This document outlines postoperative care considerations following craniotomy. It describes monitoring vital signs and neurological status, maintaining normal intracranial pressure, preventing infections and aspiration, managing pain, avoiding constipation, and providing patient and family education. Close observation is needed to monitor for complications like hemorrhage, edema, seizures, and infection.

1. Chapter VI

2.  Craniotomy is the surgical opening of the
skull to gain access to intracranial structures
to remove a tumor, relieve increased
intracranial pressure (ICP), evacuate a blood
clot, stop hemorrhage, or remove
epileptogenic tissue.

3.  Diagnostic findings, surgical procedure, and
expectations are reviewed with the patient.
 Presurgical shampoo with an antimicrobial agent
may be ordered. Shave and prep are performed
in the operating room.
 Depending on primary diagnosis, corticosteroids
may be ordered preoperatively to reduce
cerebral edema.
 Depending on the type and location of lesion,
anticonvulsants may be ordered to reduce risk of
seizures.
 The patient is prepared for the use of
intraoperative antibiotics to reduce risk of
infection, and urinary catheterization to assess
urinary volume during operative period.

4.  If cerebral edema develops, intraoperative or
postoperative osmotic diuretic (mannitol
[Osmitrol]) or corticosteroids may be ordered for
its treatment.
 Neurologic assessment is performed to evaluate
and record the patient's neurologic baseline and
vital signs for postoperative comparison.
 Family and patient are made aware of the
immediate postoperative care and where the
physician will contact the family after surgery.
 Supportive care is given as needed for neurologic
deficits.

5.  Respiratory status is assessed by monitoring rate,
depth, and pattern of respirations. A patent airway is
maintained.
 Vital signs and neurologic status are monitored, using
GCS; findings are documented.
 Arterial and central venous pressure (CVP) are
monitored, possibly with a pulmonary Swan-Ganz
catheter for accurate assessment of hemodynamic
status.
 Pharmacologic agents may be prescribed to control
increased ICP.
 Incisional and headache pain may be controlled with
mild analgesic (codeine and acetaminophen) or low
dose opioids (morphine sulfate or
fentanyl/Duragesic), as prescribed. Monitor response
to medications.

6.  Position head of bed at 15 to 30 degrees, or per
clinical status of patient, to promote venous
drainage. Determining appropriate position of head
of bed is patient-dependent and should be adjusted
based on observed changes in the patient's clinical
response and ICP to positioning. A decrease in CPP
(cerebral perfusion pressure) is observed with raising
the head of the bed to lower ICP.
 Turn side-to-side every 2 hours; positioning
restrictions will be ordered by the physician.
 CT scan of the brain is performed if patient's status
deteriorates.
 Oral fluids are provided after swallow reflex and
bowel sounds have returned. Intake and output are
monitored. Speech therapy may be ordered for
bedside swallow study or radiographic swallow study.

7.  Signs of infection are monitored by checking
craniotomy site, ventricular drainage, or
presence of CSF (fluid collection at surgical
site).
 Periorbital edema is controlled by such
measures as elevation of head of bed and
cold compresses. Removal of surgical
dressing and increase in activity will assist in
the resolution of periorbital edema.

8.  Intracranial hemorrhage/hematoma
 Cerebral edema
 Infections (eg, postoperative meningitis,
pulmonary, wound)
 Seizures
 Cranial nerve dysfunction
 Decreased CPP causing cerebral ischemia

9.  Ineffective Tissue Perfusion (cerebral)
related to increased ICP
 Risk for Aspiration related to decreased
swallow reflex and postoperative positioning
 Risk for Infection related to invasive
procedure
 Acute Pain related to physiologic changes
produced due to invasive procedure
 Constipation related to use of opioid
medication and immobility

10. Maintaining ICP Within Normal Range
 Closely monitor LOC, vital signs, pupillary
response, and ICP, if indicated. Notify health
care provider if ICP greater than 20 mm Hg
 Teach patient to avoid activities that can raise
ICP, such as excessive flexion or rotation of the
head and Valsalva maneuver (coughing, straining
with defecation).
 Administer medications as prescribed to reduce
ICP.
 Eliminate noxious tactile stimuli, such as
suctioning, prolonged physical assessment,
turning, and providing ROM exercises (based on
patient response).

11. Preventing Aspiration
 Offer fluids only when patient is alert and
swallow reflex has returned.
 Have suction equipment available at bedside.
Suction only if indicated. Pretreat with
sedation or endotracheal lidocaine to
prevent elevation of ICP.
 Elevate head of bed to maximum of order, or
per clinical status, and patient comfort.

12. Preventing Nosocomial Infections
 Use sterile technique for dressing changes, catheter care, and
ventricular drain management.
 Be aware of patients at higher risk of infection :those undergoing
lengthy operations, those with ventricular drains left in longer
than 72 hours, and those with operations of the third ventricle.
 Assess surgical site for redness, tenderness, and drainage.
 Watch for leakage of CSF, which increases the danger of
meningitis.
 Watch for sudden discharge of fluid from wound; a large leak usually
requires surgical repair.
 Warn against coughing, sneezing, or nose blowing, which may
aggravate CSF leakage.
 Assess for moderate elevation of temperature and neck rigidity.
 Note patency of ventricular catheter system.
 Institute measures to prevent respiratory or UTI postoperatively.

13. Relieving Pain
 Medicate patient as prescribed and according
to assessment findings.
 Elevate head of bed per protocol to relieve
headache.
 Darken room if patient is photophobic.

14. Avoiding Constipation
 Encourage fluids when patient is able to
manage liquids.
 Ambulate as soon as possible.
 Change to nonopioid agents for pain control
as soon as possible.
 Avoid Valsalva-like maneuvers.
 Use stool softeners and laxatives, as ordered.

15. Family Education and Support
 Keep patient and family aware of progress
and plans to transfer to step-down unit,
general nursing unit, subacute care, or
rehabilitation facility.
 Encourage frequent visiting and interaction
of family for stimulation of patient as care
allows.
 Begin discharge planning early, and obtain
referral for home care nursing, social work,
physical and occupational therapy as needed.

16.  Decreased ICP
 Gag reflex present; breath sounds clear
 Afebrile without signs of infection
 Verbalization of decreased pain
 Passed soft stool