o Maintain patient on controlled ventilation if prescribed to maintain
normal ventilatory status; monitor arterial blood gas results to determine
respiratory status.
o Elevate the head of the bed as prescribed.
o Administer nothing by mouth until active coughing and swallowing
reflexes are demonstrated, to prevent aspiration.Nursing Diagnosis: Risk for imbalanced fluid volume related to intracranial
pressure or diuretics
Goal: Attainment of fluid and electrolyte balance
Monitor for polyuria, especially during first postoperative week; diabetes
insipidus may develop in patients with lesions around the pituitary or
hypothalamus.
o Monitor urinary specific gravity.
o Monitor serum and urinary electrolyte levels.
Evaluate patient's electrolyte status; patients may retain water and sodium.
o Early postoperative weight gain indicates fluid retention; a greater-than-
estimated weight loss indicates negative water balance.
o Loss of sodium and chloride can produce weakness, lethargy, and coma.
o Low potassium levels can cause confusion, decreased level of
responsiveness, and cardiac dysrhythmias.
Weigh patient daily; keep intake and output record.
Administer prescribed IV fluids cautiously—rate and composition depend on
fluid deficit, urine output, and blood loss. Fluid intake and fluid losses should
remain relatively equal.Nursing Diagnosis: Disturbed sensory perception (visual/auditory) related to
periorbital edema and head dressings
Goal: Compensate for sensory deprivation; prevent injury
Perform supportive measures until the patient can care for self.
o Change position as indicated; position changes can increase ICP.
o Administer prescribed analgesics (eg, codeine) that do not mask the
level of responsiveness.
Use measures prescribed to relieve signs of periocular edema.
o Lubricate eyelids and around eyes with petrolatum.
o Apply light, cold compresses over eyes at specified intervals.
o Observe for signs of keratitis if cornea has no sensation.
Put extremities through range-of-motion exercises.
Evaluate and support patient during episodes of restlessness.
o Evaluate for airway obstruction, distended bladder, meningeal irritation
from bloody CSF.
o Pad patient's hands and bed rails to prevent injury.
Reinforce blood-stained dressings with sterile dressing; blood-soaked dressings
act as a culture medium for bacteria.
Orient patient frequently to time, place, and person.Monitor and Manage Complications
Cerebral edema