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lumbar puncture for nurses
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APARNA A1st year MSc Nursing
College Of NursingKottayam
LUMBAR PUNCTURE or SPINAL TAP is carried out by inserting a needle into Lumbar subarachnoid space to withdraw C S F
To obtain C S F for analysis & diagnosis of:◦ Meningitis
◦ Meningoencephalitis
◦ Subarachnoid hemorrhage
◦ Malignancy – diagnosis and treatment
◦ Pseudotumor Cerebri
◦ Other neurologic syndromes
To drain C S F & reduce intracranial space
To instill medications
Increased intracranial pressure ◦ Head CT before study if focal neurologic findings
present to rule out impending cerebral mass herniation
• If platelet count is less than 40,000 and Prothrombin time is less than 50% of control
Hydrocephalus- Enlarged ventricle size & in suspected normal pressure Hydrocephalus
Coma- If C T is negative and I C P increased
Meningitis- Exclude mass lesion & confirm diagnosis
Use smallest possible gauge [20/22]
Prefer atraumatic rather than cutting needle
•1.5 in for < 1 yr•2.5 in for 1 year to middle childhood•3.5 in for older children and adolescents•Larger for large adolescents
Needle is inserted into subarachnoid space through intervertebral space
Spinal cord ends at L1-L2, so sites for puncture are located at L3-L4 or L4-L5
Restrain patient in lateral decubitus position
◦ Maximally flex spine without compromising airway
◦ Keep alignment of feet, knees and hips
◦ Position head to left if right handed or vice versa
•Anesthetic such as:Topical- Zylocaine cream or Lidocaine 1% with 25 gauge needle and syringe
•Povidone-iodine solution & sponge•Drapes, gauze, and bandages•Manometer, stopcock, tubing and
specimen bottles
•Sterile CSF tray with
•Spinal needle
Obtain a written consent for the procedure
Explain the procedure to the patient
Determine whether patient have any doubts or misconceptions
Reassure the patient
Instruct patient to void after procedure
•Position the patient at oneside of edge of bed •Place a small pillow under patient’s head & another between the legs •Assist the patient to maintain position•Encourage patient to relax & to breath normally •Describe the procedure step by
•The physician cleanses the site with antiseptic solution and drapes the site •Local anesthetic is injected to numb the site and a spinal needle is inserted to subarachnoid space with stylet with bevel up to keep cutting edge parallel with nerve and
A specimen of C S F is collected usually in three test tubes
Needle is withdrawn & a small dressing is applied at puncture site
Sent specimen to lab
immediately
Instruct patient to lie on prone for 2 to 3 hours
Monitor patient for any complications
Encourage increased fluid intake
Headache Back pain [Occasionally with short-lived ]◦ Disc herniation if needle advanced too far
Bleeding or fluid leak around spinal cord Infection, pain, hematoma Subarachnoid epidermal cyst Ocular muscle palsy (1%) Nerve Trauma Brainstem herniation
Throbbing bifrontal & occipital headache
Dull and deep in character
Severe on sitting or standing
IT CAN BE AVOIDED BY:
Using small gauge needle
Keep patient prone after procedure for 2 hours, then side-lying for 2-3 hours, then supine or prone for 6 or more hours
Bed rest
Analgesics
Hydration
Epidural blood patch
Clear and colourless
Secreted by choroid plexus
Exists in subarachnoid space
It is about 150-200ml acts as shock absorber transports nutrients
1. If C S F is blood tinged 3 samples has to be collected
2. Uniformly stained SA H
3. CSF clears in 3rd bottle-Traumatic trap
1 2 3
1 2 3
Usually obtained for cell count, culture, glucose and protein testing
R B C and Differential W B C
Bacteriological –Gram stain and culture
Biochemical-Protein[0.15-0.45g/l]
- glucose [0.45-0.70g/l]
SAH : Spectrophotometry Malignant Tumor: Cytology Tuberculosis: Polymerase chain reaction,
Jensen Culture Non-bacterial Infection: Virology, fungal &
parasitic studies Demyelinating Disease: Oligoclonal bands Neurosyphilis: V D R L test Cryptococcus: culture, antigen detection H I V : culture, antigen detection & antiviral
antibodies