Nursing care
Craniotomy Care: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Craniotomy care centres on protecting a brain that is about to swell: hourly neurological checks, head of bed at 30 degrees after most supratentorial surgery, and positioning that depends on whether the bone flap was replaced. If it was left out, the patient never lies on the operative side. Watch for rising intracranial pressure, seizures, CSF leak and disturbances of sodium and urine output.
When it is done and why
A craniotomy opens the skull to reach the brain, and the bone flap is normally replaced at the end. Surgeons use it to remove tumours, clip aneurysms, resect arteriovenous malformations, evacuate haematomas after trauma or haemorrhagic stroke, drain abscesses and remove seizure foci. Some operations are done awake so the team can map speech and motor areas while the patient talks or moves.
The distinction that matters for nursing is craniotomy against craniectomy. In a craniectomy the flap is left out, stored in the abdominal wall or a freezer, to give a swollen brain room. Only scalp then covers that part of the brain. The handover should state which was done. If it does not, ask the surgical team before you position the patient. Do not assume the flap is back.
Preparing the patient
Record a full neurological baseline: Glasgow Coma Scale, pupil size and reaction, limb strength, speech and any existing deficit. Postoperative checks mean nothing without it. Confirm the consent names the correct side, the site is marked, and anticoagulants and antiplatelets were held for the period the surgeon specified. Check that coagulation results, group and save and electrolytes are back.
Give prescribed drugs on time. Dexamethasone is often started before surgery to reduce vasogenic oedema around a tumour, and an anticonvulsant such as levetiracetam may be loaded. Hair is clipped only where the surgeon directs; practice varies between units. Tell the patient what to expect on waking: a head dressing, possibly a drain, neurological checks every hour through the night, and a headache treated with care, because heavy sedation would mask deterioration.
The steps that matter for safety
Positioning comes first. After supratentorial surgery, keep the head of the bed at 30 degrees with the head midline to help venous drainage. After posterior fossa surgery the surgeon may want the patient flat or only slightly raised, so follow the written order. If the bone flap was removed, nurse the patient off the operative side. Many units put a sign above the bed so nobody turns the patient onto unprotected brain.
Avoid anything that raises intracranial pressure: neck flexion, extreme hip flexion, straining at stool, and clustered care. Space out suction, turning and washing. Keep oxygen saturation and carbon dioxide in the prescribed range, because hypoxia and hypercapnia both dilate cerebral vessels. Maintain normal temperature and glucose. Ask for a stool softener. Keep the head dressing dry and intact rather than piling on reinforcement that hides bleeding.
During the procedure — the nurse's role
In theatre the circulating nurse checks the site and side against the consent and the imaging at the time-out, and confirms the surgeon's plan for the bone flap. The head is fixed in pins, so the nurse pads pressure points, protects the eyes with lubricant and tape, and checks the neck is not flexed enough to obstruct jugular venous return. Antibiotic prophylaxis goes in before the incision. Mannitol or hypertonic saline may be given on the anaesthetist's request to slacken the brain.
The nurse tracks blood loss and fluid balance, keeps the patient warm, and maintains the swab, needle and instrument count. In an awake craniotomy a nurse or neurophysiologist sits with the patient, asking them to name objects, count or move a limb while the surgeon stimulates cortex, and reports any hesitation or weakness at once. Whether bone was replaced is written into the operative note and handed over aloud.
After: monitoring and complications
Neurological observations are hourly at first, more often if anything changes. A fall in Glasgow Coma Scale, a new pupil asymmetry or a fresh motor deficit suggests haematoma or oedema and needs the surgeon and an urgent CT, not another hour of watching. Bradycardia, widening pulse pressure and irregular breathing are late signs. If an external ventricular drain is in place, level it at the tragus and keep it at the set height.
Watch the fluid chart. Urine output above roughly 200 to 300 mL an hour with rising sodium suggests diabetes insipidus, which follows pituitary and hypothalamic surgery. Falling sodium with low output suggests SIADH. Check for CSF leaking from the wound, nose or ear; test clear fluid for glucose or look for a halo on the dressing. Seizures, wound infection, meningitis, venous thromboembolism and pneumonia are the other main risks. Treat nausea early, because vomiting spikes pressure.
Documentation and teaching
Document each neurological assessment against the preoperative baseline, so a slow decline is visible across shifts. Record whether the bone flap is in or out, the positioning order, dressing condition, drain output, fluid balance and every drug given with its time. If the flap is out, the discharge summary must say so, because the patient will return for cranioplasty.
Teach the patient and family what to report: worsening headache, drowsiness, confusion, weakness, fits, fever, clear fluid from the wound or nose, or a wound that is red, swollen or leaking. Driving is not allowed until the surgeon clears it, and seizure rules differ by state, so direct them to their own team. Patients without a bone flap wear a protective helmet when up and avoid contact sports. Go through the anticonvulsant and steroid taper, and warn against stopping either abruptly.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our neurological practice questions are the closest set to what this page covers.
Common questions
How should I position a patient after a craniotomy?
Head of bed at 30 degrees with the head midline after supratentorial surgery. Posterior fossa patients may be nursed flat, so check the order. If the bone flap was not replaced, never lie the patient on the operative side.
What is the earliest sign of raised intracranial pressure after brain surgery?
A change in level of consciousness. Restlessness, drowsiness or new confusion appears before pupil changes, bradycardia or a widened pulse pressure. Report any fall in Glasgow Coma Scale immediately.
Why is urine output watched so closely after a craniotomy?
Surgery near the pituitary or hypothalamus can disturb antidiuretic hormone. Large volumes of dilute urine with rising sodium suggest diabetes insipidus. Low output with falling sodium suggests SIADH. Both need prompt treatment.