一位閉鎖性頭部損傷病人出現清澈鼻水樣引流液。護理師首要行動為何？
A client with a closed head injury has developed clear, watery drainage from the nose. What is the nurse's priority action?
- AInstruct the client to blow their nose gently指示病人輕輕擤鼻子
- BInsert nasal packing插入鼻腔填塞物
- CAdminister an antihistamine for rhinitis給予抗組織胺以治療鼻炎
- DTest the drainage for glucose✓ 正解檢測引流液的葡萄糖含量
頭部外傷後出現清澈鼻水樣引流，需高度懷疑腦脊髓液（Cerebrospinal Fluid, CSF）外漏。CSF 外漏代表顱底骨折且硬腦膜受損，增加了腦膜炎的風險。測試葡萄糖為臨床常見的初步篩檢，若為 CSF，葡萄糖濃度通常高於鼻黏液。護理優先級為保護病人免受感染，並避免增加顱內壓（ICP）的動作，嚴禁造成「瓶塞效應」或逆行性感染。
Clear, watery drainage from the nose following a closed head injury suggests cerebrospinal fluid (CSF) leakage, indicating a potential basilar skull fracture. Testing the drainage for glucose is a common initial screening method, as CSF contains glucose while nasal secretions typically do not. This helps differentiate CSF from mucus to assess infection risk and guide further management.
在美國臨床，若懷疑 CSF 外漏，護理師除了檢測葡萄糖，還會觀察是否有「暈環徵象（Halo sign）」。台灣臨床亦同，但需注意在美國，護理師在執行此類評估時，必須嚴格遵循保護呼吸道與避免增加 ICP 的護理常規。