Medical Surgical Nursing

(Tina Sui) #1

Preoperative Care: Nursing Management



  • Obtain baseline neurologic assessment

  • Assess patient and family understanding of and preparation for surgery.

  • Provide information, reassurance, and support


Postoperative Care



  • Postoperative care is aimed at detecting and reducing cerebral edema, relieving pain,


preventing seizures, monitoring ICP, and neurologic status.



  • The patient may be intubated and have arterial and central venous lines.


Nursing Process: The Care of the Patient Undergoing Intracranial Surgery:


Assessment



  • Careful, frequent monitoring of respiratory function including ABGs

  • Monitor VS and LOC frequently; note any potential signs of increasing ICP

  • Assess dressing and for evidence of bleeding or CSF drainage

  • Monitor for potential seizures; if seizures occur, carefully record and report these

  • Monitor for signs and symptoms of complications

  • Monitor fluid status and laboratory data


Diagnoses



  • Ineffective cerebral tissue perfusion

  • Risk for imbalanced body temperature

  • Potential for impaired gas exchange

  • Disturbed sensory perception

  • Body image disturbance

  • Impaired communication (aphasia)

  • Risk for impaired skin integrity

  • Impaired physical mobility


Collaborative Problems/Potential Complications



  • Increased ICP

  • Bleeding and hypovolemic shock

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