Malamion,Cristine C.

Galindo, Ellen Lorie

Craniotomy is a surgical operation in which a bone flap is temporarily removed from the skull to access the brain. Craniotomies are often a critical operation performed on patients suffering from brain lesions or traumatic brain injury (TBI), and can also allow doctors to surgically implant deep brain stimulators for the treatment of Parkinson's disease, epilepsy and cerebellar tremor. The procedure is also widely used in neuroscience for extracellular recording, brain imaging, and for neurological manipulations such as electrical stimulation and chemical titration. Human craniotomy is usually performed under general anesthesia but can be also done with the patient awake using a local anaesthetic; the procedure generally does not involve significant discomfort for the patient. In general, a craniotomy will be preceded by an MRI scan which provides a picture of the brain that the surgeon uses to plan the precise location for bone removal and the appropriate angle of access to the relevant brain areas. The amount of skull that needs to be removed depends to a large extent on the type of surgery being performed. The bone flap is then replaced using titanium plates and screws or another form of fixation (wire, suture, ...etc). Craniectomy is the surgical removal of a portion of skull (cranium), leaving an opening in the skull that may be left open or covered with synthetic material. This procedure is often used to remove tumors in the rear of the brain (cerebellum) and to relieve brain swelling. A craniectomy also allows surgical treatment of diseases that affect the cranial nerves supplying sensation and movement to the structures of the head and neck. The procedure is classified as an emergency if pressure within the skull (intracranial pressure), usually from bleeding within the brain or its coverings, has increased to a dangerous level. A craniectomy is performed in a major operating room under general anesthesia. Preoperative Medical and Nursing Management. (1) Instruct patient and family about the necessity and importance of diagnostic tests to determine the exact location of the tumor. (2) Monitor and record vital signs and neurological status accurately q2-4h, or as ordered. Report changes to professional nurse immediately. (3) Institute measures to prevent inadvertent increases in intracranial pressure. (a) Elevate head of bed 30. (b) Stool softeners to prevent straining at stool (which increases intracranial pressure). (4) Institute seizure precautions at patient's bedside. (Tongue blade airway.) (5) Supportive nursing care is given depending upon the patient's symptoms and ability to perform activities of daily living. (6) Administer all doses of steroids and antiepileptic agents on time. (a) Withholding steroids can result in adrenal crisis. (b) Withholding of antiepileptic agents frequently precipitates seizure. (7) Surgery (craniotomy) is performed to remove neoplasm and alleviate symptoms.

Post Operative Nursing Care Considerations (1) Meticulous nursing management and care aimed at prevention of postoperative complications are imperative for the patient's survival. (2) Accurately monitor and record all vital signs and neurological signs. (a) Postoperative cerebral edema peaks between 48 and 60 hours following surgery. (b) Patient may be lucid during first 24 hours, then experience a decrease in level of consciousness during this time. (3) Administer artificial tears (eye drops) as ordered, to prevent corneal ulceration in the comatose patient. (4) Maintain skin integrity. (5) Bone flap may not have been replaced over surgical site; turning patient to the affected side, if the flap has been removed, can cause irreversible damage in the first 72 hours. (6) Maintain head of bed at 30elevation. (7) Perform passive range of motion exercises to all extremities every 2-4 hours. (8) Maintain body temperature. (a) Increases of body temperature in the neurosurgical patient may be due to cerebral edema around the hypothalamus. (b) Monitor rectal temperature frequently. (c) Place patient on hypothermia blanket, as ordered. (9) Institute seizure precautions at patient's bedside. (Tongue blade, airway.) (10) Maintain accurate record of intake and output. (11) Prevent pulmonary complications associated with bedrest. (a) Cough and deep breath every 2 hours. (b) Perform gentle chest percussion, with the patient in the lateral decubitus position, if tolerated. (12) Continuously talk to the patient while providing care, reorienting him to person, place, and time