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1. Incision through the cranium to gain access to the brain during neurosurgical procedures.
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Preoperative: Procedures are explained and carried out, including antiseptic shampooing of the hair and scalp, hair removal, insertion of peripheral arterial and venous lines and indwelling urinary catheter, and application of pneumatic compression dressings. The patient is prepared for postoperative recovery in the neurological intensive care unit: the presence of a large bulky head dressing, possibly with drains; use of corticosteroids, antibiotics, and analgesics; use of monitoring equipment; postoperative positioning and exercise regimens; and other specific care measures.

Postoperative: Neurological status is assessed according to protocol (every 15 to 30 min for the first 12 hr, then every hour for the next 12 hr, then every 4 hr or more frequently, depending on the patient's stability). Patterns indicating deterioration are immediately reported. The airway is protected, with gentle suctioning used if necessary. Serum electrolyte values are evaluated daily because decreased sodium, chloride, or potassium can alter neurological status, necessitating a change in treatment. Measures are taken to prevent increased intracranial pressure (ICP), and if level of consciousness is decreased, the airway is protected by positioning the patient on the side. After a supratentorial craniotomy, the patient's head is elevated 15° to 30° to increase venous return and to aid ventilatory effort. After infratentorial craniotomy, the patient is kept flat but log-rolled every 2 hr to reduce complications caused by prolonged bedrest.

The patient is gently repositioned every 2 hr and is encouraged to breathe deeply and cough without straining. Fluid is restricted as prescribed (usually 1500 ml/24 hr) or according to protocol, to minimize cerebral edema and prevent increased ICP and seizures. An NPO (“nothing by mouth”) protocol is maintained for 24 to 48 hr to prevent aspiration and vomiting, which can increase ICP. Wound care is provided as appropriate; dressings are assessed for increased tightness (indicative of swelling); and closed drainage systems are checked for patency and for volume and characteristics of any drainage. Excessive bloody drainage, possibly indicating cerebral hemorrhage, and any clear or yellow drainage, indicating a cerebrospinal fluid leak, is reported to the surgeon. Patients who have had a transphenoidal procedure are restricted from nose-blowing, and nasal drainage is checked for the presence of cerebrospinal fluid. The patient is observed for signs of wound infection.

Prescribed stool softeners are also administered to prevent increased ICP from straining during defecation. Before discharge, the patient and family are taught to perform wound care; to assess the incision regularly for redness, warmth, or tenderness; and to report such findings to the neurosurgeon. If self-conscious about appearance, the patient can wear a wig, hat, or scarf until the hair grows back and can apply a lanolin-based lotion to the scalp (but not to the incision line) to keep it supple and to decrease itching as the hair grows. Prescribed medications, such as anticonvulsants, may be continued after discharge.

2. After the death of a fetus, the breaking up of the fetal skull to facilitate delivery in difficult parturition.

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