The nurse cares for a patient after a transsphenoid hypophysectomy for hyperpituitarism. Which of the following entries should be reprted the the physician.
1. Temperature of 99.1 F, Pulse 84, Resp 20, BP 120/80
2. Instructed patient to avoid liftting and bending
3. Clear, colorness drainage noted on nasal packing
4. Encouaged patient to use incentive spirometer.
The Answer is 3.
Rational
1. Normal vital signs, does not need to be reported to physician
2. Correct teaching, does not need to be reported to physician
3. Correct answer, patient could be leaking cerebrospinal fluid.Should be reported to the physician.
4. Correct action, does not need to be reported to physician
Reference.
White, L (2005)
Foundations of Nursing; 2nd ed.
Clifton Park, NY :Delmar
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