The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client’s plan of care? Select all that apply.
check the dressing every 8 hours for excessive drainage
assess the pupils for signs of increased intracranial pressure
position the client flat with the head rotated away from the surgical site
monitor the client’s respiratory status, including rate and pattern of breathing
notify the health care provider if the dressing is saturated or the client has more than 50 mL of drainage in 8 hours
Numbers 2, 4, and 5 are correct.
Following a craniotomy, the nurse should monitor the pupils for signs of increased intracranial pressure. Report dilated or pinpoint pupils or pupils that are slow to react or nonreactive to light to the health care provider. Respiratory status is monitored closely, as even minor hypoxia can increase cerebral ischemia. Notify the surgeon immediately if the dressing is saturated or if the client has more than 50 mL drainage in 8 hours, as this can cause hypovolemic shock. Immediately post-op the nurse should check the dressing every 1 or 2 hours. The drainage area can be marked once a shift to obtain a baseline. Clients with supratentorial craniotomies should be positioned with the head elevated 30 degrees in a neutral, midline position. Avoid extreme hip or neck flexion, which can cause increased intracranial pressure.
