A female client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, nurse Jacob reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
A. “You must lie flat for 24 hours after surgery.”
B. “You must avoid coughing, sneezing, and blowing your nose.”
C. “You must restrict your fluid intake.”
D. “You must report ringing in your ears immediately.”
Correct Answer: B. “You must avoid coughing, sneezing, and blowing your nose.”
After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The need for nasal packs is dependent on the type of reconstructive technique and the surgeon’s choice (used only in a minority of cases). The nasal pack is removed on postoperative day 1. Septal splints are warranted in traditional sublabial-transseptal-transsphenoidal approaches and removed on a postoperative day 5 to 7.
Option A: The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. The first follow-up visit is 1 week after the procedure, where postoperative day 7 serum sodium levels are reviewed to rule out occult hyponatremia. Serial nasal endoscopies are done for debridement and to assess healing. The frequency of follow-up visits is determined by nasal crusting and maintenance of nasal hygiene with irrigation.
Option C: Within 24 hours after hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. DI is the most common endocrine complication after sellar surgery, with the postoperative incidence of DI ranging between 5% and 35%. Postoperative DI is often characterized by a triphasic response: polyuria and polydipsia occurring in the first 48 hours and last a few days. Following this, a period of antidiuresis and hyponatremia develops, commonly after 1 week of surgery. This is followed by the polyuric phase, ending in permanent DI.
Option D: Visual, not auditory, changes are a potential complication of hypophysectomy. Worsening of vision as a result of bleeding or manipulation and arterial hemorrhage are other immediate complications. A detailed study of preoperative imaging is essential to avoid catastrophes like optic nerve and carotid artery injury. The presence of anatomical variations such as sphenoethmoidal cell or Onodi cell places the optic nerve at risk. Suspected injury to the optic nerve would entail a full gamut of measures, from observation, intravenous high dose steroids to optic nerve decompression, depending on the degree of suspicion, time since the injury, and loss/ progressive deterioration of vision.
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