Nursing Care of Transsphenoidal Hypophysectomy - Essay Example

Post Operative Nursing Care of Transsphenoidal Hypophysectomy Abstract Transsphenoidal hypophysectomy is a surgery performed by a neurosurgeon for pituitary tumours and the care for this patient involves an understanding of the functions of the pituitary gland in our body. It is called the Master gland and is indeed true as it controls the release of most of the body's major hormones. Hypophysectomy which is the removal of the pituitary gland partially or completely and is done for tumours of the pituitary gland resulting in a deficiency of many hormones in the post operative period and hence its post operative care is crucial. Anatomy of the Pituitary Gland: Hypophysis is a small ductless gland, reddish grey coloured, 1 cm in diameter in the hypophyseal fossa in the cranial cavity attached to the infundibulum in the brain. (Gray 1918, ed. Lewis 2000) It is located in the sella turcica in the sphenoid bone in the skull. It has an anterior lobe and a posterior lobe. (Davidson 1952 ed. John 2002). The anterior lobe has two parts, the pars anterior and the pars intermedia.(Marieb,Mallatt2004). The anterior lobe, the adenohypophysis develops as an outpouching of the roof of the mouth called the Rathke's pouch. (Gray 1918, ed. Lewis 2000). The posterior lobe, the neurohypophysis develops from the floor of the third ventricle of the brain.(Gray 1918, ed. Lewis 2000). The posterior lobe has axons and it is through them that the hormones of the posterior pituitary travel from the hypothalamus where they are produced.(Austgen,Bowen,Rouge2001). The anterior has the pars distalis, pars tuberosa and the pars intermedia. The neurohypophysis has the pars nervosa, median eminence and the infundibular stalk which connects the pars nervosa to the base of the brain. (Marieb, Mallatt 2004) The adenohypophysis has three types of cells. A. Acidophils - the Somatotropes- growth hormone and the lactotropes- Prolactin. B. Basophils-Thyrotropes- TSH or the Thyroid Stimulating Hormone, the Gonadotropes- LH or the Luteinizing hormone and FSH, follicle stimulating hormone and the Corticotropes- ACTH or the Adreno-corticotrophic hormone. C. Chromophobes- do not produce any hormone.(Marieb 2004) Hypothalamus secretes Oxytocin and ADH or the Antidiuretic hormone which go down the axons and are stored in the posterior pituitary and are released when the right stimulus is present. ( Marieb 2004). The hypothalamus is connected to the anterior lobe of the pituitary through the hypothalamic-hypophyseal portal vessels. These veins from the anterior pituitary drain into the systemic blood carrying hormones to act on the target organs to stimulate the release of other hormones.(Marieb 2004). The hypothalamus secretes releasing hormones and inhibitory hormones which act on the pituitary gland and control the secretion of its hormones. (Guyton&Hall 2000). Physiology of the Pituitary Gland: Hormones released by the hypothalamus are TRH-Thyrotropin Releasing Hormone, GnRH- Gonadotropin Releasing Hormone, GHRH- Growth Hormone Releasing Hormone, CRH- Corticotropin Releasing Hormone, Somatostatin and Dopamine. ( Kasper et all 2005) TRH stimulates the release of TSH from the anterior pituitary and excess of this hormone in the blood prevents the release of TRH from the hypothalamus.(Kasper et all 2005). GHRH stimulates the release of the Growth hormone. GnRH stimulates the release of LH and FSH from the anterior pituitary. CRH causes the release of ACTH. Somatostatin acts on the anterior lobe inhibiting the release of the growth hormone. ( Kasper et all 2005).Dopamine secreted by the hypothalamus inhibits the release of Prolactin from the anterior pituitary. It is also called the Prolactin Inhibitory Factor or PIF. ( Kasper et all 2005). Various hormones of the Posterior Pituitary Gland: The Hypothalamus secretes two hormones which are stored in the posterior pituitary to be secreted when needed. These are ADH, Antidiuretic hormone and Oxytocin.(Marieb 2004). ADH acts on the collecting ducts of the kidney to increase the reabsorption of water. Its deficiency causes Diabetes Insipidus when large amounts of dilute urine is lost from the body. (Davidson 1952 ed. John 2002).Oxytocin is a hormone, also from hypothalamus, stored in the posterior pituitary.(Marieb 2004). It is released during delivery causing uterine contractions and acts on mammary glands causing the secretion of milk when the baby suckles at the mother's breast(milk ejection reflex).(Kimball 1994) Various hormones of the Anterior Pituitary Gland: TSH acts on the thyroid gland and stimulates the release of thyroid hormones,T3 and T4.(Kimball 1994) They regulate growth and development, increase metabolic rate, have a calorigenic action, increase the cardiac output and cause feedback inhibition of TSH secretion. (Kimball 1994).Growth hormone acts on the liver, adipose tissue and promotes growth and controls carbohydrate, protein and lipid metabolism. (Ganong 1999). ACTH acts on the adrenal cortex and causes the release of the glucocorticoid, cortisol which stimulates gluconeogenesis, inhibits the uptake of glucose by muscle and fatty tissue, mobilizes amino acids for gluconeogenesis and has antiinflammatory and immunosuppressive actions. (Kimball 1994). An excess of thyroid hormones causes Hyperthyroidism and deficiency causes hypothyroidism.(Kimball 1994). A deficiency of the growth hormone causes Dwarfism in the growing age whereas an excess causes Gigantism in the growing age or Acromegaly in adults. (Guyton&Hall 2000) LH acts on the ovary and converts the ruptured follicle in the female to corpus luteum that secretes progesterone. An LH and FSH surge in the mid cycle causes ovulation. LH acts on the Leydig cells of the male to produce testosterone. FSH promotes the development and maturation of ovarian follicles,release of oestrogen. (Austgen, Bowen, Rouge 2001).Prolactin acts on the mammary gland causing lactation.(Davidson 1952 ed. John 2002)An excess of the hormone ACTH causes Cushings disease which manifests with hypertension, obesity, moon face, buffalo hump, diabetes, etc. A deficiency causes Addisons disease which presents with lethargy, diarrhoea, weakness, heart disease etc. (Ganong 1999) Pituitary Tumors: Pituitary tumours can be classified as Functioning and non functioning tumours (Davidson 1952 ed. John 2002).The most common tumours are the benign adenomas (Lindsay, Bone, 2004).constituting about 10% of all brain tumours (Kasper et all 2005). A primary carcinoma of the pituitary is rare but metastatic tumours do occur from the kidney. Depending on the size, they can be micro adenomas, less than 10mm or macro adenomas which are bigger and cause compressive symptoms. Non-functioning tumours do not secrete hormones. They can be observed if micro adenomas and surgically removed if bigger in size.( Kasper et all 2005).Prolactinoma secretes the hormone prolactin in excess causing secondary amenorrhea or oligomenorrhea, menorrhagia or excessive bleeding, anovulation and infertility in women. Males with this tumour have decreased libido, lethargy and erectile impotence. (Lindsay, Bone, 2004) Microadenomas can be managed medically with Bromocriptine, Pergolide, Cabergoline drugs. But macro adenomas need a surgery(Transsphenoidal hypophysectomy). The cure rate after surgery for a micro adenoma is 80% and lesser for a bigger tumour. (Davidson 1952 ed. John 2002).Other tumours which are functioning tumours are ACTH secreting adenoma, GH secreting tumour,FSH and LH secreting tumour and TSH secreting tumour. Craniopharyngioma, a tumour in infants and children is a benign tumour which develops from the remnant of Rathke's pouch in the sella turcica or in the supra sellar space causing pressure effects, hypopituitarism and the hypothalamic syndrome with Diabetes insipidus and loss of satiety which leads to weight gain.(Lindsay, Bone, 2004).A traditional approach via craniotomy is done for this tumour as the Transsphenoidal approach is difficult here.(Lindsay, Bone, 2004) Transsphenoidal Hypophysectomy: Hypophysectomy is a neurosurgical technique for removal of pituitary tumours and has replaced craniotomy. Indications are micro adenomas, intrasellar craniopharyngiomas, tumours with CSF leak where a Transcranial approach is risky, in cases with tumour extension into the sphenoid sinus and rarely also for chordomas, pituitary abscesses or mucoceles. (Schultess, Smith et all 1998-2001) Significant extensions of tumours sub frontally, retrochiasmatically or into the middle fossa are contraindications. Pre-Op Care: Pre operative phase begins when the decision of surgery is made and ends when the patient is transferred onto the operation table.(Brunner, Suddarth 2004)Pre-admission assessment is with involvement of the family, verification of pre operative testing(Brunner, Suddarth 2004). MRI helps to plan carefully as well as to see the pneumatization of the sphenoid sinus and to locate the position of the intersphenoid septum. (Schultess, Smith et all 1998-2001) In the surgical unit, risks for post op complications are assessed. Deviations are reported. Verify operative consent form. At this point,the nurse reinforces teaching , explains about the peri-operative period.(Brunner, Suddarth 2004) Specific Measures - 1. Daily weight checking 2. 24 hours urine volume documentation for 3 consecutive days, 3. Intake-output chart for 3 days, 4.check for Urine and Serum osmolality.5. If the approach planned is oral/nasal, a swab is sent for culture & sensitivity and report collected and any deviation informed. (Brunner, Suddarth 2004) A pre-op assessment of the pituitary functions is done. On the previous day, the patient meets the junior doctors and nurses who will be taking care of him. Blood tests, chest x-ray, ECG are done. Pre Anaesthetic check up is done. The OT nursing staffs visit the patient prior to surgery. Patient is kept NBM from midnight. Ask him to practice breathing from the mouth. (Ballard 2003). Pre operatively, the patient is given Hydrocortisone, 100 mg 4 times a day, continued for a few days after surgery. All NSAIDS, Aspirin, Voltral and anticoagulants are stopped before surgery. For pain, patient can be given drugs like Tramadol or Dihydrocodone. (Bell, Tayside University Hospital 2000) In the holding Area-The patient's pain level, nutritional status are assessed. The nurse marks the site of surgery as per institutional policy. An IV line is established and pre op medications are administered. The patients comfort is ensured and psychological support is given.( Brunner, Suddarth 2004) Intra - Op Care: Patient is on the operating table. A proper functional alignment of the patient for surgery and exposure of the surgical site are assured. A grounding device is attached to the patient and all instruments are counted and a count check is maintained. Physiological monitoring and psychological support are the nurse's duty. The patients vital signs should be monitored to prevent a) hypotension, b) hypothermia and hyperthermia, c)hyperventilation. (Brunner, Suddarth 2004) Operative Procedure: The operation lasts for 1-2 hrs. Under general anaesthesia, an incision is made on the mucosa below the upper lip. Through the right nostril endoscopes are introduced for easier approach and a stereotactic view is used to enhance visibility. Minimally invasive equipment is used with a neurosurgical microscope and navigator etc. Removal of the adenoma or part or whole of the gland is done. At the end, a fat graft, taken from the abdomen or from the lateral side of the thigh is inserted to stop CSF leakage. (Bell, Tayside University Hospital 2000) Post-Operative Period: PACU-Post operative care of the patient starts from the time the patient leaves the operating room till the last follow up visit. Patients who are to recover from anaesthesia are put in the PACU for easy access to skilled anaesthetists, skilled nurses, surgeons etc. Postanesthetic care is divided into two phases (Litwack, 1999 ; Meeker&Rockroth, 1999). Phase 1 PACU, the immediate recovery phase with intensive nursing care. Phase 2 PACU has less frequent observation and less nursing care and preparation for discharge from PACU. In the PACU- Assessing the Patient - a) The nurse who receives the patient reviews the diagnosis, surgery performed with past medical history and allergies. b)Patient's general condition is assessed. c)Airway patency and vital signs are checked. d) Pulse rate and regularity, respiration rate, nature and depth, e)Blood pressure reading, Temperature measurement and oxygen saturation. f) Assessment of blood oxygen saturation level, skin colour g) level of consciousness and ability to respond to commands. (Brunner, Suddarth 2004) Pre and intra operatively administered drugs, intra operative complications are noted. The volume status of the patient, fluid administered, estimated blood loss and replacement fluids are noted. (Brunner, Suddarth 2004) Any drains, tubing's, catheters noted. The nose of the patient is packed and this has to be explained before the operation and when he wakes up, he should be asked to do mouth breathing. (Bell, Tayside University Hospital 2000) Maintaining the airway - Maintaining the airway, pulmonary ventilation and blood O2 saturation prevents hypoxemia and hypercapnia. SaO2 is noted. Secretions need the right posture to drain them.(Brunner, Suddarth 2004) Assess-a)vital signs, cardiac rhythm, skin temperature, colour, moisture, urine output b) patency of all IV lines. In the PACU, hypotension and shock (hypovolemic shock), haemorrhage, hypertension and dysrhythmias can occur.Signs of shock-pallor, cool, moist skin, rapid breathing, cyanosis of the lips, gums and tongue, rapid weak thready pulse, decreasing pulse pressure and a low blood pressure. Administration of IV fluids, blood and blood products avoids shock. (Brunner, Suddarth 2004) Nausea and vomiting in the PACU is managed with anti emetics, Droperidol, metoclopramide,prochlorperazine,promethazine. (Meeker&Rothrock 1999). Stable vital signs, orientation to person, place, time and events, uncompromised pulmonary function, adequate blood oxygenation saturations, urine output of at least 30ml/hr, minimal pain, no nausea or vomiting - then patient is fit to be discharged from the PACU. (Brunner, Suddarth 2004) Receiving the patient in the Clinical Unit -The patient's room and necessary equipment are kept ready. Data is collected on the phone from the PACU- the diagnosis, procedure performed, co morbid conditions, allergies, blood loss, fluids received, pain medications, whether the patient has voided and post operative orders orally and later in the written form. Nursing care here involves-recovery from anaesthesia, assessment of the physiological status, monitoring for complications, managing pain, teaching self care and self management of regimen. (Brunner, Suddarth 2004) Interventions in the unit/ward: Monitor vital signs, skin warmth, moisture, colour. The pulse, B.P., respiration rate are recorded every 15 mins for the first hour, every half an hour for the next 2 hours and thereafter less frequently if normal.Temperature is monitored every 4 hours. (Brunner, Suddarth 2004). A drip is attached, IV fluids started, vitals recorded. Assess SaO2, depth of breathing and administer oxygen if needed. Oxygen through mask is given in the immediate post op period. The patient can eat or drink the same night after the effect of anaesthesia wears off. (Bell, Tayside University Hospital 2000) Assess the surgical site. The nasal pack stays for 4 more days. Monitor urine output. These patients can have a transient loss of large amounts of dilute urine in the post operative period. -SIADH with transient Diabetes insipidus. (Kasper et all 2005).If input-output balance is normal, the catheter can be removed the next morning and the IV drip stopped after oral diet starts. Blood is sent for routine tests.(Bell,Tayside University Hospital 2000). Assess the level of consciousness, orientation, ability to move all extremities. Administer analgesics. Assess pain level, characteristic, timing, type of pain, ask for the last pain medication given and its route. (Brunner, Suddarth 2004). Position the patient well to aid lung expansion. Deep breathing and leg exercises taught. Elevate the head end. Instruct bed rest. Instruct not to sneeze or cough. Teach and encourage mouth breathing. (Brunner, Suddarth 2004) Call light, emesis basin, bedpan and urinal are placed within reach. The patients head is kept elevated. The dressing is changed when it is saturated. Good mouth care is done regularly. Complications-Post Op, Vigilance and Care Needed on the part of Nursing Staff: Operative mortality after a transsphenoidal hypophysectomy is about 1%. Complications- 1.Transient diabetes insipidus 2. Hypopituitarism occurs in up to 20% of patients ( Kasper et all 2005). 3. CSF leaks occur in 4% of patients (Kasper et all 2005). 4. Permanent diabetes insipidus, cranial nerve damages, loss of vision, meningitis, hypothalamic damage are few other complications. ( Kasper et all 2005).5. Endocrine deficits. Radiation therapy carries a life long risk of hypopituitarism (50-70% in the first 10 years), treated by Hormone replacement. 6. Tension pneumocephalus with a raised intra cranial pressure (ICP). Baseline neurological status of the patient noted on initial assessment. Frequent monitoring and recording of neurological signs to recognise raised Intra Cranial Pressure(ICP). (Brunner, Suddarth 2004) Signs of raised ICP: Tension pneumocephalus with raised ICP can occur( Kasper et all 2005). The normal ICP is 80-180mm of water or 0 to 15 mm of Hg. It is elevated if it's above 15mmHg. Early signs- Confusion, irritation, restlessness, deterioration in the level of consciousness(LOC), pupillary asymmetry, motor weakness. The LOC is very sensitive to the Oxygen supply to the brain and a change in the LOC is the first sign of raised ICP. Later signs-Headache, nausea, vomiting, altered vital signs, respiratory irregularities, blurring of vision, papilledema on ophthalmoscopy, pressure effect on the third cranial nerve with pupillary changes occurs late. Sometimes, continued deterioration in LOC occurs, decortication, decerebration and deep coma can occur. (Brunner, Suddarth 2004) Airway problems can occur and immediate clearance of the airway should be done promptly. Oxygen is administered. Diabetes insipidus occurs in the post op period and careful monitoring of the urine output is essential. Serum electrolytes and serum osmolality and Urine osmolality and urine electrolytes to be checked. If SIADH is confirmed, water and salt restriction as per doctor's orders is done. (Brunner, Suddarth 2004) CSF leak in the post op period has to be reported.(Ballard 2003) Meningitis in the post op period (Kasper et all 2005)-The nursing staff can recognise it by neck rigidity, headache and fever. (Ballard 2003). Good hydration is to be maintained with saline and glucose. A regular diet with restriction of salt and foods that cause diuresis is advised as the patient does not have ADH needed to prevent water loss. The input-output chart is maintained strictly with measurement of daily weight. ( Kasper et all 2005). The lab work should be up to date to monitor the hormone status and other metabolic parameters of the patient. The LOC should be noted by the staff and the importance of this explained to the next nurse on duty. (Ballard 2003). The nursing staff should be able to recognise complications and should report them to the doctor. (Ballard 2003). The nurse in charge should also counsel the patient and prepare him for life long hormone replacement therapy for the rest of the part of his life. Reference List Austgen, Laura, Bowen,R.A., Rouge,Melissa, Retrieved from world wide web, http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/index.html Austgen, Laura, Bowen,R.A., Rouge,Melissa, Retrieved from world wide web, http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/hypopit/overview.html Brunner,S.Lillian, Suddarth S. Doris, contributed Smeltzer,C. Suzanne, Bare, G.Brenda. 2004. Textbook of Medical-Surgical Nursing, 10th edition, Chapter 20, Post operative nursing management. Lippincott, Williams and Wilkins. Pages 436-459. Davidson, Stanley, Sir Davidsons principles and practice of Medicine, 19th edition , Chuchill Livingsone, 1952 ed. Hunter, John, A.A., 2002, pages 734-745. Ganong, William, F., Review of medical Physiology, 19th edition, Appleton and Lange, Section 4 Endocrinology, Metabolism and Reproductive Function . Chapter 22. The Pituitary Gland, 1999, pages 378-392, 363-364. Gray, Henry, Anatomy from Gray's Anatomy of the Human Body, 2oth edition, 2000, edited by Warren H. Lewis, Chapter 9, Splanchnology, 4 d , hypophysis cerebri, Lea and Febiger, 1918, Philadelphia. Guyton & Hall, The Pituitary Gland, Textbook of Medical Physiology, 10th edition, 2000, pages 846-857. Hypophysectomy, Tayside University Hospitals NHS Trust, Retrieved from the world wide web, Nov 14 2005. http://www.dundee.ac.uk/medther/tayendoweb/images/hypophysectomy/htm#Before Kasper,Dennis,L., Braunwald,Eugene, Fauci,Anthony,S., Hauser,Stephen,L., Harrison's Principles of Internal Medicine, 2005.16th edition, Volume 2. Chapter 318, Anterior Pituitary and Hypothalamic Disorders, Mc Graw Hill Companies, Inc. pages 2080 -2084. Kimball, John,W., Dr., Biology, 1994, Retrieved from the world wide web, http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/W/Welcome.html Lindsay,W.,Kenneth, Bone, Ian. 2004, Neurology and Neurosurgery Illustrated, 4th edition.Paperback. Churchill Livingstone. Pages 334-343. Litwack,K. ,1999, Core curriculum for for perianesthesia nursing practice, Philadelphia, W.B.Saunders. Marieb, N.Elaine, Mallat,Jon, Human Anatomy, 1997, pages 663-667. Meeker,M.H.,& Rothrock,J.C., 1999, Alexander's care of the patient in surgery. St.Louis:Mosby year book. Post-op nursing protocol, Retrieved from the world wide web Web www.unchealthcare.org/site/Nursing/nurspractice/protocols/protocols_ pdf/protocolp15.pdf Schultess, von Gustav, K. & Smith, Jorgan Hans, Medcyclopaedia, The encyclopaedia of Medical Imaging, Volume 6-1, Physics, Techniques, Procedures , 1998-2001 , Retrieved from web,http://www.amershamhealth.com/medcyclopaedia/medical/Volume%20VI%201/TRANSPHENOIDAL%20HYPOPHYSECTOMY.asp NURSING PROTOCOL TITLE : Transsphenoidal Hypophysectomy-Post op Nursing Care PURPOSE: 1.To enumerate the complications in the post op period of a Transsphenoidal hypophysectomy surgery patient 2. To understand and stress the post op care and management of this patient by the nursing staff in the ICU and the neurosurgical ward. LEVEL : Interdependent. SUPPORTIVE DATA: Hypophysectomy is removal of the pituitary gland for tumours like prolactinoma, microadenoma, craniopharyngioma and is done by the transsphenoidal route most commonly. It is a neurosurgical procedure. The post op period begins when the patient is shifted from the operation theatre to the recovery room where the patient will be kept for about 2 hours. Here the patient is received by the nursing staff on duty and managed and then transferred to the neurosurgical ward. Phase 1 is the first one hour when the patient is in the PACU until discharged by Anaesthesia. Phase 2 is in the recovery room till the patient is transferred to the neurosurgical ward. In the mean time, if the patient shows any signs of distress, the physician is informed and the patient is taken care of. If this period is uneventful, the patient reaches the neurosurgical ward without any problem. LEVEL : Interdependent PRIOR TO ARRIVAL: 1. Receive a telephonic report from the PACU regarding the medications given to the patient there. 2. Find out the patients intra and immediate post op status. 3. Post op orders and any special order to be noted down 4. Ask about the vitals of the patient, the level of consciousness of the patient, time of last urine voiding. 5. Find out about catheter placement. If catheter is not placed, arrange for it to be out in the ward since this patient will need input/output monitoring. 6. Find out about any special equipment that may be needed like if the patient is on heart monitor. 7. Obtain a pulse oximeter, cardiac monitor, Oxygen cylinder and mask, catheter placement requirements. ASSESSMENT : A physical assessment of the patient noting all the vital signs. Check the airway status. The patient in the post op period of transsphenoidal hypophysectomy has the risk of sudden airway obstruction. Check the oxygen saturation levels. Check the level of consciousness. Any deterioration as per the Glasgow Coma Scale has to be reported to the physician. Check all the 4 extremities for movements, sensations. Check the nasal packing and see if there is any bleeding or CSF leak. Ask the patient if he has any symptoms of raised intracranial tension like a headache, nausea vomiting. Check for neck rigidity. Check the IV line patency and start fluids and maintain a strict input and output chart. Check and record all the vitals including the pulse oximetry readings, oxygen saturation. Check for any leak of CSF. Any changes noted in all of the above should be noted by reviewing with all the PACU findings. The vital sings noted now are compared to the previous ones got from the telephonic conversation. In the ICU, vitals are recorded more often. HR, BP, RR, Saturation of Oxygen should be 98-100% and all vital signs are to be recorded initially every 15 minutes, then every half an hour ,then hourly until shifted to the ward. A detailed assessment should be made every 8 hours to check on all the systems and general condition of the patient. This assessment should include the level of consciousness, any CSF leak, any bleeding from the nasal mucosa, urine output, check abdominal wound in case a fat graft was taken during the surgery, mobility and self care ability of the patient, nutrition of the patient. The patient should be told that he can eat and drink the same day after the effect of anaesthesia wears off. Ask about the pain status of the patient and inform the physician if pain medication is to be added. REPORTING TO THE PHYSICIAN: The following signs or symptoms should be reported to the physician if and when they occur. Airway Obstruction. After starting Oxygen through a mask and giving immediate care, the doctor should be informed at the earliest. Input/output imbalance- A transient Diabetes Insipidus is expected in this patient and excessive losses of dilute urine is seen. The balance of fluid is thus delicate and should be monitored carefully. Any deterioration in the level of consciousness. Any fever, headache, nausea, vomiting in the post operative period suggests meningitis and is to be reported. Any liquid coming out of the nose. CSF leak should be reported. Development of sweating, hypotension, unstable hemodynamics to be reported. Respiratory distress with falling saturation levels. OTHER ESSENTIAL CARE 1. Check the patients IV line regularly for blockade or signs of thrombophlebitis. 2. Monitor the input and output every 8 hours in this case since he already has an IV live with fluids and an indwelling catheter. 3. Check if the patient is able to breathe comfortable through the mouth since he will have the nasal packing for 4 days. 4. Patient is kept NBM till the effect of anaesthesia wears off. 5. Abdominal wound dressing is done according to protocol. 6. The activity levels of the patient should be increased. Encourage the patient to take rest. 7. Salt restricted diet and to avoid foods which may cause a diuresis. 8. Daily weight monitoring along with regular lab work. SAFETY PROTOCOLS Follow the general precautions to prevent falls as for all patients after general anaesthesia. Keep the head elevated. EDUCATE THE PATIENT ABOUT Instruct the patient and the caregiver about the importance of reporting a change in level of consciousness or Altered sensorium. Instruct them to inform about any CSF leak. Mouth breathing is taught to the patient and it is to be seen to it that he is maintaining good saturations with his mouth breathing. Repeat and stress on the need to maintain strictly his input/output chart and tell the relatives not to administer any fluids without informing the nurse. Inform them about the use of the call bell in case of need. DOCUMENTATION AND LAB WORK 1.Collect all the lab work regularly. The hormone status of the patient is to be checked regularly till a definite idea is got about the status. Blood T3, T4, TSH, Cortisol are to be checked. Apart from that other pituitary hormones are also to be checked in the lab work. Routine lab work investigations all to be sent for, collected and documented. 2.Documentation of the patients status at arrival, each day, after a physicians visit, interventions done and results thereof, patient's and his/her relatives understanding of the instructions given is noted. 3.Pulse, BP, Temperature ,RR and Input/output charts to be documented hourly. 4.Documentation of physicians visits with interventions or modifications to existing treatment. Read More