Care of Patient Undergoing Neurosurgery

Introduction

Neurosurgery involves any surgical procedure performed on the brain, head, skull, and spine. These patients require specialized attention and vigilant care due to the critical nature of the condition and the high level of risk involved with the surgical procedures.

Definition

Nursing care of neurosurgical patients involves the preoperative, intraoperative, and postoperative care of patients undergoing surgery of the central or peripheral nervous system structures for diagnostic, therapeutic, or other purposes.

Purposes

• To prepare the patient for neurosurgery.
• To maintain proper positioning and monitoring.
• To control pain.
• To prevent/minimize postoperative complications.

Indications

Patients undergoing surgical procedures of the brain/spinal cord such as the following:

• Supratentorial and infratentorial craniotomy for tumor or aneurysm.
• Craniofacial and transsphenoidal surgery.
• Major spine surgery.
• Carotid artery surgery.
• Endovascular procedures including embolization of AVM and aneurysms.

Preoperative Phase

• Risk for ineffective breathing pattern related to cervical spinal nerve injury.
• Risk for ineffective cerebral tissue perfusion related to cerebral infarct, hemorrhage, occlusion, vasospasm, or cerebral edema.
• Acute pain related to increased ICP and inflammatory changes.
• Anxiety related to change in health status and threat to self-concept.
• Impaired physical mobility related to neuromuscular impairment.
• Impaired verbal communication related to neuromuscular impairment.
• Risk for injury related to sensory, integrative, and effector dysfunction.

Postoperative Phase

• Risk for ineffective breathing pattern related to postoperative cerebral edema.
• Risk for imbalanced fluid volume related to vomiting or diuretic therapy.
• Disturbed sensory perception (visual/auditory) related to periorbital edema and head dressings.

Prepare the necessary articles based on the surgical protocol.

Preoperative Care

A multidisciplinary approach is required for a successful surgical outcome.
In addition to the general aspects of preoperative preparation of patients, the following must be included:

• Detailed evaluation of surgical risk must be analyzed based on the neurological examination findings.
• All essential investigations including baseline studies, CT scan, EEG, etc., must be performed as required.
• Carefully monitor patients for signs of thromboembolism as risk for stroke may be higher due to the discontinuation of statins prior to surgery.
• Plan nursing care to stabilize vital and functional parameters which may be compromised due to the neurological disorder.
• Assess the nature and extent of postoperative complications such as pneumonia and thromboembolism, and facilitate appropriate management measures to avoid any risk during intraoperative and postoperative phases.
• Correct any existing nutritional deficiencies and electrolyte imbalances caused due to prolonged neurological illness to improve the surgical outcome.
• Prepare the patient and family adequately for understanding and managing postoperative events.

Postoperative Care

1. Maintaining Cerebral Tissue Perfusion

• Perform careful serial monitoring of the patient for safe and complete emergence and recovery from anesthesia every 15-30 minutes for the first 1-2 hours and then every hour for the next 6 hours.
• Assess GCS, and motor and sensory functions and report any changes to the physician.
• Assess the speech function.
• Remain vigilant to facilitate early identification of surgical complications (stroke, seizures, and bleeding).

       2. Seizure Prevention and Management

• Keep the head of the bed at 30° elevation to facilitate venous outflow from the brain and thereby prevent increase in ICP.
• Avoid any external compressive devices such as cervical collar, if considered safe.
• Avoid extreme head rotation and maintain the neck in a neutral position.
• In case of surgery for spinal injury, maintain spinal alignment with a collar until order is received to remove it.
• A minimum of three people are required for turning a patient on spinal cord precautions. Use pillows to ensure that body alignment is maintained.
• Remove spinal collars in every shift for skin care and inspection and document in the graphic record.
• Perform pain management measures to keep the patient calm.
• Check antiepileptic drug levels (fosphenytoin/phenytoin, valproic acid, phenobarbital, levetiracetam, and lacosamide).
• In case of status epilepticus, administer IV benzodiazepines along with anticonvulsants and high-dose sedatives/barbiturates.
• Provide seizure precautions (tongue blade available for airway, pads on the bed rails, and suction apparatus setup).

     3. Regulating Body Temperature

• Maintain normal body temperature to prevent shivering and thereby minimize systemic oxygen consumption.
• Monitor core temperature every hour. Continuous monitoring should be considered if cooling blankets and/or neuromuscular blockers are in use.
• Obtain order for paracetamol and cooling blanket if the temperature is greater than 38°C (100.4°F). If fever is severe, review with the physician other strategies such as sedation or neuromuscular blockade.
• Lower the temperature of the cooling blanket gradually to avoid shivering.
• Wrapping the arms and legs in blankets may reduce shivering.
• Neuromuscular blockers may help to reduce temperature and block shivering, but may cause rapid drop in temperature.

      4. Improving Gas Exchange

• Monitor blood gases every 6 hours and PRN during acute phase. Keep PaCO2 35-40 (or lower if ordered) and PaO₂>80-90 unless otherwise ordered. Unlike other ventilated patients, PaCO₂, is the target, not the pH.
• Reposition the patient every 2 hours to mobilize pulmonary secretions and prevent stasis.
• Protect the patient from nosocomial pulmonary infections or aspiration to prevent lung infections and coughing.
• Suction cautiously when required to prevent increase in ICP.

     5. Maintaining Fluid and Electrolyte Balance

• Monitor BP and heart rate carefully. Treat hypotension and hypovolemia promptly.
• Maintain euvolemia.
• Monitor carefully for signs of seizure activity which may deprive oxygen.
• Monitor blood sugar closely. Avoid hyperglycemia or hypoglycemia. Review target glucose with the physician if insulin is required for an increase in the lower limit range.

     6. Managing Sensory Deprivation

• Reassure the patient and family that periorbital edema is temporary and will resolve slowly.
• Use verbal communication more often to enhance interaction with the patient experiencing visual impairment.
• Report any increase in the periorbital edema to the physician.
• Provide assistive devices as required.

     7. Monitoring and Managing Complications

Cerebral Edema

• Monitor for edema of the brain tissue to identify increase in ICP.
• Perform osmotherapy which involves the administration of IV mannitol or hypertonic saline.
• Administer corticosteroids (dexamethasone or methylprednisolone) in case of cerebral edema.

Increased ICP

• Watch for signs of increased intracranial hypertension-nausea and vomiting, anisocoria, and loss of spontaneous venous pulsation on fundoscopy.
• Control postoperative nausea and vomiting to prevent increase in ICP.
• Control projectile vomiting which may be caused by hydrocephalus or intracranial hemorrhage and can further lead to aspiration, hypertension, and elevated ICP.

Infection

• Follow strict asepsis and restrict visitors.
• Administer antibiotics to prevent and treat any suspected infections.

Thromboembolism

• Administer low-dose aspirin without anticoagulants or fibrinolytics to manage signs of ischemic stroke.
• Perform prophylaxis for DVT and GI bleeding (due to mucosal bleeding).

Skin/Wound Care

• Perform frequent checks of the overall skin integrity and surgical site status for bleeding or CSF leakage.
• Ensure precautionary measures such as “No bone” or “Bone flap” sign over the area where the bone flap has been removed or above the head of the bed.

Enhancing Self-Image

• Encourage the patient to ventilate feelings and frustrations and participate in self-care as tolerated.
• Reassure the patient that facial edema, periorbital ecchymosis, hair loss, etc., are temporary and will resolve gradually.
• Encourage family involvement in care as permitted.

Continuous Monitoring

• Stay prepared to handle critical emergencies which may require assisting with tracheal intubation and mechanical ventilation.
• Assess orientation regularly and reorient the patient as required.

 Promoting Home and Community-Based Care

• Initiate neurorehabilitation including physiotherapy, speech and swallowing therapy, respiratory therapy, clinical nutrition, wellness counseling, and occupational therapy for stabilized patients.

Possible Postoperative Complications

• Sagittal sinus injury
• Venous or arterial infarction
• Hematoma
• Intracerebral hemorrhage
• CSF leakage
• Meningitis/ventriculitis due to infection
• Cerebral artery injury
• Pneumocephalus
• Nerve injuries/cranial nerve deficits
• Seizures
• Incisional edema
• Neck stiffness/pain due to intraoperative positioning
• Orbital or periorbital edema and ecchymosis
• Language or speech impairment
• Supplementary motor area (SMA) syndrome (following surgery of midline tumor or epilepsy focus near to SMA)
• Hemiparesis
• Behavioral changes (loss of inhibition, disorientation)
• Deep vein thrombosis
• Pulmonary embolism
• GI bleeding (mucosal ischemia-related hemorrhage)
• Cerebral edema
• Increased ICP
• Brain herniation syndrome
• Obtundation and coma

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

Stories are the threads that bind us; through them, we understand each other, grow, and heal.

JOHN NOORD

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