Endocrine Question #4
The nurse is caring for a client in the neuro step-down unit following transsphenoidal hypophysectomy surgery. The nurse will plan for which interventions while caring for the client?
Select all that apply.
- Provide tissues and encourage the client to blow the nose.
- Perform neuro checks every 2 hours.
- Keep the head of the bed flat.
- Teach the client to breathe through the mouth.
- Monitor for nose bleeding.
Following a transsphenoidal hypophysectomy, the nurse must implement frequent neurological assessments and report changes immediately to the health care provider; observe for signs of bleeding from the nose; teach the client to mouth breathe; and keep the head of the bed elevated. Transsphenoidal hypophysectomy is removal of the entire or partial pituitary gland via the sphenoid sinus. The client’s nose will be packed, so teaching the client to mouth breathe is implemented. Teach the client not to blow the nose for at least 2 weeks after surgery, because the nose is the route of surgical removal of the pituitary. Performing neuro checks every 2 hours is important to monitor for any changes, especially in vision or pupillary response. Monitor the client for excessive nose bleeding or cerebral spinal fluid (CSF) from the nose or frequent swallowing. Frequent swallowing indicates the nose is draining down the throat and may be blood or CSF. CSF is clear and clients describe it as tasting like salt. Hormone therapy may be indicated after surgery.
Test Taking Tip