Intracranial surgery

There are numerous types of brain surgery. The type used is based on the area of the brain and the condition being treated.
Brain surgery is a critical and complicated process. The type of brain surgery done depends highly on the condition being treated.
Intracranial surgery refers to various medical procedures that involve repairing structural problems in the brain.
Craniotomy
A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated.
During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue

Decompressive craniectomy 
It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.

1. Chirayu College Of Nursing, Bhopal Subject- Medical Surgical Nursing- I Topic- Intracranial Surgery Prepared By Mr. Migron Rubin Lecturer

2. OBJECTIVES

3. INTRODUCTION There are numerous types of brain surgery. The type used is based on the area of the brain and the condition being treated. Brain surgery is a critical and complicated process. The type of brain surgery done depends highly on the condition being treated.

4. DEFINITION Intracranial surgery refers to various medical procedures that involve repairing structural problems in the brain.

5. TYPES Craniotomy A craniotomy involves making an incision in the scalp and creating a hole known as a bone flap in the skull. The hole and incision are made near the area of the brain being treated. During open brain surgery, it is done to remove tumors, clip off an aneurysm, drain blood or fluid from an infection & remove abnormal brain tissue Decompressive craniectomy  It is a neurosurgical procedure in which part of the skull is removed to allow a swelling brain room to expand without being squeezed. It is performed on victims of traumatic brain injury, stroke and other conditions associated with raised intracranial pressure.

6. ETIOLOGY Abnormal blood vessels Aneurysm Bleeding Blood clots Damage to the protective tissue called the “dura” Epilepsy Abscesses Nerve damage or nerve irritation Parkinson’s disease Pressure after head injury Skull fracture Stroke Brain tumors Fluid building up in the brain

7. MANAGEMENT PREOPERATIVE MANAGEMENT 1.Diagnostic findings, surgical procedure, and expectations are reviewed with the patient.  2. Presurgical shampoo with an antimicrobial agent may be ordered. Skull preparation is performed in the operating  room .  3. Depending on primary diagnosis, corticosteroids may be ordered preoperatively to reduce cerebral edema.  4. Depending on the type and location of lesion, anticonvulsants may be ordered to reduce risk of seizures.  5. The patient is prepared for the use of intraoperative antibiotics to reduce risk of infection.

8. Urinary catheterization is performed to assess urinary volume during preoperative period.  If cerebral edema develops, intraoperative or postoperative osmotic diuretic -mannitol or corticosteroids may be ordered for its treatment.  Neurologic assessment is performed to evaluate and record the patient’s neurologic baseline and vital signs for postoperative comparison.  Family and patient are made aware of the immediate postoperative care and where the physician will contact the family after surgery.  Supportive care is given, as needed, for neurologic deficits. 

9. Postoperative Management  Respiratory status is assessed by monitoring rate, depth, and pattern of respirations. A patent airway is maintained . Vital signs and neurologic status are monitored using  GCS Arterial and central venous pressure (CVP) are monitored. Pharmacologic agents may be prescribed to control increased ICP.  Mannitol is given Incisional and headache pain may be controlled with mild analgesic (codeine and acetaminophen) Position head of bed at 15 to 30 degrees, or per clinical status of the patient, to promote venous drainage .

10. Turn side-to-side every 2 hours; positioning restrictions  will be ordered by the physician ( craniectomy patients should not he turned on the side of the cranial defect). Oral fluids are provided after swallow reflex and bowel  sounds have returned. Intake and Output are monitored . Speech therapy may be ordered for bedside swallow study or radiographic swallow study.  Signs of infection are monitored by checking craniotomy site, ventricular drainage, nuchal rigidity, or presence of CSF (fluid collection at surgical site). 

11. NURSING DIAGNOSES lneffective cerebral t issue p erfusion related to increased ICF Risk for Aspiration related to decreased swallow reflex and  postoperative positioning  Risk for Infection related to invasive procedure Acute Pain related to surgical wound Constipation related to use of opioids and immobility 

12. NURSING INTERVENTIONS Maintaining ICP Within Normal Range Closely monitor LOC, vital signs, pupillary response and ICP, if indicated. Notify health care provider if ICP is greater than 20 mm Hg or CPP is less than 60 mm Hg for more than 15 min.  Teach the patient to avoid activities that can raise ICP, such as excessive flexion or rotation of the head and Valsalva maneuver (coughing, straining with defecation).  Administer medications as prescribed, to reduce ICP. 4. Eliminate noxious tactile stimuli, such as suctioning, prolonged physical assessment, turning, and ROM exercises (based on patient response). 

13. Preventing Aspiration  Offer fluids only when the patient is alert and swallow reflexes have returned.  Have suction equipment available at bedside. Suction only if indicated. Pretreat with sedation or endotracheal lidocaine to prevent elevation of ICP.  Elevate head of bed to maximum of order, or per clinical  status , and patient comfort. 

14. Preventing Nosocomial Infections  1.  Use sterile technique for dressing changes, catheter care, and ventricular drain management.  2 Be aware of patients at higher risk of infection-those  undergoing lengthy operations . 3Assess surgical site for redness, tenderness, and drainage. 4Watch for leakage of CSF, which increases the danger of  meningitis . 

15. Relieving Pain Elevate head of bed as per protocol to relieve headache. . P ain management. Darken room if patient is photophobic .  Avoiding Constipation 1 . Encourage fluids when patient is able to manage liquids. 2. Ambulate as soon as possible. 3 . Change to non-opioid agents for pain control as soon as possible. 4 . Avoid Valsalva ’ like maneuvers. 5 . Use stool softeners and laxatives, as ordered.

16.  Expected Outcomes Decreased ICP maintained greater than 70 mm Hg Gag reflex present; breath sounds clear Afebrile without signs of infection Verbalizes decreased pain Passed soft stool