Definition
A lumbar puncture, also known as a spinal tap, is a medical procedure used to collect cerebrospinal fluid (CSF) from the lower back for diagnostic or therapeutic purposes. This fluid surrounds the brain and spinal cord, providing protection and cushioning.
Purposes
- To administer spinal anesthesia before surgery.
- To administer medication into spinal canal in case of meningitis.
- To reduce intracranial pressure.
- To perform diagnostic studies, e.g., myelogram.
- To detect subarachnoid block.
Contraindications
- Suspected epidural infection.
- Severe psychiatric/neurotic problems.
- Chronic backache.
- Intracranial bleeding.
Articles
A sterile tray containing (LP set) the following:
- Lumbar puncture needle with stylet.
- Sponge holding forceps.
- Small bowls.
- Specimen bottles.
- Cotton balls, gauze pieces, cotton pads, etc.
- Dressing articles
A clean tray containing the following:
- Mackintosh and towel.
- Kidney tray/paper bag.
- Spirit, iodine, tincture benzoin.
- Lignocaine 2%.
- Sterile normal saline.
- Adhesive plaster and scissors.
- Sterile gloves, gown, and mask.
- Three-way adapter, manometer, and tubing.
- Syringe and needle for local anesthesia.
Procedure
| Nursing action | Rationale | |
| Before procedure | ||
| 1. | Identify the patient and explain the procedure to him. | Relieves anxiety and fear. |
| 2. | Instruct the patient to void before the procedure. | Ensures that the patient is comfortable. |
| 3. | Instruct the patient not to make any movement during the procedure. | Movement during procedure causes injury to the spinal cord and its nerves. |
| 4. | Check BP pulse and respiration of patient. | Helps in obtaining a baseline data. |
| During procedure | ||
| 5. | Position the patient on one side at the edge of the bed, with back toward the physician. Thighs and legs are flexed as much as possible (C-shaped position). The head and neck are flexed and brought toward chest. Keep hands between knees. | Flexion of thighs and legs increases the space between vertebrae and facilitates easy entry of needle into subarachnoid space. |
| 6. | Keep a pillow under the head. | Pillow under the head maintains the spine in a horizontal position. |
| 7. | Encourage the patient to relax and breathe normally during procedures. Remind patient that he should not talk. | Hyperventilation may cause an error in pressure reading. |
| 8. | Fold back the upper garments above the waistline and the lower garments below the hip exposing the site. | Avoids overexposure of the patient. |
| 9. | Assist the physician in cleaning the puncture site with antiseptic solution and injecting local anesthetic. | Prevents risk of infection. |
| 10. | Spinal needle is inserted into the subarachnoid space by physician through the 3rd and 4th or 4th and 5th lumbar intercostal space. | |
| 11. | Physician removes the stylet and connects three-way adaptor with manometer filled with normal saline. | Obtains CSF pressure. Normal pressure is 6-13 mm of mercury or 80-180 cm of water. |
| 12. | Collect cerebrospinal fluid (CSF) specimen into three specimen bottles after measuring pressure. | |
| 13. | Needle is withdrawn by the physician. | |
| 14. | Assist physician in sealing the puncture site with tincture benzoin and apply sterile dressing. | Dressing protects and prevents leakage of CSF from puncture site. |
| 15. | Instruct the patient to be flat for 12-24 hours. | Decreases CSF pressure in the caudal area where the needle insertion occurred and decreases the risk of leakage. |
| After procedure | ||
| 16. | Monitor for complications of lumbar puncture. Check vital signs every half an hour for 3-4 hours till stable. | Post-lumbar headache may appear a few hours to several days after procedure. |
| 17. | Check puncture site frequently for CSF leakage. | |
| 18. | Encourage patient to take more fluids after the procedure. | Reduces the risk of post-lumbar headache by re-establishing the CSF volume. |
| 19. | Record the procedure with date, time, CSF pressure, amount drawn, color, nature of cerebrospinal fluid and general condition of patient during and after the procedure. | |
| 20. | Send the specimen to the laboratory with proper labels and requisition forms. | Detects chemical, bacteriological and cellular composition of CSF and helps to diagnose the disease. |
| 21. | If no complications are observed, give upright position to the patient after 24 hours. |
Complications
- Cerebrospinal fluid leakage.
- Infection.
- Post puncture headache.
- Paralysis.
- Hematoma.
Special considerations
- Monitor for neurological changes, such as change in the level of consciousness, pupil size, numbness and tingling, or pain in the legs or lower back, during and after the procedure.
- If spinal headache is present, instruct patient to:
- Increase fluid intake.
- Avoid aspirin and caffeine.
- Keep lights dim in the patient’s room.
- Avoid excessive stimulation.
- Avoid Valsalva maneuver.
- Administer pain medications.
- Maintain flat position for 12-24 hours without pillows.
- Once needle enters subarachnoid space, help the patient to slowly strengthen legs to reduce false recording of increased intracranial pressure. Increased muscle tension and compression may elevate pressure recording.
- If pressure reading is not required after introduction of the needle into the subarachnoid space, CSF specimen is taken. In this case, the three-way adapter and manometer tubing are not required.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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