Patient with head trauma,fliud leaking from nose and ears.Which is the best nursing action?

Admin June 25, 2018
Patient with head trauma,fliud leaking from nose and ears.Which is the best nursing action?

MWT Global Academy - questionA patient admitted with head trauma has fluid leaking from the nose and ears. Which is the appropriate nursing action?

  1. Pack the nose and ears with sterile gauze
  2. Raise the head of the bed so the client is sitting upright
  3. Position an ice pack on the back of the neck
  4. Place loose dressings below the nostril and ear

Answer D: Place loose dressings below the nostril and ear

Drainage from the nose and ear in a client with head trauma may be caused by leakage of cerebrospinal fluid (CSF). Applying a loose dressing to the nose and ears permits the fluid to drain and provides a visual reference to assess the type and amount of drainage. The nose and ear should not be packed if CSF leakage is suspected. If the drainage contains blood, look for the halo sign: a ring formed when protein in the CSF migrates to the edge of the wet spot as the gauze dries. If the drainage is clear, the nurse should check it for glucose. The head of the bed should be elevated 15 to 30 degrees to facilitate the drainage and decrease intracranial pressure.

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