Question

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires immediate intervention by the nurse?

options: PaCO2 35 mm Hg

Intracranial pressure (ICP) 20 mm Hg

Pulse oximetry 92%

Blood pressure 135/82

Answer 1

Nurses responsibility: postoperative craniotomy patient

• Fever of 101.5 degrees or higher
• Unrelieved nausea or vomiting
• Difficulty Breathing or Chest Pain
• Postural Headache or any new headache
• A sudden increase in severe pain, numbness or weakness
• Loss of bowel or bladder control
• Drainage from your incision (other than occasional spotting of blood)
• Acute changes in the level of consciousness (increased confusion, memory loss, speech abnormalities)
• Any change in hearing or vision
• New onset of seizures.

normal values :

PaCO2: 35-45 mmHg

ICP: 10 -15mm Hg

oxygen saturation: 90- 100 %

blood pressure: 120/80 mm Hg

here, patient findings of intracranial pressure (ICP) and blood pressure values are elevated compared with the normal range.

blood pressure

When cerebral autoregulation is disturbed or its limits are exceeded,  blood flow passively increases with blood pressure (BP). This, in turn, can increase intracranial pressure or cause breakdown of the blood-brain barrier with resultant transudation of intravascular fluid.After intracranial surgery, acute HTN may also increase morbidity and mortality by exacerbating cerebral oedema, raising intracranial pressure, or disrupting the delicate postoperative hemostatic state.

Intracranial Pressure

The skull is filled with brain matter, intravascular blood and cerebrospinal fluid (CSF), and a process of auto-regulation allows these components to adjust to each other, which maintains a level ICP. When any of these volumes stop being regulated, pressure builds inside of the skull, resulting in increased ICP.

nursing management

The nurse must monitor and report any early signs and symptoms of increasing ICP which can be done by regularly attending to neurological observations on the patient.Methods to reduce the pressure from increasing further include elevating the patient’s head to thirty degrees, keeping their neck in a neutral position, avoid overhydration, maintain a normal body temperature and maintain a normal oxygen and carbon dioxide level.