- craniectomy for large amounts- replaced by

cranioplasty- if significant cerebral edema repair may be delayed 3-6

months; administer IV antibiotics

3. minor head trauma- brain injury (injury to brain that is severe enough

to interfere with normal functioning)

concussion- sudden transient mechanical head injury with

disruption of neural activity and a change in the LOC- may or

may not lose consciousness (or may have temporary loss)

o signs: brief disruption in LOC, amnesia regarding the

event, headache; bizarre behavior (frontal lobe)

o seeing stars; dizziness

generally of short duration

o treatment depends on length of LOC-may keep in

hospital for observation; may be discharged with

instructions to notify HCP if behavioral changes occur

(changes in mental status- speech, confusion, lethargy,

vomiting, irritation, anxiety)

o observation- management of ICP if occurs


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o have patient resume normal behavior slowly

postconcussion syndrome- seen anywhere from 2 weeks to 2

months after injury

o symptoms- persistent headache, lethargy, personality

and behavioral changes, shortened attention span,decreased short term memory, changes in intellectual

ability

may be problematic if patient has had more than one concussion

or head injury- residual effects- behavior changes, attention

deficits, memory loss

4. major head trauma

Contusion- bruising of brain tissue within a focal area usually a

CLOSED HEAD INJURY (head accelerates and then rapidly

decelerates or collides with another object and brain tissue indamaged)

o May contain areas of hemorrhage, infection, necrosis,

and edema and frequently occurs at a fracture site

o Coup-contrecoup- brain moves inside skull due to high-

impact have two areas of injury- both at the site of

the direct impact and also at the opposite side

o Patient prognosis depends on amount of bleeding

o May continue to bleed- appear to blossom on CT scans

Hemorrhage is worsened by anticoagulant therapy-

also have higher mortality

Will see signs/symptoms of shock- decreased HR,

BP, temp

o Neurologic assessment- focal (symptoms related to

function of damaged area) and generalized findings-

may have seizures

o Management of ICP is treatment

o May have cerebral irritability- be conscious but easily

disturbed by stimulation

o Residual headache, vertigo

o May have seizures

Lacerations- actual tearing of brain tissue- often occur with

DEPRESSED and OPEN fractures and penetrating injuries (open

brain injuries- object penetrates skull and damages soft brain

tissue or severe blunt trauma)


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o Severe tissue damage

o Focal and generalized signs will be seen when bleeding is

deep in brain parenchyma

o Intracerebal hemorrhage- space-occupying lesion

accompanied by unconsciousness, hemiplegia oncontralateral side, and dilated pupil on ipsilateral side

Delayed responses will be seen secondary to major head

trauma- hemorrhage, hematoma formation, seizures, and

cerebral edema

Diffuse axonal injury- widespread axonal damage (cerebral

hemispheres) accruing after TBI- occurs primarily around axons

in subcortical white matter of cerebral hemispheres, basal

ganglia, thalamus, and brain stem- trauma is thought to be

caused from axon swelling and disconnection- usually takes 12-24 hours decreased LOC, increased ICP, decortication or

decerebration, global cerebral edema

o Dx- clinical symptoms and CT/MRI

Complications- Note: signs and symptoms will be determined by

size- prognosis is poorer with those that develop more rapidly

(unable to compensate for increased ICP)

o Epidural hematoma- bleeding between dura and inner

surface of skull- neurologic emergency- associated with

linear fracture crossing an artery venous hematomas

occur more slowly signs/symptoms: initial period of

unconsciousness- lucid then decreased LOC- headache,

nausea and vomiting, focal findings; will see rapid

deterioration; TX- evacuate hemorrhage (burr holes

to decrease ICP)- remove clot and place drain

o Subdural hematoma- bleeding between dura mater and

arachnoid layer of meninges- usually results from injury

to brain substance and parenchymal vessels- slower to

develop- generally venous- may be secondary to rupture

of aneurysm

Acute- signs within 48 hours of injury-similar to

those associated with brain tissue compression in

increased ICP- decreased LOC and headache- may

be drowsy and confused or unconscious- pupillary

symptoms and hemiparesis; if ICP is elevated,


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ipsilateral pupil dilates and becomes fixed- brain

injury may occur- may be fatal (coma, increased

BP, decreased HR- need immediate treatment)

Subacute subdural hematoma- 2-14 days of injury-

may appear to enlarge over time Chronic subdural hematoma- weeks or months

after minor head injury- actual injury may be

forgotten

a. 50-60 years of age- may have brain atrophy

b. Focal symptoms

c. Chronic alcoholics

d. Delay in elderly- dementia, vascular disease,

somnolence, confusion, lethargy and memory

loss may be attributed to medical conditione. Treatment is surgical evacuation of clot;

supportive care; control of ICP

o Intracerebral hematoma- bleeding within parenchyma-

usually in frontal and occipital lobes; symptoms HTN,

aneurysm, bleeding disorders (complication of

anticoagulants)

o Hematoma Treatment-surgical evacuation of blood-

craniotomy Burr-hole openings in emergency drain

Diagnosis of Head Trauma/Injury

CT scan- can note abnormalities in skull, edema, contusion

(intracerebral or extracerebral hemorrhage)

MRI, PET, evoked potential studies- may be used in differentiation

of head injuries- patient must be stable

o MRI more specific than CT- can pick up small DAI (diffuse

axonal injury)

Transcranial Doppler study

Cervical spine x-ray- cervical collar, backboard

X-ray for skull fracture

Cerebral angiography- hematomas and contusions

GCS- mild (13-15), moderate (9-12), or severe (3-8)

Timely diagnosis is key! Surgery if necessary interventions should

be rapid


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Treatment for Head Injury- Table 57-9 pg. 1442

-determine etiology- blunt vs. penetrating trauma

-assess- look at surface findings (what you can see bruising, bleeding, cuts,

raccoon eyes); look at resp. status (may be compromised with head injury-

Cheyne-Stokes, decreased O2); look at CNS (pupils, facial movements,speech, LOC, combativeness, seizure, bowel/bladder, posturing, CSF leakage,

GCS score)

Prevent secondary brain injury; stabilize cardiovascular and respiratory

function

-Emergency:

Airway- Keep HOB up 30 degrees but maintain head in neutral

midline position

Stabilize C-spine

Administer oxygen- non-rebreather IV access- large bore- NS or LR

Control external bleeding

Assess for CSF leakage or wounds

Patients clothing-

Maintain warmth

Monitor vital signs- GCS- O2 sat- LOC- Pupils

Anticipate need for intubation- gag reflex?

Assume neck injury- so protect

Administer fluids cautiously when maintaining because of

chance of ICP

Vent support

Seizure precautions

Fluid and electrolyte and nutritional support

Pain/anxiety

Nursing Management

Remember that with a head injury there is a great likelihood that

the patient will have ICP- leads to higher mortality rates and

poorer functional outcomes-

o Assess, assess, and assess- GCS , neuro status, CSF leakage

When did injury happen? What caused the injury?

Direction and force of blow? LOC- how long?


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*remember GCS- eye opening; verbal response; motor

response (15-3)

o Nursing diagnoses???

Ineffective tissue perfusion (cerebral)

Complications- decreased cerebral perfusionpressure- treat by decreasing cerebral edema-

may give fluids with caution to treat low BP

Hyperthermia- metabolism, infection, and regulatory

status

Acute pain

Risk for pain

Ineffective airway clearance

Impaired gas exchange- treat with ET and mech vent

Impaired physical mobility Anxiety

Risk for injury- seizures; assess for development of

seizure activity; administer anti-seizure meds

Nutrition- tube feedings

Risk for infection- pneumonia, UTI, wound infection,

brain abscess

Increased ICP

o Planning- Goals are:

Maintain adequate cerebral oxygenation and perfusion

Remain normothermic

Achieve control of pain and discomfort

Be free from infection

Attain maximum function

o Nursing Implementation

Health Promotion- PREVENTION IS KEY!!!! Educate on

ways to prevent car and motorcycle collisions- HELMETS-

driver ed classes- be active in discouraging DUIs

Acute Intervention- quick action- see Table 57-9 pg.

1442

Maintain oxygen and perfusion prevent secondary

cerebral ischemia- brain is sensitive to hypoxia;

Monitor ABGs and administer oxygen

Monitor for changes in neurologic status

Treat other life-threatening injuries


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Talk to family and patient- let them know what to

expect and also what to look for (behavioral

changes, combativeness)- See Table 57-11 pg.

1444- what to notify HCP about (increased

drowsiness, N/V, worsening heachache/stiff neck,seizures, vision changes, behavioral changes, motor

problems, slow heart rate, sensory problems have

someone stay with patient abstain from alcohol

check with HCP about meds avoid operating heavy

machinery, driving, etc.

Assess, assess, assess- GCS, LOC, V/S

Assess motor function- spontaneous movement;

response to painful stimuli if no spontaneous

movement Other problems-

o Eye problems include loss of corneal reflex,

periorbital ecchymosis and edema, and

diplopia may need eyedrops or tape eye

shut cold compresses initially then warm

eye patch

o Hyperthermia- damage to hypothalamus;

cerebral irritation from hemorrhage,

infection- Administer Tylenol, cooling

blankets. Use caution- do not induce

shivering (increased ICP)

o Sleep pattern disturbance- must be

awakened every hour- check level of

consciousness- group nursing activities and

decrease environmental noise

o Notify HCP immediately if CSF leakage is

suspected- raise head of bed- place loose

collection pad caution patient not to sneeze

or blow nose (increased ICP) no NG tube

o Immobilized patient- elimination needs,

protection of skin integrity (turn and

reposition, keep clean and dry)

o Antiemetic meds


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o Treat pain- acetaminophen or small doses of

codeine

o Benzos for agitation (dont affect ICP)

o Antiseizure meds

o

Calm, restful environmento Pain meds- avoid opioids

o corticosteroids

Ambulatory/Home Care

Rehab- may be chronic problems with motor,

sensory, communication, memory, intellectual

functioning

Seizure disorders may be seen- most vulnerable

time is within first week of head injury- Dilantin

Personality change- may be hard for patient andfamily to cope with- loss of concentration, memory

processing, euphoria, mood swing, lack of social

restraint, tact, emotional control may be noted

Support family- financial, personal needs,

communication help them with their expectations

and let them know how patient is doing--- dont give

false hope

Specific post hospitalization rules- no drinking,

driving, firearms, work with hazardous materials,

unsupervised smoking

Counseling- cognitive rehab activities- sensory

stimulation, behavior modification, video games,

reality orientation

Head Injuries and Ethics- Brain death- pg. 1443

Death by neurologic criteria- cerebral cortex stops functioning or is

irreversibly destroyed

Controversy- technology

Criteria- coma or unresponsiveness, absence of brainstem reflexes,

and apnea- physician

Do not address patient in permanent vegetative state- brainstem

activity enough to sustain heart and lung function

EEG- to check cerebral blood flow


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Brain Tumors- 1445 Annual rate- 18,500 with 12, 760 deaths

Frequent site of metastasis from other sites

Higher incidence in males

More common in middle-aged persons Types-

o Primary- arising from brain- rarely mets. Outside; cause

unknown- ionizing radiation is known risk factor

o Secondary- metastasis- most common type- lung, breast, kidney

Also classified according to tissue- Review Table 57-12 pg. 1446

o Gliomas (within brain tissue); most common type

Astrocytoma- supportive tissue, glial cells, and astocytes-

low to moderate grade malignancy

Glioblastoma multiforme- primitive stem cell (glioblast)-highlty malignant and invasive- one of most devastating

Oligodendroglimoma- oligodendrocytes- may be beningn

(majority) but may also be highly malignant-

Medulloblastoma- primitive neuroectodermal cell- highly

malignant and invasive metastasize to spinal cord

o Meningioma- meninges- can be benign (most) or malignant- slow-

growing; middle-aged women- symptoms result of compression;

treatment is surgery to remove

o

Acoustic neuroma- cells that form myelin sheath around nerves-commonly affects cranial nerve VIII( vestibulocochlear)-

usually benign or low grade- slow-growing; causes facial

problems- hearing loss, vertigo, headache, visual disturbances

o Pituitary adenoma- pituitary gland- usually benign- sleep;

appetite; amenorrhea (females); acromegaly; Cushings(obesity

in face, abdomen; HTN, osteoporosis, elevated glucose)

o Hemangioblastoma- blood vessels of brain- rare and benign

o Primary central nervous system lymphoma- lympocytes-

increased incidence in transplant and AIDS patientso Metastatic tumors- from lungs, breast, kidney, thyroid,

prostate-malignant

o Brain angiomas- masses composed largely of abnormal blood

vessels- usually in cerebellum; increased risk for hemorrhagic

stroke

If not treated, will be fatal because of ICP


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Clinical Manifestations

o Depends mainly on location and size of tumor- look at Figure 57-

18 pg. 1447

o Wide range of symptoms

o

Headache- worsen at night or early morning- dull and constant;deep and unrelenting; location may depend on location of tumor

o Seizures- gliomas and brain metastases

o Nausea and vomiting (projectile) - ICP

o Cognitive dysfunction- memory problem, mood and personality

changes

o Muscle weakness, sensory losses, aphasia, vision/spatial

disturbances

o Papilledema (edema of optic disk)

o

ICP, cerebral edema, obstruction of CNS pathwayso Review Table 57-13 pg. 1447

Cerebral hemisphere

Frontal lobe- unilateral- unilateral hemiplegia,

seizures, memory deficit, personality and judgment

changes, visual disturbances

Frontal lobe- bilateral- symptoms associated with

unilateral frontal lobe tumor and ataxic gait

Parietal lobe- speech disturbances may have

inability to write, spatial disorders, unilateral

neglect

Occipital lobe- vision disturbances and seizures

Temporal lobe- few symptoms- seizures, dysphagia

Localized symptoms- hemiparesis, seizures, mental

status changes

Progression of signs/symptoms is important-

indicates tumor growth and expansion

Subcortical- hemiplegia; other symptoms depend on area

of infiltration

Meningeal tumors- compression of brain and dependant on

area of tumor

Metastatic tumor- headache, nausea, vomiting.. increased

ICP depend on tumor location


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Thalamus and sellar tumors- headache, nausea, vision

disturbances, papilledema, nystagmus (ICP), diabetes

insipidus

Fourth ventricle and cerebellar tumor- headache, nausea,

papilledema, ataxic gait, changes in coordination Cerebellopontine tumors- tinnitus and vertigo, deafness

Brainstem tumors- headache on awakening, drowsiness,

vomiting, ataxic gait, facial muscle weakness, hearing

loss, dysphagia, dysarthria, crossed eyes or visual

changes, hemiparesis

Assess activities of daily living

Complications

o Hydrocephalus- occurs if ventricles or outlet is occluded

surgical treatment is necessary ventriculoatrial orventriculoperitoneal shunt rapid decompression of ICP may

cause prostration and headache keep patient in upright

position patient should avoid contact sports

Shunt malfunction- signs of ICP- decreasing LOC,

restlessness, headache, blurred vision, vomiting

Infection- high fever, persistent headache, stiff neck

Diagnostic Studies for Brain Tumor

Extensive history and workup- comprehensive neuro exam

New-onset seizures may be initial sign

MRI, PET, CT scan with contrast

EEG may be performed- abnormal brain waves in area of tumors

Angiography- blood flow to tumor

Endocrine studies

Rule out other primary sites

Obtain tissue for histology usually at time of surgery- may do a

smear in OR to help neurosurgeon know what to do further

Check for CSF

Nursing Diagnoses

Impaired tissue perfusion

Acute pain

Self-care deficits

Anxiety


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Planning

Goals:

1. maintain normal ICP

2. maximize neurologic functioning3. achieve control of pain and discomfort

4. be aware of long-term implications with respect to prognosis and

cognitive and physical functioning

Nursing Interventions

Collaborative Care

o Goals are aimed at identifying tumor type and location,

removing or decreasing tumor mass, and preventing or

managing increased ICP Surgical Therapy- preferred treatment

o Stereotactic techniques- biopsy and remove small

brain tumors- uses CT scan- localizes site- may use

gamma knife

o Outcome depends on type, size, and location of tumor

o Ultrasound, functional MRI, cortical mapping are used

to localize tumor

o Complete removal isnt always possible may reduce

tumor mass which will decrease ICP and provide some

relief of symptoms- malignant gliomas- often cant

remove all of tumor

Radiation Therapy and Radiosurgery- may be a follow-up

after surgery- often used when tumors are unable to be

completely removed

o Radiation seeds may be implanted- brachytherapy-

allows for high doses directly at site

o Complication- increased ICP and cerebral edema- high

doses of corticosteroids

o Stereotactic radiosurgery- high concentration of

radiation at a precise location within brain- may be

used when conventional surgery has failed or isnt an

option

Chemotherapy- may not cross blood-brain barrier so may not

be effective- nitrosources- wafers may be implanted during


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surgery- methotrexate and procarbazine- intrathecal

administration

o Temodar- crosses blood-brain barrier

o Corticosteroids- decrease cerebral edema

Nurse will assess, assess, assess determine limitations andhow long patient has had these

Medical history, intellectual abilities and educational level,

history of nervous system infections and trauma presence of

symptoms such as seizures, headache, N/V, pain, syncope

Assist family with coping esp. with behavioral changes

limitations

Safety- patient may become aggressive and even harmful to

self- environment- calm

Risk for aspiration- assess gag reflex and ability to swallow;reassess preop and postop

Minimize stimulation and have a routine

Antiseizure meds and seizure precautions

ADLs- assist with these but promote maintenance of self-

function self-image

Communication

Nutrition- assess status, encourage them to eat, tube

Evaluation- will reach goals set in planning stage

Cranial Surgery- 1449; Table 57-14 May be indicated for brain tumor, CNS infection, vascular

abnormalities, craniocerebral trauma, seizure disorder, or intractable

pain

Types- Table 57-15 pg. 1449

o Stereotactic surgery- precision apparatus- often computer

guided- precisely target area of brain- frame or frameless

system based on 3-dimensional coordinates

May be used to obtain tissue samples for histologic

examination

CT scan and MRI image targeted tissue

Used for removal of small brain tumors and abscesses,

drainage of hemotomas, ablative procedures for


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extrapyramidial diseases, and repair of arteriovenous

malformations

Radiosurgery- procedure that involves closed-skull

destruction of an intracranial target using ionizing

radiation focused with the assistance of an intracranialguiding device- gamma knife- may treat tumors over

several weeks

Can be used in combo with surgical lasers

Reduction in damage to surrounding tissue

o Burr hole- opening into the cranium with a drill- used to remove

localized fluid and blood beneath the dura- may be used to determine

presence of swelling and to evacuate hematoma/abscess

o Craniotomy- opening into the cranium with removal of a bone flap and

opening the dura to remove a lesion, repair a damaged area, drainblood, or relieve increased ICP- depends on location of pathologic

condition where this will be performed- incision into skull- burrholes are drilled and saw is used to connect the holes to remove flap

afterward it is wired or sutured. Drains will be placed- used for

meningioma, acoustic neuromas

o Supratentorial- above the tentorium; below tentorium into

intratentorial (posterior fossa)

o Transphenoidal approach- mouth and nasal sinuses- often for pituitary

Preop for both- CT scan, MRI, Doppler flow studies; antiseizure meds,Decadron (decreased cerebral edema and restrict fluids); Mannitol

and Lasix IV may also be given afterward; may see transient diabetes

insipidious after- vasopressin; Pre-op- endocrine tests; rhinologic

evaluation; most serious effect of pituitary tumor is localized

pressure on optic nerve/chiasm; culture nasopharyngeal secretions-

contraindicated in sinus infection; corticosteroids before and after-

no source of ACTH- may have antibiotics; Post-op- assess visual

field/visual acuity; keep HOB up to keep pressure down at least 2

weeks after surgery- keep from blowing nose; measure I & O; check

nasal packing for blood and CSF- remove 3-4 days; frequent oral care;

incision above teeth- no brushing teeth until healed; room humidifier

o Craniectomy- excision into cranium to cut away a bone flap

o Cranioplasty- repair of a cranial defect resulting from trauma,

malformation, or previous surgical procedure artificial material is

used to replace damaged or lost bone


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o Shunt procedures- alternate pathway to redirect CSF from one area

to another using a tube or implanted device- ventriculoperitoneal

shunt

Nursing Management Assessment- similar to patient with increased ICP- neuro

assessment

Diagnoses- tissue perfusion, infection, disuse syndrome

Planning- Goals are to return to normal consciousness, achieve

control of pain and discomfort, maximize neuromuscular

function, be rehabilitated to maximum ability

Nursing Interventions

Assess- compare pre and post op- level of consciousness,

neuro status ,personality, bowel and bladder; motorfunction

Acute

Compassionate nursing care- patient and family will

have coping issues because of severity of surgery

Preop teaching- general info about type of

procedure- hair will be shaved- ICU or special care

unit

Prevention of ICP is primary goal- frequent

assessment- neuro, fluid and lytes, serum

osmalarity, turning and positioning depends on type

of procedure

o Posterior fossa- flat or at slight elevation

(10-15 degrees)

o Avoid flexion of neck

o Surgical dressing- 3-5 days- if bone flap

removed- do not position on operative side

o Head dressing after surgery may have

limited hearing/vision

o Notify immediately HCP if dressing has

excessive bleeding or clear drainage

o Check drains for placement and assess area

o Antiseptic soap

Tubes- communication may be difficult


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Art lines/central venous pressure- monitor

cerebral edema, relieving pressure, prevention of

seizures, monitor ICP

HOB up 30 degrees

Avoid lying on operative side Ambulatory and Home Care

o Rehab potential depends on reason for surgery, general health,

and postop course

o Foster independence

o Careful positioning, meticulous skin and mouth care, elimination,

ROM, adequate nutrition until cerebral edema/ICP are resolved

o Referrals- ST, PT

o Deficits both cognitively and emotionally may be hard on family-

copingo Client safety- headache treatment; Decadron, Dilantin,

antiemetics

o May have SIADH, diabetes insipidus, and increased ICP post-op

head injuries, etc 2012

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