Which nursing intervention is the priority for a patient recovering
from hypophysectomy?
A Teaching the patient about avoiding the use of toothbrushes until the
incision heals
B Monitoring the patient for increased temperature
C Offering the bedpan or urinal every two hours
D Assessing the “moustache” dressing regularly for drainage
The Correct Answer and Explanation is :
The correct answer is D. Assessing the “moustache” dressing regularly for drainage.
Explanation:
A hypophysectomy is a surgical procedure to remove the pituitary gland, often performed to treat conditions like tumors or disorders affecting hormone production. The priority nursing intervention after this procedure is to assess the “moustache” dressing regularly for drainage. This dressing is applied under the nose to catch any nasal drainage, which is crucial to monitor after a hypophysectomy. It serves as a key indicator of potential complications, particularly cerebrospinal fluid (CSF) leakage.
After a hypophysectomy, there is a risk of CSF leak, which may occur if the dura (the protective membrane surrounding the brain and spinal cord) is damaged during surgery. The most common sign of a CSF leak is clear, watery drainage from the nose, which could seep into the dressing. This is often referred to as a “halo sign,” where the drainage forms a ring or halo around blood on the dressing. The CSF leak can lead to meningitis, an infection of the membranes surrounding the brain and spinal cord, so early detection is critical.
Other interventions mentioned, such as teaching the patient to avoid brushing their teeth (Option A), monitoring for increased temperature (Option B), and offering the bedpan every two hours (Option C), are important but not as immediate in preventing the serious complications of a hypophysectomy.
- Option A (avoiding toothbrush use) is important because the incision site is near the upper lip and brushing the teeth could disrupt the surgical site or increase the risk of infection. However, it does not take priority over monitoring for drainage.
- Option B (monitoring temperature) is important to detect infection, but it is not as immediate as assessing for a CSF leak.
- Option C (offering a bedpan) is a supportive measure to ensure comfort but does not directly address post-surgical complications.
Thus, assessing the “moustache” dressing regularly is the most urgent intervention to detect complications like CSF leakage and prevent infection.