A client is scheduled for transsphenoidal microsurgery for removal of a pituitary adenoma. The nurse includes which of the following preoperative instructions?
A)
Turn, cough, and deep breathe every 2 hours.
B)
The client must remain supine in bed, with sandbags alongside her head to prevent movement.
C)
The client may not use a toothbrush for several days after surgery to prevent injury to the surgical site.
D)
The client will have to take replacement growth hormone for the rest of her life.
C
Explanation:
A)
Tooth brushing could disrupt the incision, which is in the roof of the mouth. Coughing increases intracranial pressure. A semi-Fowler's to Fowler's position facilitates breathing. Lifelong replacement of pituitary hormones is necessary.
Application
Intervention
Physiological Integrity: Reduction of Risk Potential
B)
Tooth brushing could disrupt the incision, which is in the roof of the mouth. Coughing increases intracranial pressure. A semi-Fowler's to Fowler's position facilitates breathing. Lifelong replacement of pituitary hormones is necessary.
Application
Intervention
Physiological Integrity: Reduction of Risk Potential
C)
Tooth brushing could disrupt the incision, which is in the roof of the mouth. Coughing increases intracranial pressure. A semi-Fowler's to Fowler's position facilitates breathing. Lifelong replacement of pituitary hormones is necessary.
Application
Intervention
Physiological Integrity: Reduction of Risk Potential
D)
Tooth brushing could disrupt the incision, which is in the roof of the mouth. Coughing increases intracranial pressure. A semi-Fowler's to Fowler's position facilitates breathing. Lifelong replacement of pituitary hormones is necessary.
Application
Intervention
Physiological Integrity: Reduction of Risk Potential
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