AFTER CRANIOTOMY

Nursing Priorities
Accurately monitor and record all vital signs and neurological signs - Postoperative cerebral edema peaks between 48 and 68 hours following surgery. - Patient may be lucid during first 24 hours, then experience a decrease in level of consciousness during this time - Observe the patient closely at all times. Note GCS. Have family members remain with patient.

AFTER CRANIOTOMY
Nursing Priorities
Maintain body temperature.

- Increases of body temperature in the neurosurgical patient may be due to cerebral edema around the hypothalamus. - Place patient on hypothermia blanket, as ordered.

AFTER CRANIOTOMY
Nursing Priorities
Assess patients respiratory status every 2 hours and as necessary for adventitious breath sounds. Maintain head of bed at 30elevation. Institute seizure precautions at patient's bedside (Tongue blade, airway) and observe for seizure activity.

AFTER CRANIOTOMY
Nursing Priorities
Administer anticonvulsants as ordered. Monitor adverse effects. Monitor serum drug levels.

AFTER CRANIOTOMY
Discharge Goals
Cerebral function improved, neurological deficits resolving or stabilized Complications prevented or minimized

Activities of daily living met by self or with assistance of others

AFTER CRANIOTOMY
Discharge Goals
Family acknowledgements reality of situation and involved in recovery program Condition, prognosis, complications and treatment regimen understood and available resources identified Plan in place to meet needs after discharge

MEDICATION
Post-Traumatic Brain Injury Medications
Anti-convulsant/Anti-seizure
Anti-convulsant medications are used to suppress the rapid and excessive firing of neurons that start a seizure. Anti-convulsants can sometimes prevent the spread of a seizure within the brain and offer protection against possible excitotoxic effects that may result in brain damage. Dilantin (phenytoin) Valium (diazepam)

Diuretics
These drugs reduce the amount of fluid in tissues and increase urine output. Diuretics, given intravenously to people with traumatic brain injury, help reduce pressure inside the brain. Mannitol

Pain Management:
Pain management medications are used to control pain stemming from TBI, and the symptoms and effects related to the injury. NSAIDs: Aspirin (ASA) Midol (ibuprofen)

Post-Craniotomy Medications
Steroids
These will be given to you to decrease post-operative brain swelling. These medications might elevate your blood sugar so be cautious and check your blood sugar regularly if you are a diabetic. Increased blood glucose will increase brain swelling.

Anti-seizure
These medicines (Dilantin, Phenobarb, Tegratol) will decrease your chance of post-operative seizures. Please take as directed.

AUTONOMIC DYSREFLEXIA
Monitor blood pressure and pulse every 2-5 minutes until the patient has stabilized Use an antihypertensive agent with rapid onset and short duration while the causes of AD are being investigated if the blood pressure is at or above 150 mm Hg systolic. The most commonly used agents are nifedipine and nitrates

The patient should be placed in the highest sitting position possible with legs lowered

AUTONOMIC DYSREFLEXIA
Any clothing or leg straps considered tight or restrictive should be loosened or removed. Check the bladder - Irrigation of a catheter should be done slowly and gently In the absence of bladder distention, examine the rectum for the presence of stool

AUTONOMIC DYSREFLEXIA
A digital rectal examination should be conducted following the application of a local anaesthetic to reduce rectal stimulation If there is poor response to treatment and/or if the cause of the AD has not been identified, send the patient to the emergency room (ER) for monitoring, maintenance of pharmacologic control of blood pressure, and investigation of other possible causes of the AD. Remember to document the episode of AD.

INEFFECTIVE TISSUE PERFUSION RELATED TO FLUID EXCESS SECONDARY TO POSTOPERATIVE PROCEDURE

INTERVENTIONS:

Independent:
Determine factors related to individual situation, cause for come or decreased cerebral perfusion and potential for increased ICP Monitor vital signs: BP, noting onset of and continuing systolic hypertension and widening pulse pressure; observe for hypotension in multiple trauma client Monitor and document neurological status frequency and compare with baseline: GCS during the first 48hrs Evaluate pupils, noting size, shape, equality, and light reactivity

INEFFECTIVE TISSUE PERFUSION RELATED TO FLUID EXCESS SECONDARY TO POSTOPERATIVE PROCEDURE

Monitor intake and output (I&O). Weigh as indicated. Note skin turgor and status of mucous membranes. Assess higher functions, including speech, if client is alert

Position head slightly (20-30 ) elevated as tolerated

Prevent straining at stool or holding breath Assess for nuchal rigidity, twitching, increased restlessness, irritability, and onset of seizure activity

INEFFECTIVE TISSUE PERFUSION RELATED TO FLUID EXCESS SECONDARY TO POSTOPERATIVE PROCEDURE

Collaborative
Maintain patients on supplemental oxygen via mechanical ventilator as indicated Administer isotonic IV fluids Administer diuretics such as mannitol and Fusosemide lasix as ordered

ACUTE PAIN RELATED TO POST-OPERATIVE PROCEDURE

INTERVENTIONS:
Independent assess contributing factors to pain (noise, wrong positioning, environment) provide comfort measures such as repositioning the client in a comfortable position and providing a hot or cold compress encouraged adequate rest periods assist in self-care activities as tolerated provide calm and quiet environment

Collaborative
administer medications as ordered by physician (analgesics, etc.)

INEFFECTIVE BREATHING PATTERN RELATED TO SPINAL CORD INJURY

INTERVENTIONS:
Independent
Auscultate chest to evaluate presence or character of breath sounds/secretions Observe rate and depth of respiration

Suction Airway as needed

Elevate Head of Bed if appropriate Monitor pulse O2 Administer 4L of O2 as ordered by the

physician

HEALTH INSTRUCTIONS
Provision of information about TBI
Education provided to patients and their support system about the nature and common manifestations of TBI is a critical aspect of intervention. Communication of health information from providers helps manage patient

expectations and can prevent the development of TBI symptoms and/or reduce their duration, number, and severity.

HEALTH INSTRUCTIONS
Supervision
Due to concerns of safety, some patients will be instructed to have supervision.

This will mean that they would need a responsible adult to be with them at all
times.

Mood Changes
Inform relative for irritability and emotional changes of the patient. Some people show emotions more easily after a brain injury. Some may even get violent. This behavior does not necessarily mean that they are feeling a deep emotion, but can occur because the brain is not regulating emotions to the same extent as before the injury.

HEALTH INSTRUCTIONS
Healthy Rest
Getting a good nights sleep has to do with many factors, and is also a treatment

for insomnia. Also instruct patient to avoid exerting physical and mental effort.

Physical Therapy
Instruct patient that they may need the help of a Physical Rehabilitation Therapists to aid in restoring and maintaining function, slowing disease

progression, and improving quality of life.

Speech Therapy
Inform patient and relative about speech therapy. Some patients may have

problems in speech occurring after a TBI.

MEDICATION
Antibiotic
Prophylactic antibiotics are given to prevent infection. Bacterial meningitis is the most common complication of post operative craniotomy. Vancomycin Penicillin Cefotaxime

Anti-emetic
Craniotomy surgery can irritate and inflame a patient's brain matter. This can cause patients to experience brain swelling complications after brain surgery. Brain swelling causes fluid to abnormally accumulate within the skull. Affected patients may experience severe headaches, dizziness, nausea or vomiting. Droperidol

POSTTRAUMATIC SEIZURES

POSTTRAUMATIC SEIZURES
Approximately 5-10% of individuals with traumatic brain injury (TBI) experience new- onset seizures. The risk is greatest in the first two years after injury and gradually declines thereafter. All types of seizures may occur as a result of trauma, but the most frequent are focal or partial complex seizures. Generalized complex seizures (which are commonly called "grand mal' seizures) occur in approximately 33% of cases.

It is not completely understood what physiological mechanisms cause seizures after injury, but early seizures are thought to have different underlying processes than late ones. Late seizures are thought to indicate permanent changes in the brain's structure and to imply epilepsy.

Factors that may result in seizures that occur within two weeks of an insult include the presence of blood within the brain; alterations in the blood brain barrier; excessive release of excitatory neurotransmitters such as glutamate; damage to tissues caused by free radicals; and changes in the way cells produce energy.
Late seizures are thought to be the result of epileptogenesis, in which neural networks are restructured in a way that increases the likelihood that they will become excited, leading to seizures

PREVENTION
Medications used to prevent seizures include valproate, phenytoin, and phenobarbital. It is recommended that treatment with anti-seizure medication be initiated as soon as possible after TBI.

DEEP VEIN THROMBOSIS

DEEP VEIN THROMBOSIS

Deep vein thrombosis (DVT) is common in persons with TBI, with an incidence as high as 54%. In patients with TBI, risk factors for DVT include immobility, lower extremity fracture, paralysis, and disruption in coagulation and fibrinolysis.

Complications of DVT include pulmonary embolism (PE) and recurrence. Because DVT can result in PE, it can be critical. Given the rapid decline in pulmonary function when a PE has completely occluded the pulmonary capillary system, sudden death may be the

first clinical sign. Other clinical signs of PE include shortness of

breath, chest pain, and pulmonary crackles; these are usually present with small emboli.

The most recognized risk factor for venous thromboembolism are venostasis, initial damage of the vessel wall, and a hypercoagulable state.
Patients with a severe brain injury are commonly immobilized for periods of time as a result of the fractures they experience in their extremities or spine. The incidence of DVT appears to be impacted by length of stay in the ICU. Patients involved in trauma that does not specifically involve vessel injury are still at increased risk of thromboembolism, suggesting a trauma-induced hypercoagulable state. Therefore persons who have sustained a TBI appear to be at increased risk of developing venous thromboembolism.

PREVENTION
Prophylaxis for DVT should be started as soon as possible. Use of elastic compression stockings Warfarin

HETEROTROPHIC OSSIFICATION
Heterotopic ossification is described as ectopic bone formation in the soft tissue surrounding the joints. In TBI, the incidence of heterotopic ossification is 11-76%, with a 10-20% incidence of clinically significant heterotopic ossification. Heterotopic ossification generally causes joint pain and decreases range of motion (ROM).

In decreasing order of frequency, heterotopic ossification occurs in

the hips, knees, elbows, shoulders, hands, and spine.

Risk factors associated with the development of heterotopic

ossification after TBI are a posttraumatic coma lasting longer than 2 weeks, limb spasticity, and decreased mobility.

The risk of heterotopic ossification is greatest during the first 3-4 months after injury.

The pathophysiology of HO is not well understood. HO forms through a

typical process beginning with the formation of osteoid to full calcification within a matter of weeks. Over the next few months, the calcified osteoid remodels into well-organized trabecular bone at which point it is considered to have matured. Several months after the initial trauma, these patients develop paraarticular and intramuscular bone formation and experience restricted range of motion, pain and ankylosis.

The bony lesion has been found to have a high metabolic rate, with a rate of bone formation more than three times greater than that of normal bone and an osteoclastic density of more than twice the number of

osteoclasts found in normal bone.It is believed that there is a neurogenic

factor contributing to HO, although this mechanism is not yet understood.

Circulating factors promoting heterotopic ossification may be present in head injured patients. In one animal study, the serum from patients with head injuries has been shown to promote mitogenesis and cell division in a rat osteoblast cell culture model.

Many studies have shown enhanced osteogenesis in patients sustaining traumatic brain injury (TBI). Accelerated fracture healing and heterotopic ossifications are well-known phenomena in these patients.

PREVENTION
Range of motion exercises Nonsteroidal anti-inflammatory medications (NSAIDs) Low-dose radiation Warfarin Etridonate disodium

IMPAIRED PHYSICAL MOBILITY RELATED TO POST-OPERATIVE PROCEDURE

INTERVENTIONS
Ensure the patients safety. Always keep the side rails up Turn patient every 2 hours to prevent pressure ulcers Perform Range of Motion Exercise. Discuss the proper usage of assistive devices and its functions Ensure that the patient always have a relative present for any need for assistance. Provide emotional support for the patient.

IMPAIRED VERBAL COMMUNICATION RELATED TO ALTERATION IN CNS

INTERVENTIONS

Independent Establish rapport simply by listening carefully and attending to the patients verbal and non verbal expressions Assess patients readiness to participation to alternative means of communication Encourage patient to express his thoughts via nonverbal movements like eye blinking, the picture board, computer or anything that is available to which the patient prefers to use Always speak to the patient in a calm voice Allow patient to complete what hes saying Provide encouragement and reassurance to the patient at all times when they are attempting to communicate Collaborative Refer to speech therapist

NAUSEA RELATED TO INCREASED INTRACRANIAL PRESSURE INTERVENTIONS:

Assess contributing factors to nausea.

Administer anti-emetic drugs.

Provided instructions to the patients on appropriate food and fluid choices, and encourage frequent intake of clear liquids in small amounts. Caution them not to drink excessive amounts of carbonated beverages, such

as soft drinks
Administer Mannitol.