Definition and Terminology.

Lumbar Puncture- Lumbar puncture involves withdrawing cerebrospinal fluid by the insertion of a hollow needle with a stylet into the lumbar subarachnoid space.(Hickey 1997) Indications Purpose of performing a Lumber Puncture are, 1.In order to withdraw an adequate amount of CSF for appropriate laboratory examination. 2.In order to measure the circulating pressure of CSF 3.In order to remove a small amount of CSF for: (a)Treatment of Benign Intracranial Hypertension (b)Diagnosis of normal pressure hydrocephalus Contra-indications 1.Patient without neuro-imaging, unless documented by the Consultant that it is safe to undertake the procedure without a CT scan or MRI. 2.If there are any other signs, evidence or suspicion of increased intracranial pressure caused by a space occupying lesion. 3.Patients under-going anti-coagulation therapy. 4.Patients who are likely to have a structural lesion pressing on the spinal cord. 5.If the nurse undertaking the procedure has assessed the patient and remains unsure about proceeding with the investigation. This might be due to: High clinical activity in the unit Lack of confidence in performing the procedure safely . Patient may be exhibiting non-compliant behaviour or perceived lack of confidence in the nurse practitioner The procedure may have been particularly difficult in that patient on a previous occasion Procedure Equipment required 1.Antiseptic skin-cleansing agents 2.Selection of needles and syringes 3.Local anaesthetic, e.g. lidocaine 1% 4.Sterile gloves, apron, eye protection 5.Sterile dressing pack 6.Lumbar Puncture needles of assorted sizes 7. Disposable manometer 8.Three sterile specimen bottles. (These should be labelled 1,2 and 3. The first specimen, which may be bloodstained due to needle trauma, should go into the first bottle.This will assist the laboratory to differentiate between blood due to procedure trauma and that due to Subarachnoid haemorrhage). 9.Plaster dressing or plastic dressing spray Procedure : 1. Explain procedure to the patient 2. Secure written consent 3. Prepare all supplies needed at bedside 4. Assist patient to assume fetal position (lateral recumbent position with back arched, head and neck flexion on chest) to that maximal widening of intervertebral space id achieved 5. Assist physicians in setting up lumbar puncture equipment and during the procedure 6. When lumbar tap is completed, instruct patient to : A. Remain flat on bed for 4 hours or as ordered by physician B. Take nothing by mouth for 4 hours or as ordered by physician 7. Monitor the following: A. Vital signs B. Neurologic status 8. Record the following

A. Time lumbar tap was completed B. Changes in neurological status and vital signs C. Medications administered D. Diagnostic tests requested 9. Send specimen to laboratory with proper label after encoding Procedure Procedure Check medical notes 1. CT scan normal 2. Or imaging not necessary 3. Check anti-coagulation i.e. warfarin Explain and discuss the procedure and check that: 1. Consent form has been signed. 2. the Ct or MRI has been seen and checked by the patients doctor. Assist patient into position. 1. Wash hands thoroughly and apply apron and eye protection. 2. Place the patient in the left lateral position. the lumbosacral region should be as close to the edge of the bed as possible. 3. Ask the patient to curl up to the maximum extent possible and to clasp his hands around the knees and hug them as close to the chest as possible. 4. The neck should be flexed forward and the patients back should be perpendicular to the ground Infection control -Wash hands thoroughly and apply sterile gloves. -Prepare the lumbosacral region by swabbing in a spiral from the L4-5 interspace outwards until an area of aprox 20cm in diameter has been covered using the chlorhexidine 70% or betadine solution. -Ensure that all trace of iodine is removed with alcohol prior to performing the L.P Analgesia -A lumber puncture can be performed at any of the lumber interspaces although the L4-5,L3-4,L23 -Using a syringe and size 20 gauge needle (orange). -Inject the lignocaine under the subcutaneous layer to raise a wheal. Rationale a) To ensure patient does not have raised intracranial pressure (b) Avoid bleeding

Ensure patient gives valid informed consent

To ensure maximum widening of the intervertebral spaces and thus easier access

Using aseptic technique throughout the whole procedure.

The introduction of iodine into the Subarachnoid space can produce irritative arachnoiditis This is below the level of the spinal cord but still within the subarachnoid space. To minimize discomfort Allow the analgesia to take effect. 35mins (check with the point of a needle against the skin surface).

Procedure Change needle size to 18 gauge (blue); proceed as if performing the procedure into the lumber interspace. Draw back the syringe to ensure that the needle is not contaminated with blood or CSF. Slowly inject about 2ml of analgesia at that interspace. Introduce the spinal needle in the exact midline between the 2 ndand 3 rd lumbar vertebrae and into Subarachnoid space. The needle shouldbe parallel to the ground at all times. Insertion is continued until a slight pop is felt. Withdraw the stylet to ensure it is in the Subarachnoid space allow only one drop of CSF to escape, otherwise an erroneously low pressure recording will result. If the needle strikes bone it should be withdrawn to just below the skin, then reinserted. Following three failed attempts, the practitioner should discontinue the procedure and refer to the patients doctor Measuring the pressure -The manometer is attached to the hub of the needle with a three-way stopcock in the appropriate position. When cerebral-spinal fluid is seen, attach the manometer to the spinal needle. Record the pressure. -Obtain the appropriate specimens of cerebralspinal fluid -Closing pressures should be measured before withdrawal of the needle. After withdrawal, the needle puncture point should be briefly massaged with a sterile piece of gauze and a plaster applied -The patient can rest for as long as they wish or alternatively the patient can get straight up -Document the procedure: (a) Complexity of procedure (b) Amount of local anaesthetic used (c) Opening pressure (d) Closing pressure

Most errors are made by aiming the needle too far caudally, by being off the midline or if the needle is not precisely parallel to the ground.

To minimise the patients discomfort and anxiety

Normal pressure is 11-16 cm H

To establish diagnosis.

To maintain sepsis and stop fluid leak To prevent infection

Provide accurate record of procedure

(e) Colour of CSF -Ensure that specimens are labelled appropriately and sent with correct forms. To ensure correct patient results Symptoms of Normal Pressure hydrocephalus include apraxia and decline in cognitive function. Aim of the procedure is to determine if patients neurological status improves temporarily after removal of 20-30ml of CSF

Special procedures for suspected Normal hydrocephalus: -Ensure patient understands purpose of procedure. Before undertaking lumbar puncture undertake 10 metre timed walk, mini mental test and any other assessment detailed by referring consultant.

POTENTIAL PROBLEMS PROBLEM Pain down one leg during the procedure Headache may develop up to 24 hrs following procedure CAUSE The spinal needle may have touched a dorsal nerve root Removal of cerebrospinal fluid ACTION a. Reposition the needle. b. Reassure the patient a) Reassure patient b) Relieve by lying flat c) Encourage increased fluid intake d) Take analgesia e) If severe and increasing inform G.P a) Reassure patient b) Lie flat c) Take analgesia a) No further action required b) Report immediately if associated with other symptoms

Backache Leakage

a) Insertion of needle b) Position required to procedure a) Leakage of cerebro- spinal fluid.

Bibliography
1. Department of Health (2000). The NHS Plan: A plan for investment, a plan for reform: Department of

Health: London 2. Department of Health (1999). Making a Difference: Strengthening the nursing, midwifery and health visiting contribution to health and health core. Department of Health. London 3. Hickey, J. (1997). The Clinical Practice of Neurology and Neurosurgical nursing 4 th ed. J.B Lippincott. Philodelphia.

4. NMC (202). Code of Professional Practice, London: United Kingdom Central Council for Nursing,

Midwifery and Health Visiting. 5. UKCC (1995) PREP, London United Kingdom Central Council for Nursing, Midwifery and Health Visiting

Procedure demonstration On Lumbar Puncture

Submitted to: Mrs. Reshma Razak Lecturer NUINS Submitted By: Ms. Shesly P. Jose II Year MSc (N) NUINS

Submitted On:16.08.2010