Question

The nurse is assessing the nasal dressing on a client who had a transsphenoidal resection of the pituitary gland. The nurse notes a small amount of serosanguineous drainage that is surrounded by clear fluid on the nasal dressing. Which nursing action is most appropriate?

1.Document the findings. 2.Reinforce the dressing.
3.Notify the health care provider (HCP).
4.Mark the area of drainage with a pen and monitor for further drainage.

Answer 1

The most appropriate nursing action when noting clear fluid around serosanguineous drainage on a nasal dressing post-pituitary surgery is to notify the health care provider immediately because of the potential for a cerebrospinal fluid leak, then mark the area on the dressing, and document the findings.

Step-by-step explanation:

The presence of clear fluid surrounding serosanguineous drainage on a nasal dressing after a transsphenoidal resection of the pituitary gland is a potential indicator of cerebrospinal fluid (CSF) leakage. It is critical for a nurse to recognize this as a possible CSF leak because it can lead to complications such as meningitis. The most appropriate nursing action is to notify the health care provider (HCP) immediately, as it may require prompt medical intervention.

In addition to notifying the HCP, the nurse should mark the area of drainage on the dressing with a pen to monitor for increases in size, which signifies further drainage. Documenting the findings thoroughly in the patient's medical record, including the appearance, amount, and any changes in the drainage, is also essential. However, before these actions, notifying the HCP takes precedence because of the urgency of the situation.

Finally, while reinforcement of the dressing might be necessary, it should not supersede the action of informing the HCP. Reinforcement may be done after evaluation and instruction from the HCP.