Transcript Slide 1

Head Injury, Cranial Surgery
and IICP
NUR 2549
Unconsciousness
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An abnormal state in which client is unaware
of self or environment
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Can be for very short time to long term coma
Care is designed to
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Determine the cause
Maintain bodily functions
Support vital functions
Protect client from injury
Etiology
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Arousal
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State of being awake that depends on a group of
neurons in the brainstem
Can maintain level of wakefulness even without
functioning cortex
From Human
Physiology
RAS is located in
brain stem
Etiology
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Content part of consciousness
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Ability to reason, think and feel
Also to react to stimulus with purpose and
awareness
Controlled by cerebral hemispheres (higher
centers)
Intellect and emotional function are also controlled
in the same area.
Major Reactions
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Two reactions affecting cerebral metabolism
occur:
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Cerebral ischemia /anoxia – brain isn’t getting
enough oxygen and compensatory mechanisms
take place
Cerebral edema results because the brain
compensates by dilating blood vessels trying to
get more oxygen
Behavior
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Document accurately what the client’s
behavior is. Example: if the client opens
eyes on command but not spontaneously,
chart it as such. Be descriptive.
Glascow Coma Scale
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Used to document assessment in three areas
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Eyes
Verbal response
Motor response
Normal is 15 and less than 8 indicates coma
From Rehabilitation
Nursing
From Rehabilitation
Nursing
Other Assessment
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Assess bodily function including respiratory,
circulatory and elimination
Pupil checks – are pupils equal and how they
react to light
Extremity strength
Corneal reflex test
Intracranial Pressure
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Monro-Kellie hypothesis (applies only to
children with a rigid skull and not neonates)
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Skull is an enclosed space with three variables
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Brain tissue
Blood
Cerebrospinal fluid
Intracranial Pressure
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The skull cannot expand to allow for extra
space occupying tissue or fluid
If one of the three components increases the
other two must decrease in order to
compensate
Intracranial Pressure
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Other factors that influence intracranial
pressure
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Arterial pressure
Venous pressure
Intraabdominal and intrathoracic pressure
Posture
Temperature
Blood gases (left off handout)
Normal Intracranial Pressure
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Pressure exerted by total volume from:
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Brain tissue
Blood
Cerebrospinal fluid
Normal manometer reading – 80-180
Normal transducer reading – 0-15mm Hg
Cerebral Blood Flow
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Amount of blood going through 100g of brain
tissue in 1 minute – cerebral blood flow is
50ml/min per 100g
Brain uses 20% of the body’s oxygen
Brain uses 25% of body’s glucose
Autoregulation of Cerebral Blood Flow
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Blood vessels alter their diameter to ensure a
constant cerebral blood flow
Lower limit for MAP is 50mm Hg.
Below this, cerebral flow decreases and there is risk
of ischemia
Upper limit is MAP of 150mmHg. Above this the
cerebral blood vessels are maximally constricted.
Blood vessels cannot constrict more to control high
pressure. Blood brain barrier is disrupted and
cerebral edema and ICP results
MAP= DBP + 1/3 Pulse Pressure
Cerebral Perfusion Pressure (CPP)
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Pressure needed to maintain blood flow to
the brain
MAP-ICP=CPP
Normal CPP is 60-100
CPP>100 is hyperperfusion and IICP
CPP< 60 hypoperfusion
CPP<30 incompatible with life
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Elastance – stiffness of the brain
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High elasticity –high elastance ICP increases with
small increases in volume
Low elasticity – brain compensates and ICP stays
stable
Compliance
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Low compliance is same as high elastance
High compliance – ICP remains stable
Blood pressure
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If MAP is low, blood vessels in brain dilate to bring
in more blood
If MAP is high, blood vessels constrict to shunt
away blood from brain
Metabolic Factors affecting
cerebral blood flow
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Oxygen tension – When oxygen tension
(PaO2) falls below 50, cerebral arteries dilate
to increase cerebral blood flow. If this fails to
happen, the brain metabolism changes to
anaerobic metabolism and lactic acid builds
up
Carbon dioxide tension - If the blood
becomes acidic, the blood vessels dilate to
increase cerebral blood flow (increased CO2
and acidosis are potent vasodilators)
Metabolic Factors
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Globally
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extreme cardiovascular changes (asystole)
Pathophysiologic states (diabetic coma)
Focally
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Trauma and tumors
Stages of Increased ICP
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Stage 1 – High compliance and low
elastance. Autoregulation is functioning
Stage 2 – Compliance is lower and elastance
is increased. An increase in volume places
client at risk for IICP
Stage 3 – High elastance and low
compliance. Small changes in volume will
cause large increase in ICP
Stages of Increased ICP
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Stage 4 – ICP rises to terminal levels with
little increase in volume. Brain herniates
leading to
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REST IN
PEACE
Increased Intracranial Pressure
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From an increase in cranial volume that
results from increase in one or more of the
following:
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Brain tissue
Blood
Cerebrospinal fluid
Increased Intracranial Pressure
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Cerebral edema – regardless of cause,
increases tissue volume, can lead to IICP
Types –
 Vasogenic-most common (tumors, abscesses,
ingested toxins)
 Cytotoxic-local disruption of cell membranes
(lesions or trauma)
 Interstitial-uncontrolled hydrocephalus,
hyponatremia
Complications of IICP
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Inadequate cerebral perfusion
Cerebral herniation
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Brain shift : Lateral, downward, or both
Irreversible
Edema and ischemia further increased
Compression of brainstem and cranial nerves may
be fatal
Cerebellum and brainstem forced through
foramen magnum
Clinical Manifestations
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Change in level of consciousness is the
most sensitive and important indicator of
neuro status
May be pronounced or subtle
Early signs may be nonspecific: restlessness,
irritability, generalized lethargy
Clinical Manifestations
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Changes in vital signs-this is ominous sign
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This is a late sign – Cushing’s triad
Increasing systolic blood pressure
Pulse slowing and is bounding
Irregular respiratory pattern
May also have a change in temperature
Clinical Manifestations
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Ocular signs
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Pupil changes are from pressure on third cranial
nerve
Pupils become sluggish, unequal. This is
because of brain shift. May also be pressure on
other cranial nerves
Clinical Manifestations
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Decrease in motor function
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May have hemiparesis or hemiplegia
May see posturing – either decorticate or
decerebrate
Decerebrate – more serious from damage in
midbrain and brainstem
Decorticate – from interruption of voluntary motor
tracts
Clinical Manifestations
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Headache
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From compression on the walls of cranial nerves,
arteries and veins
Worse in the morning
Straining and movement makes worse
Clinical Manifestations
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Vomiting
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NOT preceded by nausea- “unexpected”
May be projectile
Diagnostic Tests
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CT
MRI
Cerebral angiography
EEG
PET
No lumbar puncture if there is ICP because sudden
release of pressure can cause brain to herniate
ABG’s – keep O2 at 100% (Lewis 1615) and PCO2
as related to ICP (25-35)
Drug Therapy
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Mannitol – Rapid short acting diuretic that
decreases ICP. Decreases total brain water
content
Watch fluids and electrolytes closely (I and O
and labs)
Don’t give in cases of renal failure or if serum
osmolality increased
Drug Therapy
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Loop diuretics – reduce blood volume and
tissue volume
Corticosteroids – Decadron most common
steroid used. Watch for side effects. Should
be on antacids or H2 receptor blockers to
prevent ulcers.
Drug Therapy
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Barbiturates – causes decrease in
metabolism and ICP. Causes reduction in
cerebral edema and blood flow to brain.
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Watch for hangover effects and drowsiness. Side
effects make it harder to check LOC. Watch for
constipation – do not want client straining.
Skeletal muscle paralyzers may be used (Pavulon)
Antiseizure drugs - Dilantin
Nutrition
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Clients need higher amounts of glucose to
survive.
Will need nutritional support quickly.
Watch sodium if on Mannitol – may need to
give additional salt.
Also may need additional free water if
dehydrated – watch I and O closely.
Give low CHO diet to help with CO2
Nutrition
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Fluid balance is controversial
Do not want too dry
Keep normavolemic
Give saline either .45% or normal saline – not
glucose to help prevent additional cerebral
edema
Laboratory Work
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ABGs regularly
Electrolytes daily
Nursing Interventions
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Airway and respiratory – suction only as
needed and for 10 seconds at a time, only 2
passes. Give 100% O2 prior to suctioning.
Avoid abdominal distention – may need NG
tube to decompress stomach
Sedate with care – if not on a vent, use
sedation that will not interfere with respiration
or mask any neuro changes
Nursing Interventions
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Keep HOB elevated 30 degrees if BP is
normal
If BP is low will need to put HOB flat
Keep head in alignment to prevent cutting off
venous flow from the head
Don’t elevate knees – this will increase
intrathoracic pressure
Turn gently from side to side – if turning
raises ICP, client will need to stay on back
Nursing Interventions
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If client is posturing frequently during care,
will need to sedate first and then do only one
thing at a time. Minimize stimulation
These clients can become agitated and
combative – avoid over stimulating them
Restraining them will make them MORE
AGITATED and RAISE THEIR ICP!
Nursing Interventions
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Use minimal stimulation – perhaps one family
member that is particularly calming – not the
entire neighborhood can stay with client
Use a calm voice when talking to the client
Calmly tell the client what you are going to do
when providing care
NO TV IN ROOM
Keep room darkened if needed
Nursing Interventions
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Keep body temperature within normal limits
Give ordered PRN antipyretics (probably
Tylenol)
May need to use cooling blanket
Do not use ice on client
Nursing Interventions
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Hygiene – keep skin clean and dry. Watch
for skin breakdown
May need to be on a special bed
Keep mouth clean and moist
May need eye drops to moisten eyes
Families need a lot of support even after
client leaves ICU
Client may benefit from rehab to help him
adapt and progress
Nursing Interventions
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Prevent infection
Protect from injury
Avoid factors that increase ICP
Psychological support
Pediatric Considerations
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Open fontanels allow expansion of skull
Neuro changes may be harder to detect
because child cannot communicate as well
Cushing’s triad rarely seen in children
Compare child’s behavior with their
developmental level
Pediatric Considerations
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Assess for developmental differences and
physical anomalies
Is child appropriate for age?
Look for physical injuries such as bites,
bruises
Use special Glascow coma scale for child
Pediatric Considerations
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Allow parent to stay with child as much as
possible
Avoid unnecessary stimulation
Crying will increase ICP
Head Trauma
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Usually signifies craniocerebral trauma
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Includes alteration in consciousness
High potential for poor outcome
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Death at injury
Death within 2 hours after injury
Death 3 weeks after injury
Head Trauma statistics
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3 million/year in the U.S.
Mortality rate is 19 per 100,000
MVAs and falls have decreased as causes
Firearm-related head injury deaths have
increased
Head Trauma
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Scalp lacerations – scalp has many blood vessels
and will bleed profusely. Watch for infection
Skull fracture types
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Linear
Depressed
Simple
Comminuted
Compound
Skull Fracture Locations
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Frontal
Orbital fracture
Temporal fracture
Parietal fracture
Posterior fossa fracture
Basilar skull fracture
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Occurs at base of the skull
Watch for rhinorrhea and otorrhea
Test fluid leaking from nose or ear for glucose and
watch for halo
If the drainage is CSF then the fracture has crossed
the dura
Head Trauma
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Check head injury client for bruising around
eyes called raccoon eyes
Also look at hairline at nape of neck behind
ear for bruising called Battle’s sign
Major complications of basilar skull fracture
are infection and hematoma
Battle’s sign
Minor Head Trauma
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Concussion – client may not lose
consciousness
Will be a brief change in LOC, client may not
remember the event and will have headache
Post-concussion syndrome is 2 weeks to 2
months after injury
Post Concussion Syndrome
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Persistent headache
Lethargy
Personality changes
Short attention span
Decreased short-term memory
When client is discharged after concussion
nurse should instruct family on what to watch
for and when to call Dr.
Major Head Trauma
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Contusion – bruising of brain tissue
Has area of necrosis infarction and
hemorrhage
Often from coup - contrecoup injury
Seizures are common after contusion
Major Head Trauma
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Lacerations
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Tearing of brain tissue
Occurs with depressed skull fracture and
penetrating injuries
May have bleeding into the brain structuresintracerebral hemorrhage
Very difficult to remove blood
Major Head Trauma
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Epidural hematoma
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Comes from bleeding between dura and inner
surface of the skull
Will be unconscious, then awake, and then
deteriorate
Headache, nausea and vomiting
Needs surgical intervention to prevent brain
herniation and death
Subdural Hematoma
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Usually bleeding is from veins, so bleeding is
GENERALLY slower than epidurals
CAN be from arteries and these require
IMMEDIATE removal
Administration of anticoagulants is one of the
causes of CHRONIC TYPES esp. in the
elderly.
Diagnostic Studies
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Skull xrays routine to r/o or identify fracture
CT/MRI are best to determine trauma rapidly
Emergency Management-Initial
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Airway
Stabilize cervical spine
Oxygen administration
IV access (2 large bore catheters), LR or NS
Control external bleeding with pressure
Assess for rhinorrhea, otorrhea, scalp
wounds
Remove clothing
Emergency Management-Ongoing
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Maintain patient warmth
Monitor VS, LOC, O2 sats, cardiac rhythm,
GCS, pupil size and reactivity
Anticipate intubation if absent gag reflex
Assume neck injury with head injury
Administer fluids cautiously to prevent IICP
Rehab
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Most head trauma requires rehab
Some rehab units do coma management
Client may have trouble swallowing and need
speech therapy
Client may agitate easily and act out sexually
May be a flight risk and have to be in a
locked ward until passes through the
agitation phase
From Rehabilitation Nursing
From
Rehabilitation
Nursing
Pediatric Client
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Child is vulnerable to acceleration
deceleration injuries because their neck is
supple and moves around easily and the
head is larger in proportion to their bodies
In a very young child the cranium may be
able to expand enough to allow for some
edema
Pediatric Client
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Epidural hemorrhage is rare in children
Subdural hemorrhage – from shaken baby
syndrome, falls
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Can result in quadriplegia, hyperthermia, bulging
fontanels
Retinal hemorrhages
Dizziness
Unsteady gait
Elderly
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At risk for head trauma from falls
Be alert if client has fallen and is taking
anticoagulants
Cranial Surgery
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Brain tumor (benign or malignant)
CNS infection
Hydrocephalus
Vascular abnormalities
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Craniocerebral trauma
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Intracranial bleeding
Aneurysm repair
Arteriovenous malformation
Skull fractures
Epilepsy
Intractable pain
Types of Cranial Surgery: Stereotactic
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Stereotactic: neurosurgery
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Often computer assisted to precisely target area
CT and MRI used to image targeted tissue
Burr hole or bone flap for entry
Can remove small tumors and abscesses, drain
hematomas, perform ablative procedures, repair
AV malformation
Reduces damage to surrounding tissue
Types of Cranial Surgery: Craniotomy
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Location varies
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Frontal
Parietal
Occipital
Temporal
Combination
Burr holes drilled, saw to remove bone flap
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Bone flap wired or sutured after surgery
Drain may be placed to remove blood or fluid
Nursing Care: Pre-op
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Compassion
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Uncertainty and fear about prognosis/complications
Teaching
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What can be expected
Hair will be shaved
Client will be in ICU after surgery
Nursing Care: Post-op
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Prevent increased ICP!!!
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Frequent assessment of neuro status x 48 hrs.
Monitor fluids, electrolytes, osmolality closely
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Maximum swelling occurs within 24-48 hours
Detects changes in sodium regulation, onset of
diabetes insipidus, severe hypovolemia
Positioning varies depending on procedure
Assess dressing, drainage, incision
Care to prevent wound infection
Nursing Care: ambulatory and home
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Rehab potential depends on reason for
surgery, post-op course of recovery, and
client’s general health
Nursing considerations
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Foster independence for as long as possible to
highest degree possible
Positioning, skin and mouth care, ROM exercises,
bowel and bladder care, adequate nutrition
Potential recovery cannot be determined until
cerebral edema and IICP subside