Question

The clear drainage must be analyzed to determine whether it is nasal drainage or CSF. The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip. What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

1. Compress the nares
2. Tilt the head back
3. Collect the drainage
4. Administer an antihistamine for postnasal drip

Answer 1

The first action a nurse should take when a client with a head injury has clear nasal drainage is to collect the drainage for analysis to determine whether it is CSF or nasal drainage.

Step-by-step explanation:

When a patient with a head injury begins to exhibit clear drainage from the nose, the first action a nurse should take is to collect the drainage. This is essential because the clear drainage could potentially be cerebrospinal fluid (CSF), which may indicate a skull fracture or another serious condition. Collecting the drainage helps in testing and diagnosing the nature of the fluid. Administering an antihistamine, compressing the nares, or tilting the head back could impede accurate diagnosis and appropriate treatment.

It is critical for the collected CSF to be clear, as cloudiness can signal an infection. A test, such as a lumbar puncture, can be done later to determine the presence of microorganisms in the CSF if it is cloudy. However, in the immediate situation, preventing contamination and sample collection is paramount.