Medical Surgical Nursing

Other nursing diagnoses may include impaired communication (aphasia) related to
insult to brain tissue and high risk for impaired skin integrity related to immobility,
pressure, and incontinence; impaired physical mobility related to a neurologic deficit
secondary to the neurosurgical procedure or to the underlying disorder may also occur.
Collaborative Problems/Potential Complications
Potential complications include the following:

 Increased ICP

 Bleeding and hypovolemic shock

 Fluid and electrolyte disturbances

 Infection

 Seizures

Planning and Goals
The major goals for the patient include neurologic homeostasis to improve cerebral
tissue perfusion, adequate thermoregulation, normal ventilation and gas exchange,
ability to cope with sensory deprivation, adaptation to changes in body image, and
absence of complications.
Nursing Interventions
Maintaining Cerebral Tissue Perfusion
Attention to the patient's respiratory status is essential, because even slight decreases in
the oxygen level (hypoxia) or slight increases in the carbon dioxide level (hypercarbia)
can affect cerebral perfusion, the clinical course, and the patient's outcome. The
endotracheal tube is left in place until the patient shows signs of awakening and has
adequate spontaneous ventilation, as evaluated clinically and by arterial blood gas
analysis. Secondary brain damage can result from impaired cerebral oxygenation.
Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36
hours after surgery, producing decreased responsiveness on the second postoperative
day. The control of cerebral edema was discussed earlier. Nursing strategies used to
control factors that may raise ICP were presented in the previous Nursing Process
section on increased ICP.

Intraventricular drainage is carefully monitored, using strict asepsis when any part of

the system is handled.

Overview of Nursing Management for the Patient after Intracranial Surgery

Postoperative Interventions

Nursing Diagnosis: Risk for ineffective breathing pattern related to postoperative
cerebral edema
Goal: Achievement of adequate respiratory function

 Establish proper respiratory exchange to eliminate systemic hypercapnia and

hypoxia, which increase cerebral edema.

o Unless contraindicated, place the patient in a lateral or a semiprone

position to facilitate respiratory gas exchange until consciousness

returns.

o Suction trachea and pharynx cautiously to remove secretions; suctioning

can raise ICP.