A patient recovering from a craniotomy is complaining of a headache and has the head of the bed elevated. The nurse also sees a damp mark on the patient's pillow

Question

The nurse should: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check the drainage for the presence of glucose.
2. Alert the physician.
3. Elevate the head of the bed to 45 degrees.
4. Plan for insertion of an external ventricular drain.
5. Apply an occlusive dressing to stop the leak.

Answer 1

1,2
Rationale 1: A cerebrospinal fluid leak can be identified by clear fluid containing glucose that is leaking from the patient's ear or nose and forming a halo as it settles on a pillowcase. The patient will complain of a headache.
Rationale 2: The nurse should notify the health care provider regarding the presence of cerebrospinal fluid leakage in the event surgical intervention is required to close the tear.
Rationale 3: Raising the head of the bed further would create more irritation to the dura and thus worsen the headache. A CSF leak may also be related to increased ICP and raising the head of the bed would increase the risk of herniation.
Rationale 4: The insertion of an external ventricular drain would further deplete cerebrospinal fluid. As this is also an invasive procedure, there would be an increased risk for the development of meningitis.
Rationale 5: An occlusive dressing would be contraindicated because the cerebrospinal fluid should be allowed to flow freely. This is to prevent an increase of intracerebral pressure.