Craniectomy

1. Decrease intracranial pressure. Hypercapnia, hypoxia, and acidosis are potent cerebral vasodilating mechanisms that can cause increased intracranial pressure.

A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The physician orders manual hyperventilation to keep the Paco2 between 25 and 29 mm Hg and the Pao2 between 80 and 100 mm Hg. The nurse interprets this order based on the understanding that this action will accomplish which of the following? 1. Decrease intracranial pressure. 2. Ensure a patent airway. 3. Lower the arousal level. 4. Produce hypoxia.

3. "There are no major risks from this surgery." There are risks with both the surgical procedure and the general anesthesia required for a craniotomy. The risks involved in the procedure are a part of the informed consent. Other information that is part of an informed consent includes potential complications, expected benefits, inability of the surgeon to predict results, irreversibility of the procedure (if applicable), and other available treatments.

A client is being prepared to have a craniotomy for a brain tumor. As a client advocate, the nurse is evaluating the client's understanding of the informed consent before witnessing the client's signature on the operative consent form. Which of the following indicates that the nurse needs to contact the surgeon for further communication with the client? 1. "We talked about the effect of my diabetes on healing." 2. "The surgeon explained how the craniotomy was done." 3. "There are no major risks from this surgery." 4. "I will die if the tumor is not removed from my brain."

4. Cranial nerve VII, facial nerve An acoustic neuroma (or vestibular schwannoma) is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII) enters the internal auditory canal. It is important that an early diagnosis be made, because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. Cranial nerve I, olfactory 2. Cranial nerve IV, trochlear 3. Cranial nerve III, oculomotor 4. Cranial nerve VII, facial nerve

3. Transport the victim to the operating room for surgery. In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. Obtain a court order for the surgical procedure. 2. Ask the EMS team to sign the informed consent. 3. Transport the victim to the operating room for surgery. 4. Call the police to identify the client and locate the family.

3. Morphine sulfate. Administration of morphine sulfate is contraindicated because morphine causes respiratory depression. It may also increase intracranial pressure if the client is not ventilating properly, which could result in an accumulation of CO2 , a potent vasodilator. Ibuprofen, naproxen, and acetaminophen are not likely to mask symptoms of increased intracranial pressure or impact respiratory status.

A client is transferred to his room from the intensive care unit after a craniotomy for treatment of a malignant brain tumor in the occipital region. The nurse should question which of these orders? 1. 400 mg of ibuprofen (Motrin). 2. 500 mg of naproxen (Naprosyn). 3. Morphine sulfate. 4. Acetaminophen (Tylenol).

1. Serum osmolarity Mannitol, an osmotic diuretic, increases the serum osmolarity and pulls fluid from the tissues, decreasing cerebral edema postoperatively. Serum osmolarity levels are assessed as a parameter to determine proper dosage.

A client who had a craniotomy 2 days earlier is receiving mannitol (Osmitrol®) intravenously to decrease intracranial pressure. Which diagnostic laboratory value should be monitored while the client is receiving this medication? 1. Serum osmolarity 2. White blood cell (WBC) count 3. Serum cholesterol 4. Erythrocyte sedimentation rate (ESR)

2. Wrap her hands in soft "mitten" restraints. It is best for the client to wear mitts, which help prevent the client from pulling on the I.V. without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)? 1. Place her in a jacket restraint. 2. Wrap her hands in soft "mitten" restraints. 3. Tuck her arms and hands under the drawsheet. 4. Apply a wrist restraint to each arm.

3. Side-lying. After surgery for an infratentorial tumor, the child is usually positioned fl at on either side, with the head and neck in midline and the body slightly extended. Pillows against the back, not the head, help maintain position. Such a position helps avoid pressure on the operative site.

After a child undergoes a craniotomy for an infratentorial brain tumor, the nurse should place the child in which of the following positions to prevent undue strain on the sutures? 1. Prone. 2. Semi-Fowler's. 3. Side-lying. 4. Trendelenburg.

2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. The nurse should maintain ICP by elevating the head of the bed and monitoring neurologic status. An ICP greater than 20 mm Hg indicates increased ICP, and the nurse should notify the health care provider. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.

Following a craniotomy, a client has been admitted to the neurologic intensive care unit. The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range. What should the nurse do? Select all that apply. 1. Encourage the client to cough and take deep breaths. 2. Elevate the head of the bed 15 to 30 degrees. 3. Contact the health care provider if ICP is greater than 20 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of-motion exercises.

2. Elevating the head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death.

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other. 2. Elevating the head of the bed to 30 degrees. 3. Logrolling or turning as a unit when turning. 4. Keeping the neck in a neutral position.

3. A positive Brudzinski's sign Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1. A negative Kernig's sign 2. Absence of nuchal rigidity 3. A positive Brudzinski's sign 4. A Glasgow Coma Scale score of 15

1. Vomiting The brain, although well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. A change in the size of the brain, such as occurs with edema or increased volume of intracranial blood or cerebrospinal fluid without a compensatory change, leads to an increase in ICP, which may be life-threatening.

The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? 1. Vomiting 2. Bulging anterior fontanel 3. Increasing head circumference 4. Complaints of a frontal headache

3. Test the fluid for glucose. Glucose in this clear, colorless fluid indicates the presence of cerebrospinal fluid. Excessive fluid leakage should be reported to the physician.

Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor? 1. Change the dressing. 2. Elevate the head of the bed. 3. Test the fluid for glucose. 4. Notify the physician.

1. "After this, I'll never let her out of my sight again." It is not uncommon for a child to be concerned about a change in appearance when the entire head or only part of the head has been shaved. The child should be encouraged to participate in decisions about her care when possible. Asking her if she would like to wear a hat is one way to encourage this participation.

Which of the following statements made by the mother of a school-age child who has had a craniotomy for a brain tumor would warrant further exploration by the nurse? 1. "After this, I'll never let her out of my sight again." 2. "I hope that she'll be able to go back to school soon." 3. "I wonder how long it will be before she can ride her bike." 4. "Her best friend is eager to see her; I hope she won't be upset."