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CRANIOTOMY (IMMEDIATE POST OPERATIVE) - Coggle Diagram
CRANIOTOMY
(IMMEDIATE POST OPERATIVE)
Assessment
Vital signs
Pain level
Level of consciousness
Glasgow Coma Scale
Intake and output
Surgical Incision site
Potential complications
Increased ICp
CSF leakage
Stroke, seizures, or coma
Infection
Sign and symptoms
Hypotension
Pale conjunctiva and nail beds
(+) anisocoria- 3mm OD and 5mm OS
Medications
Acetaminophen
for relieving mild pain
Codeine
to relive headache
Dopamine drip
to treat hypotension
Anticonvulsant medication (phenytoin, levetiracetam)
to avoid seizures
Mannitol
to reduce cerebral edema
Nursing Diagnosis
Potential for impaired gas exchange related to hypoventilation, aspiration, and immobility
Risk for infection related to neurosurgical procedure
Risk for ineffective cerebral tissue perfusion related to cerebral edema
Risk for imbalanced body temperature related to damage to the hypothalamus, dehydration, and infection
Disturbed body image related to change in appearance or physical disabilities
Ineffective coping related to sensory perception changes
Nursing Interventions
Improve gas exchange
Repositioning the patient every 2 hours
Encouraged deep breathing exercises, coughing, yawning, and use of incentive spirometry
Increasing the humidity in the oxygen
Prevent infection
The dressing is reinforced with sterile pads
Keep the incision clean
Examine skin for breaks or irritation, signs of infection
Maintaining cerebral tissue perfusion
Assess vital signs and neurological status
Avoid extreme head rotation
Monitor patient's respiratory status
Place the patient on supine position
Elevate the head of the bed
Regulation of body temperature
Assess environmental temperature and modify
Rewarming should occur slowly
Assess body temperature frequently
Enhancing self-image
Encourage verbalization of feelings
Encourage social interaction
Provide factual information
Attention to grooming,
Laboratory and Diagnostic Test
CT cisternogram
to determine the origin of the CSF leakage
CT scan and MRI
to identify the condition or structure of the brain
Pledget Study
to determine CSF leakage