Lumber puncture-1.pptx general handout about lumber puncture defenition types procedure indications

Lumber puncture

1. Lumber puncture Aminu M Hussain

2. Introduction In a lumbar puncture (LP, or spinal tap), cerebrospinal fluid ( CSF) is withdrawn through a needle inserted into the subarachnoid space of the spinal canal between the third and fourth lumbar vertebrae or between the fourth and fifth lumbar vertebrae. At this level the needle avoids damaging the spinal cord and major nerve roots. The client is positioned laterally with the head bent toward the chest, the knees flexed onto the abdomen, and the back at the edge of the bed or examining table

3. Definition Lumbar puncture , also known as  spinal tap , is an invasive procedure where a hollow needle is inserted into the space surrounding the subarachnoid space in the lower back to obtain samples of  cerebrospinal fluid  (CSF) for qualitative analysis. Most of the disorders of the central nervous system are diagnosed in relation to the changes in the composition and dynamics of the CSF .

4. A lumbar puncture may also be used to measure CSF, instill medications, or introduce a contrast medium into the spinal canal. The procedure usually takes around 30 to 45 minutes and can be done on an outpatient basis at a hospital or clinic.

5. Responsibilities One of the responsibilities of the  nurse  during a lumbar puncture is to provide information and instructions before, during, and after the procedure. It will decrease  fear  and  anxiety  among the patient and their families, and it will also lessen the occurrence of potential complications post-lumbar puncture .

6. A local anesthetic will be given to minimize discomfort. Explain when and where the procedure will occur (e.g., the bedside or in a treatment room) and who will be present (e.g., the primary care provider and the nurse). Explain that it will be necessary to lie in a certain position without moving for about 15 min. A slight pinprick will be felt when the local anesthetic is injected and a sensation of pressure as the spinal needle is inserted.

7. Indication Measure cerebrospinal fluid (CSF) pressure Assist in the diagnosis of suspected CNS infections (bacterial or viral  meningitis , meningo encephalitis ), intracranial or subarachnoid  hemorrhage , and some malignant disorders Evaluate and diagnose demyelinating or inflammatory CNS processes such as  Multiple Sclerosis , Guillan-Barré Syndrome (GBS), Acute Disseminated Encephalomyelitis (ADEM)

8. Infuse medications which include spinal  anesthesia  before  surgery , contrast material for diagnostic imaging such as CT- myelography , and  chemotherapy  drugs directly into the spinal canal Treat normal pressure  hydrocephalus , cerebrospinal fistulas, and idiopathic intracranial  hypertension  (IIH). Placement of a lumbar CSF drainage catheter

9. Contraindication Absolute contraindications for lumbar puncture are as follows: Increased intracranial pressure due to a brain   tumor .  Cerebral or cerebellar herniation with severe neurological deterioration may occur after the  withdrawal  of CSF fluid. Skin  infection  near the puncture site.  The presence of skin infection near the site of the lumbar puncture increases the risk of contamination of infected material into the CSF .

10. Severe degenerative vertebral joint disease.  There will be difficulty in passing the needle through the degenerated arthritic inter spinal space. Severe coagulopathy.  Due to the significant risk of epidural hematoma formation.

11. Equipments The lumbar puncture kit contains: Sterile gloves Sterile drapes and procedure tray Sterile gauze pads Aseptic solution: povidone - iodine solution  ( Betadine ) Local anesthetic:  Lidocaine  1% solution

12. 25G needle 10ml syringe (1) Spinal needle with stylet (size 22G or 25G) CSF tube (2 to 4) Stopcock Manometer tubing

13. Procedure Step-by-step procedure for a lumbar puncture (spinal tap): Position the patient in a fetal position . The patient is positioned on his side at the edge of the bed with his knees drawn up to his abdomen and chin tucked against his chest (fetal position) or sitting while leaning over a bedside table. When the patient is positioned  supine , pillows are provided to support the spine on a horizontal plane .

14. Sterilize the site of  insertion . The skin site is prepared and draped, and a local anesthetic is injected. Insert the spinal needle . The spinal needle is inserted in the midline between the spinous processes of the vertebrae (usually between the third fourth or fourth and fifth lumbar vertebrae).

15. Remove the stylet from the needle . The stylet is removed from the needle. CSF will drip out of the needle if it’s properly positioned. A stopcock and manometer are attached to the needle to measure the initial (opening) CSF pressure. Collect specimen . Specimens are collected and placed in the appropriate containers. Remove the needle . The needle is removed, and a small sterile  dressing  is applied.

16. Nursing Responsibility for Lumbar Puncture Before the procedure The following are the nursing interventions prior to a lumbar puncture: Explain the procedure to the patient.  Explain to the patient the purpose of lumbar puncture, how and where it’s done, and who will perform the procedure. Obtain informed consent.  Make sure the patient has signed a consent form if required by the institution. Reinforce diet.  Advise the patient that fasting is not required. Promote comfort.  Instruct the patient to empty the  bladder  and  bowel  before the procedure .

17. Establish baseline  assessment  data.  Do vital signs monitoring and neurologic assessment of the legs by assessing the patient’s  movement , strength, and sensation. Place the client in a lateral decubitus position.  Assist the client to assume a lateral decubitus (fetal) position, near the side of the bed with the neck, hips, and knees drawn up to the chest. An alternative position is to have the patient sit on the edge of the bed while leaning over a bedside table. Instruct to remain still.  Explain that he or she must lie very still throughout the procedure. Any unnecessary movement may cause traumatic  injury .

18. Reassure the client throughout the procedure by explaining what is happening. Encourage normal breathing and relaxation . Observe the client’s color, respirations , and pulse during the procedure. Ask the client to report headache or persistent pain at the insertion site. Handle specimen tubes appropriately : Wear gloves when handling test tubes. Label the specimen tubes in sequence . Send the CSF specimens to the laboratory immediately. Place a small sterile dressing over the puncture site.

19. After the procedure Apply brief pressure to the puncture site.  Pressure will be applied to avoid  bleeding , and the site is covered by a small occlusive dressing or band-aid . Place the patient flat on the  bed. The patient remains flat on the bed for 4 to 6 hours depending on the physician. He or she may turn from side to side as long as the head is not elevated. Monitor vital signs, neurologic status, and  intake and output .  Take vital signs, measure intake, and output, and assess neurologic status at least every 4 hours for 24 hours to allow further  evaluation  of the patient’s condition. Monitor the puncture site for signs of CSF leakage and drainage of  blood .  Signs of CSF leakage include positional headaches,  nausea  and  vomiting , neck stiffness, photophobia (sensitivity to light), sense of imbalance, tinnitus (ringing in the ear), and phonophobia (sensitivity to sound ).

20. Encourage increased fluid intake.  An increased amount of fluid intake (up to 3,000 ml in 24 hours) will replace CSF removed during the lumbar puncture. Label and number the specimen tube correctly.  Ensure all samples are properly labeled and sent to the laboratory immediately for further evaluation. Administer analgesia as ordered.  Headaches after the procedure can last for a few hours or days and are usually treated with analgesics.

21. Document the procedure on the client’s chart : • D ate and time performed; the primary care provider’s name; the color, character, and amount of CSF ; and the number of specimens obtained. Also document CSF pressure and the nurse’s assessments and interventions.

22. Normal Results CSF samples for analysis with normal values typically range as follows: Pressure:  70 to 180 mm H 2 0. Appearance:  CSF is normally clear and colorless. CSF total protein:  15-45 mg/ dL Gamma globulin:  3 to 12% of the total protein CSF  glucose :  50 to 80 mg/dl CSF cell count:  Normal CSF contains no red blood cells (RBCs), and the white blood cell (WBC) count is 0-5 WBCs per microliter (all mononuclear) CSF Chloride:  118 to 130 mEq /L Gram stain:  No microorganism (bacteria,  fungi , or virus) is present .

23. Abnormal Results Pressure : Increased intracranial pressure (ICP) occurs as a result of a tumor,  hemorrhage , or trauma-induced  edema . Decreased intracranial pressure (ICP) may reveal a spinal subarachnoid obstruction . Appearance: Cloudy appearance indicating infection. Yellow to reddish appearance indicating  spinal cord  obstruction or intracranial hemorrhage. Brown to orange appearance indicating increased protein levels or RBC breakdown. CSF Protein: Increased protein indicating tumor, trauma,  diabetes mellitus , or blood in cerebrospinal fluid (CSF). Decreased protein indicates rapid CSF production. Gamma globulin: Increased gamma globulin indicates a demyelinating disease such as multiple sclerosis, neurosyphilis , or Guillan-Barré Syndrome.

24. CSF Glucose: Increased glucose indicates high  blood sugar  ( hyperglycemia ). Decreased glucose indicates low blood sugar (hypoglycemia), bacterial or fungal infection,  tuberculosis , or  meningitis . CSF cell count: Increased white blood cells in the CSF suggest meningitis, tumor, abscess, acute infection,  stroke , or demyelinating disease. Red blood cells in the CSF indicate bleeding into the spinal fluid or the result of a traumatic lumbar puncture. CSF Chloride: Decreased chloride indicating infected meninges. Gram stain: Gram-positive or Gram-negative organisms indicate  bacterial meningitis .

25. Complications The possible complications after a lumbar puncture are: Post-lumbar puncture headache.  The most common complication of LP occurs due to the leakage of CSF from the puncture site or into the tissues around it. The  pain  is aggravated while sitting, standing, or  coughing and resolves after lying down. Back pain.  Pain or discomfort in the lower back may happen as a result of trauma to the local soft tissue. Pain or numbness.  A feeling of tingling sensation and numbness in the lower back and legs is felt temporarily. Bleeding.  Bleeding is usually noted in the area of the punctured site, or in some rare cases into the subarachnoid, subdural, or epidural space. Brainstem herniation:  The increased pressure caused by the removal of CSF during LP will cause a sudden shifting of brain tissue that can lead to the compression or herniation of the brainstem.