Applying a loose gauze pad under the patient nose is the action by the nurse is most appropriate.
A frontal skull fracture might cause CSF rhinorrhea (clear or bloody discharge from the nose). If a loose collecting pad is put under the nose, the blood will coagulate and a yellow halo will appear if CSF is present. If there is clear discharge, testing for glucose will reveal the presence of CSF.
Because blood includes glucose, mixed blood and CSF will both test positive for glucose. If CSF rhinorrhea develops, the nurse should notify the doctor right away. To allow a tear to close, the head of the bed can be lifted. The nurse should not insert a dressing or tube into the patient's nasal cavity, and the patient should not sneeze.
Interventions for lowering or stabilizing ICP include raising the head of the bed to thirty degrees, maintaining a neutral neck posture, maintaining a normal body temperature, and avoiding volume overload.
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