Neurosurgical nursing care involves caring of patients with neurosurgical conditions – conditions related to the brain, such as brain surgery, spinal surgery and neurological trauma. Patient-centered care is provided to the patient through a multidisciplinary team that includes consultants, HST (higher surgical trainees), BST (basic specialist trainees), HO (house officer), nurses, physiotherapists, occupational therapists, speech therapists, social workers, carers and cleaners.
Anatomy and Physiology of the Brain
The brain occupies 80% of the cranium and is comprised of 3 major structures – the Cerebrum, the Cerebellum and the Brainstem. It received 15% of cardiac output, consumes 20% of the body’s oxygen and requires constant circulation to function. Lack of blood supply to the brain results in unconsciousness within 10 seconds and death in 4-6 minutes.
Brain Tumors
Hydrocephalus
External Ventricular Drain
Haematoma
Preoperative Neurosurgical Nursing Care
- Patient is orientated to the ward
- Past medical and surgical history, social history, as well as list of current medications and allergies are attained
- Neurological assessment is performed
- Medical notes are attained
- A consent form is signed by both the doctor and the patient or legal guardian or next of kin
- Blood tests (including cross match) are performed and chased
- Imaging results are attained
- Pre-surgery fasting is required
- Bowel preparation is required
- Patient should be washed with Chlorhexidine and dressed up in a hospital gown and TED stockings
- Head should be shaved
- Certain medications may be omitted in the morning prior to the operation, or changed to IV
- Patient pre-op (blue) checklist should be completed
- Psychological care and support should be offered to the patient pre-op and post-op, and to family members whilst waiting for the patient to come up from surgery
Postoperative Neurosurgical Nursing Care
- Neurological assessment should be performed at least hourly (more frequently if needed, depending on the patient’s condition and level of consciousness
- Blood pressure monitoring and SPO2 should be performed continuously
- Oxygen administration as required
- Blood tests should be performed
- Drain care may be required if the patient has a drain with suction, half suction or no suction
- Intake and Output charting should be maintained
- Urine catheter care should be maintained
- Monitor patient for DVT – TED stockings should only be removed for bathing and monitoring purposes
- Keep the patient and family updated of any procedures being carried out and reassure
Possible Complications
- focal or generalised seizures
- facial assymetry and/or drooling
- aphasia (a condition which affects a person’s ability to speak, write and understand language, both verbal and written)
- dysphagia (difficulty swallowing) – may lead to chest infection, poor nutritional intake, need for enteral feeding
- bleeding
- raised ICP due to post-op oedema and bleeding
- loss of consciousness, confusion, nausea and/or vomiting
- visual disturbance
- gait disturbance (inability to walk normally)
- hemiplegia (lack of limb power)
- wound, chest, and/or CSF infection
- DVT – LMWH (Low-Molecular-Weight-Heparin) and TED stockings
- patient safety should be prioritised so as to avoid falls – assist patients in showering, ensure proper non-slip footwear and avoid slippery floors
- constant supervision may be required in confused patients
Possible Post-Op Complication – Dysphagia
Assessing the Level of Consciousness in Neurosurgical Nursing Care
A state of general awareness of oneself and the environment, including the ability to orientate towards new stimuli
Hickey, 2003
Consciousness is a dynamic state resulting from integrated activities of the reticular formation and interaction with the cerebral cortex. To measure the level of consciousness of a patient, we need to measure the patient’s awareness and arousal levels, as well as if appropriate voluntary motor activities are being exhibited.
Do the patient’s eyes open spontaneously as you walk into the room? Or do they open them to command? What type of arousal level is required for this to be performed?
Is the patient aware of surroundings? Check if patient is orientated and notice communication – i.e. is speech delayed, slurred?
Is the patient drowsy and showing incomplete reaction to outside stimuli? Any signs of hallucinations, delusions or delirium?
Is the patient showing signs of stupor (mute, immobile and unresponsive but with open eyes and following external stimuli)?
Coma
A patient in a coma exhibits no voluntary movement or behaviour, and painful stimuli trigger no response. From this state, a patient can either recover to the original level of function (if cause is reversible), or is left with a degree of disabilities (in the case of irreversible damage), or ends up in a persistent vegetative state.
Persistent Vegetative State
Persistent Vegetative State is characterised by profound unresponsiveness in wakeful state as a result of brain damage at any level due to a non-functional cerebral cortex, lack of response to external stimuli, akinesia (loss/impairment of voluntary movement power), mutism (inability to speech), and inability to signal.
Locked-In Syndrome
In locked-in syndrome, the patient is fully aware and awake, has no loss of cognitive function, but is unable to move or communicate verbally due to complete paralysis of the body’s voluntary muscles, except the eyes.
Total locked-in syndrome is a version of the locked-in syndrome where the eyes are unable to move as well.
Brain Stem Death
A patient with brain stem death features irreversible unconsciousness with irreversible apnoea and irreversible loss of brain stem reflexes. Prior to being diagnosed with brain stem death, potential reversible causes such as hypothermia, metabolic causes and toxin/drug effect should be excluded.
Assessing the Level of Consciousness
The AVPU and the Glasgow Coma Scale are assessment tools which allow complete assessing of the conscious level of the patient. These can also be used within the Early Warning Score system.
Rapid deterioration of neurological patients is quite possible, and an initial examination is never enough. Continuous neurological assessment AND consecutive neurocharting is a MUST for the identification of patient deterioration. This ensures early identification, management of reversible causes, and thus, reduction of permanent neurological deficit.
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