Page 2045 - Saunders Comprehensive Review For NCLEX-RN

position.

▪ Provide a quiet environment.
▪ Monitor the head dressing frequently for signs of drainage.
▪ Mark any area of drainage at least once each nursing shift for baseline
comparison.
▪ Monitor the drain, which may be in place for 24 hours; maintain suction on the
drain as prescribed.

▪ Measure drainage from the drain every 8 hours, and record the amount and
color.
▪ Notify the PHCP if drainage is more than the normal amount of 30 to 50 mL per
shift.
▪ Notify the PHCP immediately of excessive amounts of drainage or a saturated
head dressing.
▪ Record strict measurement of hourly intake and output.
▪ Maintain fluid restriction at 1500 mL/day as prescribed.
▪ Monitor electrolyte levels.

▪ Monitor for dysrhythmias, which may occur as a result of fluid or electrolyte
imbalance.
▪ Apply ice packs or cool compresses as prescribed; expect periorbital edema and
ecchymosis of 1 or both eyes.
▪ Provide range-of-motion exercises every 8 hours.
▪ Place antiembolism stockings on the client as prescribed.

▪ Administer antiseizure medications, antacids, corticosteroids, and antibiotics as
prescribed.
▪ Administer analgesics such as codeine sulfate or acetaminophen as prescribed
for pain.

Box 58-11
Client Positioning Following Craniotomy

▪ Positions prescribed following a craniotomy vary with the type of surgery and
the specific postoperative primary health care provider’s (PHCP’s) prescription.
▪ Always check the PHCP’s prescription regarding client positioning.
▪ Incorrect positioning may cause serious and possibly fatal complications.

Removal of a Bone Flap for Decompression

▪ To facilitate brain expansion, the client should be turned from the back to the
nonoperative side, but not to the side on which the operation was performed.

Posterior Fossa Surgery

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