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Introduction to qualitative research: the main approaches and designs. The main methods (phenomenology, ethnography, Grounded, narrative enquiry and case studies) and sampling technique of qualitative research are briefly outlined. A practical example is presented for each method.

Preoperative scalp shaving has been a well-established practice among neurosurgeons based on the belief that hair removal prevents postoperative infections. Apart from aiding in improved visualization of the incision line, ease of closure, and dressing application, there are concerns that the presence of hair at the surgical site may interfere with the surgical procedure. Preoperative scalp shaving is a controversial practice, and many neurosurgeons are moving toward not removing any hair or clipping minimal hair along the incision line rather than shaving the scalp. The following is a systematic review of articles related to preoperative scalp shaving before cranial surgeries and the implications for postoperative wound infections. Eighteen articles were identified as potentially relevant based on the search criteria. These articles were selected based on the inclusion and exclusion criteria to provide concise background information and an explanation of scalp-shaving practices in neurosurgery leading to the clinical question posed. An evidence table was compiled to organize the study data and identify key points. The review brings strong evidence that preoperative scalp shaving does not confer any benefit against postoperative wound infection and, paradoxically, may lead to higher rates of infection. Because hair removal neither contributes benefits to the surgery itself nor decreases the risk of wound infection but has considerable cosmetic value for the patient, many of the authors recommended that cranial surgeries should be done without hair shaving.

Aims and Objectives: The aim of this research was to investigate the effect of five selected intensive care nursing interventions on the intracranial pressure (ICP) of moderate to severe traumatic brain-injured children in intensive care., Background: The physiological effects of many nursing interventions in paediatric intensive care (PIC) are not known. This results in the lack of an evidence base for many PIC nursing practices., Design: Prospective observational cohort study conducted over 3 years in a single tertiary referral paediatric intensive care unit (PICU) in the North West of England., Methods: Five selected commonly performed nursing interventions were studied: endotracheal suctioning and manual ventilation (ETSMV), turning via a log-rolling (LR) approach, eye care, oral care and washing. These were studied in the first 72 h after injury., Results: A total of 25 children with moderate to severe traumatic brain injury and intraparenchymal ICP monitoring in intensive care (aged 2-17 years) were enrolled. Both ETSMV and LR were associated with clinically and statistically significant changes in ICP from baseline to maximal ICP (p = 0·001 ETSMV; p = < 0·001 LR) and from maximal post-ICP (p = < 0·001 ETSMV; p = < 0.001 LR). Eye care, oral care or washing did not cause any clinically significant change in ICP from baseline. After decompressive craniectomy, none of the interventions caused significant changes in ICP., Conclusions: Only two of the five nursing interventions, endotracheal suctioning and LR, caused intracranial hypertension in moderate to severe traumatic brain-injured children, and after craniectomy, no care interventions caused any significant change in ICP., Relevance to Clinical Practice: Knowledge about the physiological effects of many intensive care nursing interventions is lacking and this is magnified in paediatrics. This study provides a significant addition to the evidence base in this area and allows intensive care nurses to plan, implement and evaluate more effectively their nursing care for brain-injured children., (© 2011 The Authors. Nursing in Critical Care © 2011 British Association of Critical Care Nurses.)

Children with brain tumors routinely undergo craniotomies for tumor resections. Nurses and nurse practitioners are critical in closely monitoring these patients. Postoperatively, these children may develop inappropriate vasopressin secretion, cerebral salt wasting syndrome, or a combination of both. Inappropriate fluid and electrolyte administration may exacerbate symptoms. Both high and low sodium levels are associated with significant complications. Sodium levels were prospectively observed for 72 hours perioperatively. Overall, 36 patients had 201 serum sodium levels measured over the course of 1 year. Postoperatively, 79 (39%) of the sodium levels were <135 mEq/L or >145 mEq/L. Of these abnormal sodium levels, 3 (1%) were <125 mEq/L and 2 (1%) were >165 mEq/L. All the abnormal sodium levels occurred in patients with suprasellar or hypothalamic lesions. This study suggests that children with resections of suprasellar or hypothalamic tumors need specialist attention in postoperative management of fluid and electrolytes. The nurse is in the ideal role to monitor closely the pediatric brain tumor patient at high risk for abnormal sodium levels.

Penetrating craniocerebral trauma is an injury in which a projectile violates the skull but does not exit. The significance of penetrating injuries to the head depends largely on the circumstances of the injury, the velocity of impact, and attributes of the projectile. While most penetrating head injuries are caused by firearms, lower-velocity mechanisms of penetrating brain injury present unique challenges for the multidisciplinary team involved with the delivery of care. Appropriate management can lead to optimal outcomes and limit secondary brain injury.

The purpose of this meta-analysis was to estimate the efficacy of prophylactic administration of 5-HT3 receptor antagonists for postoperative vomiting (POV) in pediatric craniotomy patients at 24 hours. By updating a previously published systematic literature search, we found a recently published pediatric study to combine with the one already identified. The two published randomized placebo-controlled trials were combined for a total of 135 participants aged 2 to 20 (79 treatment and 56 controls). The only study drug was ondansetron. The combined relative risk (RR) of vomiting was not statistically significant in the treatment group compared to the control group (RR = 0.77; 95% CI: 0.50-1.19). There was also no evidence of efficacy for ondansetron in reducing the use of rescue antiemetics in the treatment group compared to the control group (RR = .71; 95% CI: 0.34-1.49). While combining these randomized placebo-controlled trials did not show efficacy for ondansetron in preventing POV in craniotomy patients aged 2 to 20, a clinically significant effect cannot be excluded, as even the combined sample size remained small. Thus, there is no current evidence for or against this class of drugs for preventing POV in children after craniotomy, and clinical decision-making must be based on studies in other populations and clinical experience. Ongoing assessment of nausea and vomiting and ongoing evaluation of the effectiveness of treatments in individual children and young adults remains an essential part of perianesthesia and postoperative neuroscience nursing.

In awake craniotomy is a unique neurosurgical procedure in which the patient is conscious during part of the procedure. Little has been documented about how instrument nurses (ie, scrub persons) react to this complex procedure and to the tasks of caring for a conscious patient. A phenomenological investigation was conducted to document the experiences of nine instrument nurses. The nurses were challenged by having to manage the conscious presence of the patient, they placed great importance on controlling the surgical situation, and they reported that participating in this procedure had a compelling emotional effect on them.

The awake craniotomy procedure has become the gold standard for tumour resection in eligible patients. In this paper, the awake craniotomy procedure is reviewed, including the advantages of the procedure over the standard craniotomy procedure. The role of the neuroscience nurse in awake craniotomies is highlighted.

Increased intracranial pressure (ICP) is a cause of death and disability in neurological patients. Patients experiencing malignant stroke of the middle cerebral artery (MCA) have a high mortality related to cerebral edema, increased ICP, and subsequent cerebral herniation. Decompressive hemicraniectomy with duraplasty is a surgical option for those experiencing large volume MCA stroke. When decompressive hemicraniectomy with duraplasty is performed, functional outcomes improve if the MCA stroke candidate is younger, the onset of increased ICP occurred less than 24 hours before surgery, and surgery is performed before clinical signs of herniation syndrome occur. The level of care required for these patients makes nursing care challenging.

Craniopharyngiomas account for approximately nine per cent of pediatric brain tumours and one to two per cent of adult brain tumours. Though considered benign, the compressive nature of these relentless tumours can produce catastrophic sequelae. This case study pays tribute to a 33-year-old woman who faced numerous surgeries, adjuvant therapy, and many of the complications associated with a craniopharyngioma. The interdisciplinary neuroscience team, along with colleagues from neuroradiology, ophthalmology, and endocrinology, joined together to care for Kerry and her family to meet their complex health and psychosocial needs. However, it was Kerry who taught us about perseverance, strength, and the power of an unconquerable human spirit.

Objectives: To provide an overview of the diagnostic work-up, intraoperative technologies, postoperative treatment options, and investigational new therapies in patients with malignant brain tumors., Data Sources: Published textbooks and articles and other reference materials., Conclusion: Recent improvements in diagnostic and surgical equipment have influenced outcomes and overall quality of life for patients with central nervous system tumors. The ability to more accurately target and more safely remove brain tumors has enhanced the postoperative period and decreased hospital stays. However, malignant neoplasms continue to be refractory to current treatments, necessitating innovative surgical approaches at the time of initial diagnosis and at tumor recurrence., Implications for Nursing Practice: Nurses with an understanding of current diagnostic and surgical treatment modalities for brain tumors are able to provide accurate patient education and comprehensive care, enhancing the overall hospital and outpatient experience.

Traditionally, surgical correction of craniosynostosis involves calvarial remodeling, large blood losses necessitating transfusions, hospital stays of several days, and less-than-satisfactory results. In this study, outcomes from a minimally invasive technique called endoscopic strip craniectomy, along with a postoperative molding helmet, to correct craniosynostosis in young infants were evaluated. The endoscopic strip craniectomy was performed on 185 patients with clinical signs of craniosynostosis, with the following distribution: 107 sagittal, 42 coronal, 37 metopic, and 7 lambdoid, for a total of 198 sutures. The mean blood loss was 29.4 cc, and only two patients underwent intraoperative blood transfusion. Fourteen patients underwent postoperative blood transfusion; none was life-threatening. There were no deaths, complications, neurological injuries, or infections. All but six patients were discharged on the first postoperative day. A majority of the patients achieved or approached normocephaly, and there were no complications. Neuroscience nurses need to be aware of this technique when they discuss treatment options with the families of infants with craniosynostosis.

The purpose of this study was to examine the effects of a nurse-designed discharge-planning project in a teaching hospital in Taiwan. A before-and-after quasi-experimental design was used. Craniotomy (n = 112) and stroke (n = 171) patients were recruited and divided into control and intervention groups. Outcome indicators included length of hospital stay, change in activities of daily living (ADL), rate of nursing home placement, rate of unplanned readmission, and level of satisfaction. In the stroke sample length of hospital stay was shorter in the intervention group than in the control group. In the craniotomy sample unplanned readmission was less frequent in the intervention group than in the control group. No differences were found between the control and intervention groups in other outcome indicators., (Copyright 2003 Wiley Periodicals, Inc.)

Historically, reconstruction of the skull with intraoperatively modeled implants has been restricted severely by limitations in implant material, unpredictable aesthetic results, prolonged OR time, and indirect techniques that cause decreased precision and increased expense. This article discusses modern computer-aided design and manufacturing systems that allow for direct preoperative fabrication of implants out of pure titanium with a variety of enhanced construction details. Between 1997 and 1999, 135 cranial and craniofacial reconstructions with defects measuring up to 22 cm were performed using this technique at 25 health care centers in Europe. The results obtained in these patients were predictable and constant and demonstrated dramatically reduced OR times.

Sagittal synostosis is the most common form of craniosynostosis (i.e., premature fusion of cranial sutures). Sagittal synostosis, which is the premature fusion of the sagittal suture, occurs in 56% to 58% of all reported cases of craniosynostosis. This article describes calvarial vault remodeling, the procedure of choice at Children's Hospital Los Angeles for surgical intervention to correct sagittal synostosis. Perioperative interventions to minimize patients' risks and maximize benefits are explained. A case study is presented to describe the experience of one patient and his family members.

Intramuscular codeine is the most regularly prescribed analgesia for post-surgery craniotomy patients. Morphine is avoided for this patient group because of fears of side-effects. A literature search found evidence that titrated morphine has no inherent risks if patients are well observed.

Although clival chordomas account for only a small percentage (0.2%) of all intracranial tumors, they represent a considerable challenge for the neurosurgical team. The problems of surgical accessibility to the clivus, management of postoperative complications and tendency of the chordoma to recur are well recognized. This infiltrative tumor located at the skull base has the potential to metastasize and recur, thus meeting the characteristics of a malignant tumor. The maxillotomy, as well as a number of other surgical approaches to the clivus, has been developed and refined for removal of this formidable tumor. It is important to have an understanding of the anatomy of the clivus, the pathology of a chordoma and the surgical technique of a maxillotomy. A case report demonstrates these concepts and nursing considerations for the patient undergoing a maxillotomy for resection of a clival chordoma.

Both patients and families require helpful information, skills and support throughout the hospitalization for craniotomy surgery to ensure effective coping patterns. Research has demonstrated that patients who have participated in successful teaching programmes exhibit less anxiety and develop a more positive perception of their health care experience. The purpose of this paper is to examine the development, content, implementation and evaluation of a multimedia educational programme, designed to respond to the identified learning needs of the preoperative craniotomy patients and families. In order to identify learning needs, data from a sample of 25 postoperative patients and families was compared with the perceived learning needs of this same study group contributed by 48 nursing staff.

The immediate purposes of this study are (a) to indicate the I.C.U. and hospital length of stay in elective craniotomy patients with brain tumour, and (b) to identify the clinical indicators that contribute to the I.C.U. length of stay. The ultimate purpose is to contribute to a growing body of knowledge in providing quality and cost effective patient outcomes by creating appropriate vehicles for further research in the field of neuroscience. The following clinical indicators are identified: pre-op patient admission to ward or same day admit unit, O.R. cancellations, type of tumour, nursing staff availability, intubation on admission, I.C.U. length of stay, and post-op complications. The results of this pilot study, with sample size of 55 patients, could assist us in the nursing profession to develop an appropriate Care Map for craniotomy patients with brain tumour.

The purpose of this article was to describe the use of TA method to study nurses' reasoning and decision making in a neurosurgical setting. The feasibility and benefit of the method were explored, and examples were provided from data collected on a neurosurgical unit during the immediate post operative care of craniotomy patients. The authors hope that this report will encourage other investigators to consider using this method to examine nurses' reasoning and decision making. They also hope that future investigators will be encouraged to move TA to clinical practice settings, rather than continuing to rely on simulations, which can never fully replicate the realities of clinical practice.

The study included 70 patients admitted to Neurosurgical ICU (NICU) with the diagnosis of Supratentorial Craniotomy for Brain Tumour. These patients were followed throughout their hospitalization in NICU, to the ward and until discharge from hospital. The purposes of the study were (a) to indicated the NICU and floor length of stay (LOS) in this group of patients, prior to the use of care map and compare it to a developed care map, and (b) to identify the variables that contribute toe overall prolonged hospital LOS. The findings indicated that, prior to the use of care map, 68.8% of Supratentorial Craniotomy Patients with Brain Tumour had an ICU LOS of one day. However, only 38.6% of these patients were discharged from hospital within the care map indicated 5 day post ICU, floor LOS. The findings also showed that the overall hospital LOS, in 71.4% of the patients, was over 7 days, as indicated on the developed care cap. Several variables such as patient complications, consults, rehab/placement, patient falls and additional diagnostic tests contributed to the overall pronged hospital LOS. Thus, by monitoring these variables with the use of a care map, may produce measurements to evaluate cost effectiveness, and allow health care professionals to provide more effective and quality patient care.

An 84 year-old white female developed Guillain Barré syndrome (GBS) following a craniotomy for resection of a meningioma. GBS is a rare, idiopathic disease which presents multiple nursing challenges. To effectively care for the patient with GBS, it is necessary to be familiar with symptomatology, incidence and pathology. Using this information, nursing assessment may be performed and interventions developed and individualized as needed.

1. Knowledge of the patient and the planned positioning allows the perioperative nurse to prepare for the needs of the individual craniotomy patient in surgery. 2. Microsurgical instrumentation often required with a craniotomy requires special handling and care. 3. Methylene blue should never be used in neurosurgical procedures. 4. The sitting position for posterior fossa surgery requires special precautions.

Presented in this article is a brief overview of cranial anatomy and physiology, highlights of surgical indications, and the surgical procedure for craniotomy. Nursing interventions and their rationales are emphasized.

There are many indications for a craniotomy, and there are several possible complications. Despite this, the assessment of the craniotomy patient includes parameters common to many surgical patients and most neurological patients.

Selected postoperative complications following a craniotomy are discussed in relation to assessment and nursing care. Clinical differentiation between structural and metabolic postoperative complications is emphasized. The signs, symptoms, diagnostic aids and nursing implications related to each of these two major classifications of complications are presented. The specific postoperative complications discussed include: cerebral edema, intracranial bleeding, hydrocephalus, cerebral infarction, tension pneumocephalus, hypoxia, water and electrolyte imbalances, hypoglycemia, endocrine disturbances, hyperthermia, and seizures.

Hospital cost containment and nursing shortages have diminished resources available in surgical intensive care units (SICU). To provide a more quantitative approach to management of these resources, the nursing intervention scoring system (NISS) devised by Greenburg et al was instituted in the SICU at the VA Medical Center, Gainesville, Fla. The NISS scores for patients in the SICU were calculated without computer support. During a four-month study period, 725 NISS evaluations on 70 patients were collected. Characteristic curves of NISS scores versus postoperative days were generated from the data and were predictive of workloads in the unit. In addition, NISS patient scores provided a basis for day-to-day bed control and provided an effective tool for management of nursing service staffing. The hospital administrators responded positively to quantitative documentation of SICU resource requirements by providing additional personnel, equipment, and intermediate care facilities. We have concluded that the NISS is an effective means of providing optimal day-to-day use of SICU beds. In addition, the NISS also provides the data needed to quantitate unit needs for nursing service and administration.