The nurse is caring for a patient who had a craniotomy for a brain tumor and has developed postoperative leakage of cerebrospinal fluid (CSF) from the nose. What are appropriate nursing interventions for this patient?
Select all that apply.
1. Keep patient turned on side of leakage and keep the head of the bed elevated 20 degrees.
2. Assess the patient for constant swallowing.
3. Observe for thick, yellow, odorous drainage.
4. Insert sterile packing into the area.
5. Encourage the patient to blow his or her nose frequently.
Correct Answer: 1, 2
Appropriate interventions include positioning the patient on the side of leakage if it is from the ear and keeping the head of the bed elevated to 20 degrees if the leak is from the nose. Assess the patient for constant swallowing and the presence of clear drainage from the nose, ears, or wound. Do not insert packing. Tell the patient not to put a finger in the nose or ear or blow the nose.
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