A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
A. Position the client flat in bed.
B. Check the fluid for dextrose with a dipstick.
C. Suction the nose to maintain airway patency.
D. Insert nasal and ear packing with sterile gauze.
Correct Answer: B. Check the fluid for dextrose with a dipstick.
Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. CSF Leak is a condition in which CSF is able to escape from the subarachnoid space through a hole in the surrounding dura. The volume of CSF lost in a leak is very variable, ranging from insignificant to very substantial amounts.
Option A: Placing the client flat in bed may increase ICP and promote pulmonary aspiration. If the loss of CSF is great enough, spontaneous intracranial hypotension (SIH) may occur. SIH most often presents with a positional headache caused by downward displacement of the brain due to loss of buoyancy previously provided by the CSF. Posterior neck stiffness, nausea, and vomiting are also common symptoms.
Option C: The nose wouldn’t be suctioned because of the risk for suctioning brain tissue through the sinuses. Diagnosis is aided by typical MRI findings, such as an increase of intracranial venous volume, pituitary hyperemia, enhanced pachymeninges, and descent of the brain. Many cases of SIH resolve without any treatment.
Option D: Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection. Conservative approaches such as bed rest, hydration, and increased caffeine intake may also prove to be effective; however, more drastic measures may be necessary.
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