44. Leakage of spinal fluid is a potential neurosurgical complication. How should a nurse assess for this complication?
44. Leakage of spinal fluid is a potential neurosurgical complication. How should a nurse assess for this complication?
. Check for urine specific gravity greater than 1.030.
. Monitor for urine output greater than 5–10 L/day.
. Test all nasal and ear drainage for glucose.
. Test all spinal fluid from lumbar punctures for glucose.
Test-Taking Tip
Remember: cerebrospinal fluid is high in glucose.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications from Surgical Procedures and Health Alterations
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Answer 1 is incorrect because spinal fluid does not affect the concentration of the urine. Head trauma may cause a disorder of the posterior pituitary, but the urine specific gravity would be low. Answer 2 is incorrect because an excessive output would be more likely to result from trauma to the posterior pituitary, not from a cerebrospinal fluid (CSF) leak. Answer 3 is correct because spinal fluid contains glucose. The RN should also look for the "halo" sign of blood drainage with a yellow ring of spinal fluid. In addition, nose and ears should be kept clean to reduce the chance of infection. Answer 4 is incorrect because the concern is leakage of CSF as a result of a tear that would allow fluid to leak from the nose or ears, not a result of a lumbar puncture.