PRACTICE TEACHING ON

PRE AND POST OP NURSING CARE OF

NEUROSURGERY PATIENTS
INTRODUCTION
A preoperative assessment clinic is essential to gather all information, optimise co
morbidities, and then organise anaesthetic, surgical and postoperative care before surgery
actually takes place. The pre-operative nurses can assess the knowledge and use this
information in developing a plan for an event full preoperative course. The aim of
postoperative care is to provide the patient with a quick, painless and safe recovery from
surgery as possible.
There are mainly three phases of surgery –
1. Pre operative phase
2. Intra operative phase
3. Post operative phase

Surgical safety checklist

covers three distinct phases of an operation:
 Sign-in: Before the patient is given anesthesia
 Time-out: Before the surgeon makes the skin incision
 Sign-out: Before the patient leaves the operating room.

Preoperative phase
The preoperative phase begins when the decision to proceed with surgical intervention is
made and ends with the transfer of the patient onto the operating room table.
The preoperative phase is the period that is used to physically and psychologically prepare
the patient for surgery. The length of the preoperative period varies. For the patient whose
surgery is elective, the period may be lengthy. For the patient whose surgery is urgent, the
period is brief; the patient may have no awareness of this period

Preoperative teaching and support

The nurse is tasked with the major responsibility for patient and family preparation and for
provision of emotional support throughout the experience. The teaching plan is individualized
and directed toward providing information and anticipatory guidance about activities
associated with the neurosurgical procedure.

GENERAL PREOPERATIVE TEACHING PLAN FOR

NEUROSURGICAL PROCEDURES
Patient and family
1. Clarify and reinforce information provided by the physician.
2. Describe preparatory events before surgery (e.g., blood work, electrocardiogram,
chest radiograph, application of thromboembolic (TED) stockings and sequential
compression device, visit from anaesthesiologist, NPO before surgery).
3. Discuss the need to cut/shave some hair from the scalp for the procedure.
4. Teach any special activities, such as leg exercises or deep breathing exercises.
5. Review what to expect throughout hospitalization and after.
 6. Discuss: Location of the waiting area and amenities (e.g., telephones, restrooms,
food), Location of where the neurosurgeon will talk to the family after the surgery. If
not physically present, how the family can be reached by telephone
7. Provisions for periodic updates if the surgery time is extended
8. Unit to which the patient will go after surgery (e.g., recovery room; intensive care unit
[ICU]), Visiting hours before surgery and in the ICU. Estimated length of intracranial
surgery (may take several hours and this is not unusual). What to expect in the ICU
(e.g., tubes, monitors, intravenous lines, change in appearance for dressings or
ecchymosis)

PRE MEDICATIONS
To minimize the risk of excessive bleeding during and after surgery, discontinue all aspirin-
containing medications and non-steroidal anti-inflammatory drugs (NSAIDs, Ibuprofen,
Celebrex, Vioxx, etc.) at least one week prior to your surgery. Take all of your routine
medications the morning of surgery with a sip of water.
The only exceptions are:
• Aspirin-containing medications
• NSAIDs
• Blood-thinners such as coumadin, Plavix, Ticlid, persantine, etc.
• Diabetic medications such as insulin, Glucotrol, Glucophage, etc.
Informed Consent
It is an active, shared decision-making process between the health care provider and the
recipient of care.
In obtaining informed consent, the physician discusses the purpose of surgery, alternative
treatments, potential risks, and expected outcomes.
Discussing these points honestly and answering all questions can reduce the possibility of
misunderstandings and litigation. Because altered consciousness, impaired cognition, or both
can severely influence comprehension, a responsible family member should be present during
the discussion.
Recheck and review the consent before surgery.
Part preparation - Carefully wash and clean the skin around the incision site.
Use an alcohol-based CHG solution (usually, a 2% chlorhexidine isopropanol solution) for
surgical site skin preparation.Apply the solution using sterile gauze and instruments
Remove hair with a dedicated clipping device with a prepackaged razor in the preoperative
area the same day as surgery
Attache all lab reports- The tests help find possible problems that might complicate surgery
if not found and treated early.
Identification band - Patient ID bands are an important way to reduce patient safety risks.
Patient mis-identification continues to result in medication errors, transfusion errors, testing
errors, wrong person procedures and discharge
Checking of all vitals signs - Pre-operative assessment is required prior to the majority of
elective surgical procedures, primarily to ensure that the patient is fit to undergo surgery.

Immediate Management
 The immediate management of the patient at the scene of the injury is critical,
because improper handling can cause further damage and loss of neurologic function.
 Any patient involved in a motor vehicle or diving injury, a contact sports injury, a fall,
or any direct trauma to the head and neck must be considered to have SCI until such
an injury is ruled out.
 At the scene of the injury, the patient must be immobilized on a spinal (back) board,
with head and neck in a neutral position, to prevent an incomplete injury from
becoming complete.
 If cervical injury is there put a cervical collar on neck to maintain immobilization.
 Use log roll technique in spinal cord injury to maintain proper alignment. Reassure
the casualty.
 Open their airway using the jaw-thrust technique.

ASSESSMENT OF PATIENTS UNDERGOING EMERGENCY OR

TRAUMA SURGERY
PHYSICAL EXAMINATION
An initial look at the patient for obvious injuries and then a primary and secondary survey.
One need to consider other injuries such as thoracic, abdominal and long bone fracture.
1) Primary Survey
A. Airway
 look for any obstruction, chest wall movement, retraction and nasal flaring
 Listen to breathe sound, stridor and obstructed breathing
B. Breathing
 Look to see if ventilation is adequate
 Look for open pneumothorax open chest wound and flial segment.
 Listen for bilateral chest sound.
C. Circulation
 Feel peripheral pulse, measure blood pressure, capillary refill and perform an ECG.
D. Disability (Neurological state)
 Check level of consciousness
 AVPU
o A-Alert
o V-response to verbal stimuli
 o P-response to painful stimuli
o U-Unresponsiveness to stimuli
E. Exposure- Expose patient fully for complete examination
2) Secondary survey – (SAMPLE)
 S= sign and symptoms
 A= allergies
 M= medications
 P= pertinent past medical history
 L= Last oral intake
 E= event leading to illness or injury
Includes obtaining patient's history, vital signs and full head to toe examination.
NEUROLOGICAL SYSTEM
Neurological observations should include sign of increased ICP, GCS, cranial nerve function,
limb power and sensation, and pupillary responses.
Peripheral Nervous System
A history of weakness of arms and or legs and loss of sensation should besort.
The exact level of these helps to determine the location of the lesion. Bladder dysfunction
indicates sacral nerve root dysfunction.
FAST and E-FAST
Focussed Assessment with Sonography for Trauma (FAST) scan
E-FAST (Extended Focused Assessment with Sonography in Trauma) is a bedside
ultrasonographic protocol designed to detect peritoneal fluid, pericardial fluid, pneumothorax,
and/or hemothorax in a trauma patient.
NEUROANESTHESIA
Pt is graded on a 5-point scale (Class 1 healthy – Class 5 moribund pts) Combination of
inhalants and IV drugs are chosen considering their effects on CBF (the volume of arterial
blood delivered to a unit mass of brain tissue per unit of time) and ICP

Goal

➢ To preserve CBF and avoid hypoxia and hypoxemia

➢ Cerebral protection – Hypothermia

Hypotension
Hyperventilation

❖ Mannitol to reduce brain volume

❖ EVD and LD to reduce CSF

❖ Decadron to reduce brain edema

❖ Dilantin to prevent seizure

❖ Antibiotic as prophylaxis

❖ Cardiac drugs to control BP

NEUROSURGICAL PROCEDURES
Craniotomy
Craniectomy
Cranioplasty
 Burr hole
 Stereotactic surgery
 Laser Gamma knife
 Transphenoidal Hypophysectomy
Craniotomy

➢ Surgical opening of the skull

➢ To provide access of intracranial contents – tumor, aneurysm, SDH

➢ Involves creation of bone flap

➢ Free flap: Bone is completely removed and preserved for later

replacement

➢ Bone flap: Muscle is left attached to the skull to maintain vascular

supply
Awake Craniotomy

➢ Procedure is useful when the tumor involves the motor strip, sensory areas, and speech).

➢ Medical team can interact with the patient during surgery and monitor for
complications.
Craniectomy

➢ Excision of a portion of skull without replacement

➢ Procedure may be done to achieve decompression after removal of bone fragments post
skull fracture.
Cranioplasty

➢ Repair of the skull to re-establish the contour and integrity of the skull

➢ Procedure involves replacement of part of the cranium with a synthetic

material
Burr Hole

➢ Creation of a hole in the cranium using a special drill

➢ Used for evacuation of extra-cerebral clots or in preparation of craniotomy

Stereotactic Surgery
➢ Stereotactic frame is inserted Target site is located (X-Y-Z)

➢ Point of intersection of all 3 coordinates identify the target tissue

➢ The stereotaxic probe is passed to target area

➢ Used in precise localization and treatment of deep brain lesions

In this context “stereo” means 3-dimensional and “tactic” means touch
Radiosurgery: Gamma Knife

➢ Consists of heavily shielded helmet containing radioactive Cobalt

➢ Stereotacsix is used to focus point of radiation

➢ Capable of destroying deep and inaccessible lesions

Transphenoidal Hypophysectomy
Used for pituitary adenomas, craniopharyngeomas and complete hypophysectomy for control
of bone pain in metastatic cancer.

POST OPERATIVE NURSING MANAGEMENT

The management of the patient after surgery. This includes care given during the
immediate post operative period, both in the operating room and the post anaesthesia care
unit (PACU), as well as the days following surgery.

Basic Nursing Management After Cranial Surgery

(airway maintenance, bp monitoring and maintain temp regulation, positiong, check vital
signs every 15 min, GCS, ABG analysis every 4 hrly or atlest evry day)
• Give basic hygienic care until the patient is able to participate in self-care (e.g., bath, oral
hygiene, hair combing, nail cutting).
• Apply thigh-high elastic stockings and sequential compression air boots, and inspect legs
daily. Note any signs of thrombophlebitis (redness, tenderness, warmth, swelling).
• Provide skin care every 4 hours.
• Turn patient every 2 hours, being careful to maintain the patient’s body alignment. (It may
be necessary to use pillows and other similar devices to maintain good body alignment.)
• Carry out range-of-motion exercises four times daily.
• Provide urinary catheter care daily using soap and water. Pin the catheter to prevent undue
traction on the meatus. Remove the catheter as soon as possible.
• Apply warm or cold moist compresses to the eye area.
• Inspect eyes every 4 hours for signs of irritation or dryness. Lubricate the eye with normal
saline; commercially prepared eye lubricant. To protect the eye from injury (corneal
ulcerations or abrasions) if the lids do not tightly cover the eye, use an eye shield, or tape the
eye closed.
• Pull up the side rails of the bed, and apply restrains as necessary.
• Evaluate periods of restlessness for an underlying cause (check for patency of the airway,
evidence of pain, or distention of the bladder).
• Administer analgesics as ordered
• Do not combine nursing activities that are known to increase intracranial pressure (ICP) in
the patient at risk.
• Monitor routine vital signs.
• Assess neurological signs at prescribed intervals: Level of consciousness and orientation,
Pupillary reaction, Eye movement, Motor function, Sensory function.
Surgery can be classified by anatomic location.
• Supratentorial- area is above the tentorium and includes the cerebral hemispheres. The
supratentorial approach is used to gain access to lesions of the frontal, parietal, temporal, and
occipital lobes.
• Infratentorial- area is below the tentorium in the posterior fossa and includes the brainstem
(midbrain, pons, medulla) and cerebellum. It gains access to lesions of the brain- stem or
cerebellum.

Management
INCISION
• In supratentorial the scalp incision is made on the cerebral hemispher and in Infratentorial
incision is made on the nape of neck.
• Sutures are usually removed within 7–10 days.
HEAD DRESSING
• A turban-style dressing is applied initially. • Many physicians remove the dressing
completely after 24 hours.
• Monitor for evidence of blood or cerebrospinal fluid (CSF) drainage.
• The incision is monitored for redness, drainage, or signs of wound
infection.
POSITIONING OF THE HEAD OF THE BED
The HOB is elevated 30 degrees (This position facilitates venous blood return from the brain
and promotes a decrease in intracranial pressure).
• A pillow may be placed under the patient’s head and shoulders in supratentorial incision
The neck should be maintained in a neutral position.
• Do not angulate the neck anteriorly or laterally. A small pillow is placed under the head for
comfort in Infratentorial incision.
TURNING AND POSITIONING
• There is usually no restriction on turning.
• If a large tumor has been removed avoid positioning on the operative site.
• Positioning an unconscious patient or one who is recovering from anaesthesia on the side
facilitates drainage of oral secretions and promotes a patent airway.
• When positioning a patient, avoid extreme flexion of the upper legs or lateral or anterior
flexion of the neck. A soft collar may be applied to keep the neck in a neutral position.
AMBULATION
The patient is allowed out of bed as soon as tolerated in supratentorial procedure.
Patients undergoing infratentorial procedures maintained on longer bed rest because of the
frequency of dizziness experienced by these patients. This dizziness is caused by transient
edema in the area of cranial nerve VIII.
NUTRITION
• The patient is given nothing by mouth (NPO) for 24 hours; IV fluids are administered
slowly.
• If the patient is not experiencing nausea or vomiting and can protect his or her airway, clear
fluids are started. The diet is progressed as tolerated.
ELIMINATION
• Removed the indwelling catheter as soon as possible if present. If there is difficulty with
voiding, a bladder retraining program is begun.
• Constipation can occur as a result of diuretics, pain medication, immobility, and dietary
alterations.
Undesirable straining at stool initiates the Valsalva’s maneuver, which can increase ICP.
A bowel program is begun to avoid straining at stool and/or constipation.
FLUID AND ELECTROLYTE BALANCE
• An intake and output record is maintained, and the fluid restriction is adhered to strictly.
• Serum electrolyte and osmolarity levels are monitored.
• If surgery is performed in the area of the pituitary gland or hypothalamus, transient diabetes
insipidus may develop. Urinary outputand specific gravity are monitored every 1–4 hours.
PREVENTION OF COMPLICATIONS
Airway Obstruction- It can be due to improper positioning and accumulation of mucus.
• Unconscious patients should not be positioned on their backs with the head of bed flat
because the tongue can easily slip backward and obstruct the aIrway.
• Maintain the neck in neutral position.
Cardiopulmonary and Cardiovascular Management
Hemodynamics (e.g., CVP, cardiac output), oxygenation and vital should be monitored
frequently. Fluid replacement using a bolus of isotonic crystalloid solutionsbsuch as normal
saline(0.9%) or lactated Ringer’s, colloid solutions such as Plasmanate and albumin (5% to
25%), or blood products. Vasopressors (e.g., phenylephrine, hydrochloride, norepinephrine,
vasopressin, or dopamine) may be given as an adjunct to fluid replacement.
Cardiac Arrhythmias- Continuous cardiac monitoring is important in the immediate
postoperative period and throughout episodes of critical neurological dysfunction. serum
potassium levels should be monitored for depletion secondary to diuresis, which can also
cause arrhythmias.
Endotracheal intubation may be necessary to protect the airway. Aspiration can be
minimized by properly positioning the patient and frequent oral care to minimize pooling of
secretions. Treatment depends on CT findings and may require coagulopathy diagnosis and
cor- rection, control of hypertension (HTN), or even emergency surgery.
Increased Intracranial Pressure- management of the
underlying cause, judicious use of osmotic diuretics, and
possible ventricular drainage.
Pneumocephalus- Pneumocephalus is entry of air into the
subdural, extradural, subarachnoid, intracerebral, or intra- ventricular compartments.
Treatment includes surgical evacuation of the air. Hydrocephalus- The usual treatment is a
ventriculostomy to drain CSF temporarily. If the hydro- cephalus does not resolve, a surgical
shunting procedure is warranted.
Seizures- Patient management during seizure activity is directed at adequate oxygenation,
pre- venting aspiration and injury from motor activity, monitoring vital signs, and possible
administration of a benzo- diazepine to break the seizure activity if sustained
Cerebrospinal Fluid Leakage- CSF will show a glu- cose level that is approximately 60% to
80% that of the blood level and a chloride level greater than the serum level.
A CSF leak will often seal spontaneously. Serial lumbar punctures or a lumbar drain may be
necessary to keep CSF pressure low. If these measures are not successful, surgical repair may
be indicated.
Prophylactic antibiotics are ordered to prevent infection when a CSF leak is discovered.
Meningitis- Meningitis is treated with antibiotics, fever control, fluid and electrolyte
management, pain control, and a quiet environmen
Other Complications
Wound Infection- Treatment includes antibiotics, fever manage- ment, and wound care.
Severe wound infections may require incision and drainage.
Gastric Ulceration/HemorrhageMagnagement- sodium hydroxide, sucralfate, an H2
receptor antagonist, or a proton pump inhibitor may be used.
Deep Vein Thrombosis- Elastic TED stockings and/or SCDs are
applied early in the admission and should be used on a continuous basis in the postoperative
period until the patient is ambulatory or anticoagulation can safely be instituted.
Metabolic Imbalances.
Diabetes Insipidus- An indwelling urinary catheter is placed in the early postoperative
period when DI is most apt to see appear. An accurate intake and output record must be kept
and serial serum sodium checks monitored. The specific gravity of urine is monitored every 1
to 4 hours.
If the condition does not correct itself or there is difficulty maintaining euvolemia,
desmopressin (DDAVP) is usedto reduce urine output.
Cerebral Salt Wasting- Hyponatremia is common in the neurosurgical population,
particularly after subarach- noid hemorrhage. Assess for
signs and symptoms of dehydration and hyponatremia (confusion, lethargy)
Treatment is saline solution to correct fluid balance and low sodium levels. Hypertonic
saline, oral salt supple- mentation, or fludrocortisone may be added.
Syndrome of Inappropriate Antidiuretic Hormone Secretion
Treatment is fluid restriction. If hyponatremia is compromising the
patient’s mental status, hypertonic saline and diuresis may be added to slowly correct the salt
balance. Hyperglycemia.Monitor glucose periodically and treat with regular insulin to avoid
aggravation of cerebral edema.
NEUROLOGICAL DEFICITS IN THE POSTOPERATIVE PERIOD
Diminished Level of Consciousnes- As cerebral edema sub- sides postoperatively, ICP
decreases and the level of con- sciousness (LOC) improves.
Communication Deficits-The postoperative ability to express
oneself verbally and to understand the spoken word depends on deficits present before
surgery and which part of the brain was subject to surgical manipulation. Recovery will be
slower if the deficit was prominent before surgery or if surgical dissection was close to the
language area. Referral to a speech therapist will be helpful.
Motor and Sensory Deficits- As with other deficits, a decrease in cerebral edema results in
improved motor andsensory function. The nurse encourages the patient to use a weak limb in
the activities of daily living (ADLs), administers range-of-motion (ROM) exercises, ensures
proper positioning, applies prescribed braces and splints, andhelps the patient ambulate.
Headache- A cool pack can be applied to decrease edema and topical pain. Narcotic pain
relievers are com- monly ordered to control headache. A quiet environment with limited
direct light or a dimly lit room can be soothing.
Elevation in Temperature- treated with antipyretic drugs, such as acetaminophen. Adjunct
therapies, such as a hypothermia blanket, controlling the environmental temperature, removal
of excess bedclothes, and cool water sponging, may be utilized. If shivering occurs,
meperidine (Demerol)or chlorpromazine (Thorazine) may be ordered
Diminished Gag/Swallowing Reflexes- oral intake should not be started until the patient is
able to protect his or her air- way. Suction equipment should be readily available. As edema
subsides, the reflexes return.
Periorbital Edema- Cold compresses helpreduce edema. Gently cleanse the eyes to prevent
crusting and lubricate the eye with saline drops as the blinking mechanism may be impaired
by the edema.
Visual Disturbances-If diplopia is present, a unilateral eye patch can be worn to control the
symptoms.
NURSE’S ROLE IN REHABILITATION AND DISCHARGE PLANNING
Independent Nursing Role
assesses the patient’s functional level and collects the following data,which will be used for
planning nursing care and for dis- charge planning:
• Level of consciousness and cognitive function
• Presence of neurological deficits
• Verbal communication skills
• Independence in performing ADLs
• Emotional response to surgery and underlying problems (e.g., depression)
• Safety concerns
• Previous family role and responsibilities
• Support systems and living situation
Involve the patient with the environment and ADLs as much as possible. The family is
encouraged to participate in basic care and ADL routines to
develop skill and confidence in posthospital care.Anxiety, ambivalence, hostility, and
depression are com- mon in the postoperative period and continue even after transition to the
home.
During the hospital stay and initially after discharge, recovery and improvement are often
rapid. If one were to chart this on a graph.
Help patients to set more realistic goal In these circumstances, A sympathetic approach and
explanation of the postoperative course is helpful.
Collaborative and Interdisciplinary Role
Needs of each patient vary, themost frequent referrals are made to physical therapy, occu-
pational therapy, speech therapy, social services, and sometimes psychiatry. After the patient
has been evaluated and patient needs are identified in concrete terms, a discharge plan is for-
malized and implemented. Depending on the reason for surgery and the prognosis, the patient
or family may need to make major deci- sions about postacute care facilities and choice of
treatment.
PATIENT TEACHING
 Medication must be taken daily- failure may be life threatening
 Dosage must be increased during period of stress, illness, excessive exercise, fever
and infection. Gastric irritation can be minimised with antacid
 Check presence of tarry stool
 Check for behavioural changes (restless, depression, sleeplessness)
 Check BP (may elevate BP)
 Check hyperglycemia
 Wear medical alert bracelet
 Always carry kit of hydrocortisone sodium succinate.

REFERENCES
 HickeyJoanne V.The Clinical Practice of Neurological and Neurosurgical
NursingSIX. 6th Edition. 2009 Wolters Kluwer Health | Lippincott Williams &
Wilkins. Page no. 330-357
 Siddharth & Brunner, Textbook of Medical-Surgical Nursing. 10th edition. 2014
Lippincott Williams & Wilkins. Page no.398-444