A patient is recovering from posterior fossa surgery. What should the nurse include in the patient's plan of care?
1. Assess vital signs and level of consciousness every hour.
2. Maintain the patient flat in bed for at least 24 hours.
3. Maintain the patient's neck in hyperextension.
4. Observe the patient for the development of diabetes insipidus.
1
Rationale 1: The tumor was near the brainstem, which has vasomotor control over the vital signs. There is also potential for cerebral edema and increased intracranial pressure so assessment of level of consciousness is very important.
Rationale 2: The head of the bed needs to be elevated from 10 to 60 degrees to promote venous drainage from the brain. This is to help prevent cerebral edema and control intracranial pressure.
Rationale 3: The neck needs to remain in a neutral position to promote venous drainage and to reduce stress on the surgical site. This is accomplished by the application of a stiff dressing or the use of a soft cervical collar.
Rationale 4: This complication is associated with pressure on the pituitary gland and transphenoidal hypophesectomy.
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