Question

Which action would the nurse include in the plan of care for a client undergoing a transsphenoidal hypophysectomy? Select all that apply. One, some, or all responses may be correct. a. Assessing for clear nasal drainage b. Maintaining strict intake and output c. Increasing daily dietary fiber intake d. Elevating the head of the bed 30 degrees e. Instructing on the use of an incentive spirometer

Answer 1

The plan of care for a client undergoing a transsphenoidal hypophysectomy should include assessing for clear nasal drainage, maintaining strict intake and output, increasing dietary fiber, elevating the head of the bed, and using an incentive spirometer.

Step-by-step explanation:

A transsphenoidal hypophysectomy is a surgical procedure to remove a pituitary tumor through the sphenoid sinus, which is located at the base of the skull. Postoperative care for clients undergoing this surgery should focus on monitoring the patient diligently to prevent complications and to promote healing. With this in mind, several actions are recommended to be included in the plan of care:

• Assessing for clear nasal drainage: This is crucial as the presence of clear, watery drainage could indicate a cerebrospinal fluid leak, which could lead to serious complications such as meningitis.
• Maintaining strict intake and output: Monitoring fluid balance is essential due to the potential risk of diabetes insipidus following pituitary surgery, as the pituitary gland regulates kidney function.
• Increasing daily dietary fibre intake: Constipation is a common issue post-surgery, particularly with reduced activity, so the increasing fiber can help reduce this risk.
• Elevating the head of the bed 30 degrees: This helps to reduce swelling and can aid in decreasing the pressure on the sella turcica, where the pituitary gland sits, facilitating proper drainage and healing.
• Instructing on the use of an incentive spirometer: This is often done after surgery to help the patient take deep breaths effectively, which can prevent respiratory complications such as atelectasis or pneumonia.

These are essential components of postoperative care to ensure a safe and smooth recovery after a transsphenoidal hypophysectomy.

Answer 2

For a client undergoing a transsphenoidal hypophysectomy, the nurse should assess for clear nasal drainage, maintain strict intake and output, increase daily dietary fiber intake, elevate the head of the bed 30 degrees, and instruct on the use of an incentive spirometer to ensure a smooth recovery.

Step-by-step explanation:

A transsphenoidal hypophysectomy is a surgical procedure to remove a pituitary tumor through the sphenoid sinus, which is located at the base of the skull. Proper postoperative care is essential for a successful recovery. When planning the care for a client undergoing a transsphenoidal hypophysectomy, the nurse should:

• Assess for clear nasal drainage: The nurse must monitor for cerebrospinal fluid (CSF) leak, which could manifest as clear nasal drainage. It is crucial to distinguish between ordinary nasal discharge and CSF.
• Maintain strict intake and output: It is important to monitor the balance of fluids meticulously to identify any issues with fluid imbalance, which can signal complications like diabetes insipidus or syndrome of inappropriate antidiuretic hormone (SIADH).
• Increasing daily dietary fiber intake: Postoperative ileus or constipation can occur after surgery, so increasing fiber can help prevent gastrointestinal complications.
• Elevating the head of the bed 30 degrees: This position can help reduce pressure on the sella turcica (the cavity in the skull that contains the pituitary gland) post-surgery and help with drainage.
• Instructing on the use of an incentive spirometer: The incentive spirometer helps prevent respiratory complications such as pneumonia, which the patient may be prone to following anesthesia and surgery.