NURSING CARE OF PATIENTS UNDERGOING CRANIAL AND SPINAL.pptx

Medical surgical nursing

1. NURSING CARE OF PATIENTS UNDERGOING CRANIAL AND SPINAL SURGERIES

2. CRANIAL SURGERIES The term “cranial surgery” refers to various medical procedures that involve repairing structural problems in the brain. There are numerous types of brain surgeries. The type used is based on the area of the brain and the condition being treated. The type of brain surgery done depends highly on the condition being treated.

3. INDICATIONS Abnormal blood vessels Ananeurysm Bleeding Blood clots Damage to the protective tissue “ dura ” Abscesses Pressure after head injury Skull fracture Stroke Brain tumors Fluid building up in the brain

4. CRANIAL SURGERIES Burr hole / Craniotomy Craniectomy Cranioplasty LASER Surgery Stereotactic surgeries Microsurgery

5. CRANIOTOMY Craniotomy is a surgery to cut a bony opening in the skull. A craniotomy may be small or large depending on the problem. It may be performed to treat brain tumors, hematomas (blood clots), aneurysms or AVMs, traumatic head injury, foreign objects (bullets), swelling of the brain, or infection. The bone flap is usually replaced at the end of the procedure with tiny plates and screws.

6. CRANIECTOMY Craniectomy is a neurosurgical procedure that involves removing a portion of the skull, where the patient's scalp is closed without re-implantation of the bone, leaving a resultant cranial defect. Craniectomy may be used in nonemergent circumstances to augment the opening of a craniotomy. Decompressive Craniectomy is used in urgent or emergent conditions where there is substantial brain swelling from bleeding, stroke or infection.

7. CRANIOPLASTY Cranioplasty is a surgical procedure to correct a deformity or defect of the skull. Reconstruction of the skull- cranioplasty may be performed with titanium mesh or other artificial products.

8. STEREOTACTIC SURGERY Stereotactic radiosurgery (SRS) uses many precisely focused radiation beams to treat tumors and other problems in the brain, neck, lungs, liver, spine and other parts of the body. Stereotactic radiosurgery uses 3D imaging to target high doses of radiation to the affected area with minimal impact on the surrounding healthy tissue. Three types of technology to deliver radiation during stereotactic radiosurgery in the brain   Linear accelerator (LINAC) machines Gamma Knife machines use 192 or 201 small beams of gamma rays to target and treat cancerous and noncancerous brain abnormalities. Proton beam therapy (charged particle radiosurgery ) is the newest type of stereotactic radiosurgery

9. LASER THERAPY MRI-guided  laser ablation is a minimally invasive neurosurgical option for the treatment of brain tumors. The procedure may reduce certain surgical risks associated with traditional open brain tumor surgery, and may reduce pain and shorten recovery time.

10. BIOPSY This procedure is used to remove a small amount of brain tissue or a tumor so it can be examined under a microscope. This involves a small incision and hole in the skull.  

11. MINIMALLY INVASIVE NEUROENDOSCOPY Similar to minimally invasive endonasal endoscopic surgery, neuroendoscopy uses endoscopes to remove brain tumors. Your surgeon may make small, dime-sized holes in the skull to access parts of your brain during this surgery

12. DEEP BRAIN STIMULATION As with a biopsy, this procedure involves making a small hole in the skull, but instead of removing a piece of tissue, your surgeon will insert a small electrode into a deep portion of the brain. The electrode will be connected to a battery at the chest, like a pacemaker, and electrical signals will be transmitted to help symptoms of different disorders, such as Parkinson’s disease.

13. COMPLICATIONS OF BRAIN SURGERIES Bleeding Infection in the brain or at the wound site Seizures Abnormalities in cerebrospinal fluid (CSF) absorption / brain swelling Coma Impaired speech, vision, coordination, or balance Memory problems Further damage to the brain Stroke Death

14. PREPARATION FOR BRAIN SURGERY Consent forms are signed Inform the surgeon about your medical history (e.g., allergies, medicines, anesthesia reactions, previous surgeries). Before surgery, conduct tests (e.g., electrocardiogram, chest x-ray, and blood work) to make sure that you are cleared for surgery. It is important to discontinue all non-steroidal anti-inflammatory medicines and blood thinners typically at least 1 week before surgery. Stop smoking, chewing tobacco, and drinking alcohol 1 week before and 2 weeks after surgery because these activities can cause bleeding problems

15. If image-guided surgery is planned, an MRI will be scheduled before surgery small markers may be placed on your forehead and behind the ears. The markers help align the preoperative MRI to the image guidance system. The markings must stay in place and cannot be moved or removed prior to surgery to ensure the accuracy of the scan. Do not eat or drink after midnight the night before surgery. An anesthesiologist will talk with you to explain the effects of anesthesia and its risks.

16. INTRAOPERATIVE PERIOD Remove any clothing, jewelry, or other objects that may interfere with the procedure. An intravenous (IV) line will be inserted in arm or hand. A urinary catheter will be inserted Position on the operating table in a manner that provides the best access to the side of the brain to be operated on. The anesthesiologist will continuously monitor heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Head will be shaved and the skin over the surgical site will be cleansed with an antiseptic solution. There are various types of incisions that may be used, depending on the affected area of the brain. An incision may be made from behind the hairline in front of ear and the nape of neck, or in another location depending on the location of the problem. If an endoscope is used, the incisions may be smaller.

17. Head will be held in place by a device which will be removed at the end of the surgery. The scalp will be pulled up and clipped to control bleeding while providing access to the brain. A medical drill may be used to make burr holes in the skull. A special saw may be used to carefully cut the bone. The bone flap will be removed and saved. The dura mater (the thick outer covering of the brain directly underneath the bone) will be separated from the bone and carefully cut open to expose the brain.

18. Excess fluid will be allowed to flow out of the brain, if needed. Microsurgical instruments, such as a surgical microscope to magnify the area being treated, may be used. This can enable the surgeon a better view of the brain structures and distinguish between abnormal tissue and healthy tissue. Tissue samples may be sent to the lab for testing. A device, such as a drain or a special type of monitor, may be placed in the brain tissue to measure the pressure inside the skull, or intracranial pressure (ICP). ICP is pressure created by the brain tissue, cerebral spinal fluid (CSF), and blood supply inside the closed skull.

19. Once the surgery is completed, the surgeon will suture (sew) the layers of tissue together. The bone flap will be reattached using plates, sutures, or wires. If a tumor or an infection is found in the bone, the flap may not be replaced. Also, if decompression (to reduce pressure in the brain) is required, the bone flap may not be replaced. The skin incision (scalp) will be closed with sutures or surgical staples. A sterile bandage or dressing will be applied over the incision.  

20. POST OP CARE Vigilance and early detection of surgical complications (stroke, seizures and bleeding) Emergence and recovery from anesthesia Assessment of impaired consciousness Restoring and maintaining normal body temperature Pain management Post-operative nausea and vomiting Prophylaxis for DVT and GI bleeding

21. Hospital management Immediately after the procedure, Patient will be taken to a recovery room for observation before being taken to the intensive care unit (ICU) to be closely monitored. Or, may be taken directly to the ICU from the operating room. In the ICU, medicine is given to decrease the brain swelling. Recovery process will vary depending upon the type of procedure done and the type of anesthesia given. Once blood pressure, pulse, and breathing are stable and alert, patient may be taken to the ICU or hospital room.

22. Administer need oxygen for a period of time after surgery. Patient is taught deep-breathing exercises to help re-expand the lungs and prevent pneumonia. Frequent neurological checks will be done to test brain function .Patient will be asked to follow a variety of basic commands, such as moving arms and legs, to assess brain function. Pupils will be checked with a flash light, and asked questions to assess orientation. The strength of arms and legs will also be tested. 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.

23. 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) Turn side-to-side every 2 hours; positioning restrictions will be ordered by the physician ( craniectomy patients should not be turned on the side of the cranial defect).

24. 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). The head of bed may be elevated to 30-40 degree to prevent swelling of your face and head. (cerebral edema) Patient will be encouraged to move around as tolerated while in bed and to get out of bed and walk around, with assistance at first, as the strength improves. A physical therapist (PT) may be asked to evaluate strength, balance, and mobility, and give suggestions for exercises to do both in the hospital and at home .

25. Patient is asked to sequential compression devices (SCDs) placed on legs to prevent blood clot formation. Depending on the situation, patients may be given liquids to drink a few hours after surgery. Diet may be gradually changed to include more solid foods as tolerated. Patient may be catheterized. Be sure to report any painful urination or other urinary symptoms that occur after the catheter is removed, as these may be signs of an infection that can be treated. Depending on patient status, patient may be transferred to a rehabilitation facility for a period of time to regain your strength. Before discharge from the hospital, arrangements will be made for a follow-up visit with your doctor.

26. NURSING DIAGNOSES Ineffective airway clearance related to effect of anesthesia lneffective cerebral tissue perfusion related to increased ICP Acute Pain related to surgical wound Altered thought process related to presence of cerebral edema Risk for Aspiration related to decreased swallow reflex and postoperative positioning Risk for Infection related to invasive procedure Constipation related to use of opioids and immobility

27. 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. Eliminate noxious tactile stimuli, such as suctioning, prolonged physical assessment, turning, and ROM exercises (based on patient response).

28. 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

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

30. Relieving Pain Elevate head of bed as per protocol to relieve headache. . Pain management. Darken room if patient is photophobic.

31. Avoiding Constipation Encourage fluids when patient is able to manage liquids. Ambulate as soon as possible. Change to non- opioid agents for pain control as soon as possible. Avoid Valsalva ’ like maneuvers. Use stool softeners and laxatives, as ordered.

32. SPINAL SURGERIES Indications Mechanical back pain (usually attributed to disc degeneration, called degenerative disc disease) Spinal stenosis (where there is an associated deformity) Ischemic spondylolisthesis . Fractures. Tumors.

33. Surgical approaches Anterior approach: The surgeon accesses the spine from the front of your body, through the abdomen. Posterior approach: An incision is made in the back. Lateral approach: The pathway to the spine is made through the side.

34. Surgeries Discectomy or Microdiscectomy : Removal of a herniated intervertebral disc. Therefore, removing pressure from the compressed nerve. Laminectomy : Removal of the thin bony plate on the back of the vertebra called the laminae to increase space within the spinal canal and relieve pressure. Laminotomy : Removal of a portion of the vertebral arch (lamina) that covers the spinal cord. A laminotomy removes less bone than a laminectomy .

35. Foraminotomy : Removal of bone or tissue at/in the passageway (called the neuroforamen ) where nerve roots branch off the spinal cord and exit the spinal column. Disc replacement : As an alternative to fusion, the injured disc is replaced with an artificial one. Spinal fusion : A surgical technique used to join two vertebrae. Spinal fusion may include the use of bone graft with or without instrumentation ( eg , rods, screws). There are different types of bone graft, such as from own bone ( autograft ) and donor bone (allograft).

36. Risks of spinal surgeries Reaction to anesthesia or other drugs Bleeding Infection Blood clots, for instance in your legs or lungs Heart attack Stroke Herniated disk Nerve damage, which can lead to weakness, paralysis, pain, sexual dysfunction, or loss of bowel or bladder control

37. Post op care Most patients experience some pain and drowsiness. The more intense pain typically lasts a couple of days after surgery, and pain medication is administered regularly to manage it. This medication may be given in the vein or by injection into the muscle of the arm or leg. Sometimes a patient-controlled analgesia (PCA) pump is used, in which the patient controls when an attached device administers the pain medication. As the pain decreases, transition to oral medication will happen. Oxygen may be administered to ease breathing, and a heart monitor may track the heart rate and rhythm after surgery.

38. Patients work with physical and occupational therapists each day to learn the safest ways to dress, sit, stand, walk, and take part in other activities without putting added stress on the back. Some patients are fitted with a back brace to limit motion in the spine. Be careful to prevent skin irritation such as rashes or blisters Follow activity Restrictions - No bending of spine, No lifting, No twisting, No driving.

39. Surgical incision site infections are most likely to arise about 2 to 4 weeks after surgery.  Some symptoms to be aware of include: Fever (101 degrees or higher) Expanding redness at the incision site Increasing back pain Change in the amount, appearance, or odor of drainage

40. Nursing Diagnosis Ineffective breathing pattern Impaired physical mobility Pain Ineffective tissue perfusion Risk for trauma Constipation Urinary retention risk Risk for infection Knowledge deficit