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HEAD AND NECK SERVICES

NEUROSCIENCE’S UNIT

LUMBAR PUNCTURE
PROCEDURE

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Sheffield Teaching Hospitals
NHS Trust

Title: Lumber Puncture Investigation Unique Identifier

Scope: Neuroscience Dept.

Issue date – 2nd draft Replaces – New Policy


July 2003

Author/Originator Cath Waterhouse

Authorised by – Dr. G. Venables July 2003

Review Date – July 2004

Contents page no.

Introduction 3
Purpose and scope of the policy 3
Policy statement 4
Definition and terminology 4
Indications for the procedure 5
Contra-Indications 5
Anatomy and physiology 6
Physiology of Cerebral Spinal Fluid 7
Spinal diagram (lateral view) 8
Principles of practice 9
Potential problems and complications of lumber puncture 12
Assessment of practice 14
Appendix 18
References 23

Introduction

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This protocol has been written by a small group of multi professional staff
within the Neuroscience’s unit to provide a standard necessary to provide the
basis of high quality patient care.

Purpose

This policy is to be adhered to sequentially; none of the stages are to be


omitted.
This policy for nurses undertaking a lumbar puncture is a multi disciplinary
approach resulting in the safe and successful removal and measurement of
cerebral spinal fluid (CSF) made on the basis of an individual patient
assessment.

Scope

The policy aims to provide a standard procedure to enable the safe


appropriate removal of a CSF sample following a lumbar puncture. It applies
to medical staff and experienced nursing staff with a minimum of five years
working in the specialty.

1. It is the responsibility of the medical staff to prescribe the investigation,


document the reason to undertake the procedure and the samples
required.
2. The nurse undertaking the lumbar puncture must be satisfied they are
competent to perform the procedure.

3. The approach must recognise registered nurses entering the Trust with
differing levels of competency

4. Whilst undergoing the training to achieve competence: -


(a) Patient must be consented to undergo the procedure by the
learning nurse
(b) The Clinical Director, Director of Nursing and Matron are
responsible for agreeing with the individual trained nurse,
following appropriate training, that they are competent to
undertake the procedure.
5. If at any time the nurse feels that she cannot perform the procedure,
medical staff must take on responsibility to perform the investigation.

6. A consistent approach to competency practice is required

7. Competency must be used to its fullest extent, i.e. across directorate


boundaries

8. The approach must recognise the managers responsibilities to


maintaining standards

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9. If six months elapses without the skill being undertaken, the individual
is advised to refresh themselves

Policy Statement

All patients requiring a lumber puncture for either therapeutic or diagnostic


purposes within the Sheffield Teaching Hospitals are to be treated according
to this policy.

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)

Cerebral Spinal Fluid – Clear, lymph-like fluid that fills the entire subarachnoid
space and surrounds and protects the brain.

Lumbar puncture stylet – Sterile hollow, double lumen needle in varying


lengths and gauges.

Manometer – Clear glass or plastic tube use to measure pressure in the


cerebro spinal fluid.

Competent healthcare practitioner - describes the practice of a skilled and


knowedgable doer. The practitioner is required to be able to apply critical
thinking and be capable of doing or selecting the best choice in particular
situations. (Cooper et al 2000).

INDICATIONS.

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Purpose of performing a Lumber Puncture on the Neurosciences
Programmed Investigation Unit: -

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. Patient’s under-going anti-coagulation therapy.

4. Patient’s 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.

ANATOMY AND PHYSIOLOGY

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The spinal cord lies within the spinal column, beginning at the foramen
magnum and terminating about the Level of the first Lumbar vertebra (fig 1).
Like the brain, the spinal cord is enclosed and protected by the meninges, that
is, the dura mater, arachnoid mater and pia mater. The dura and arachnoid
mater are separated by a potential space known as the subdural space, which
contains the CSF. Below the first Lumbar vertebra, the Subarachnoid space
contains the CSF, the filum terminale and the cauda equina, (Weldon 1998).
To avoid any damage to the spinal cord, it is imperative that the Lumbar
Puncture is performed below the first Lumbar vertebra where the cord
terminates (fig 2). The cord serves as the main pathway for the ascending
and descending fibre tracts that connect the peripheral and spinal nerves with
the brain. The peripheral nerves are attached to the spinal cord by 31 pairs of
spinal nerves.

Figure 1. Saggital section through lumbosacral spine. The most common


site for lumbar puncture is between L3 and L4 and between L4 and L5 as the
spinal cord terminates at L1.

Cerebrospinal Fluid (CSF)

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CSF is formed primarily by filtration and secretion from networks of capillaries
called choroids plexuses, located in the ventricles of the brain. Eventually,
absorption takes place through the arachnoid villi, which are finger-like
projections of the arachnoid mater that push into the dural venous sinuses.
CSF is clear, colourless and slightly alkaline with a specific gravity of 1005
(Draper 1989). In an adult, approximately 500ml of CSF are produced and
reabsorbed each day (Welton 1998), with 120-150ml present at one time.
CSF constituents include: -

1. Water
2. Mineral salts
3. Glucose
4. Protein (20-30mg) per 100ml (keel et al 1983)
5. Urea and creatinine

The functions of CSF include: -

1. Pulsatile displacement into the spinal canal to enable arterial blood to


enter the brain in a pulsatile manner
2. To act as a shock absorber
3. To carry nutrients to the brain
4. To remove metabolites from the brain
5. To support and protect the brain and spinal cord
6. To keep the brain and spinal cord moist (Bickey 1997)

LABORATORY DETERMINATIONS:

The following tests are routinely obtained on CSF’S, appearance, protein,


glucose, serology, cell count, and if indicated, bacterial and fungal cultures.

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Figure 2. Lateral view of the spinal column and vertebrae.

1. Cervical vertebrae (C1-7)

2. Thoracic vertebrae (T1-


12)
3. Lumbar vertebrae (L1-5)
4. Sacrum (5 pieces)
5. Coccyx (3-4 pieces)
6. Atlas
7. Axis
8. Vertebrae prominens

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PROCEDURE

Equipment required

1. Antiseptic skin-cleansing agents e.g. chlorhexidine


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 Rationale
Check medical notes
1. CT scan normal (a) To ensure patient does not have
2. Or imaging not necessary raised intracranial pressure
3. Check anti-coagulation i.e. warfarin (b) Avoid bleeding

Explain and discuss the procedure and check


that: - Ensure patient gives valid informed
consent.
1. Consent form has been signed.
2. the Ct or MRI has been seen and checked
by the patient’s doctor.
Assist patient into position.
1. Wash hands thoroughly and apply apron
and eye protection. To ensure maximum widening of the
2. Place the patient in the left lateral position. intervertebral spaces and thus easier
the lumbosacral region should be as close access
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
patient’s back should be perpendicular to
the ground.

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Procedure Rationale
Infection control

Wash hands thoroughly and apply sterile Using aseptic technique throughout
gloves. the whole procedure. Refer to
Infection Control STH Trust Policy
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. The introduction of iodine into the
Subarachnoid space can produce
Ensure that all trace of iodine is removed with irritative arachnoiditis.
alcohol prior to performing the L.P

Analgesia
This is below the level of the spinal
A lumber puncture can be performed at any of cord but still within the subarachnoid
the lumber interspaces although the L2/3 or space.
below.
To minimize discomfort
Using a syringe and size 20 gauge needle
(orange). Inject the lignocaine under the Allow the analgesia to take effect. 3-
subcutaneous layer to raise a wheal. 5mins (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 Most errors are made by aiming the
lumber interspace. Draw back the syringe to needle too far caudally, by being off
ensure that the needle is not contaminated the midline or if the needle is not
with blood or CSF. Slowly inject about 2ml of precisely parallel to the ground.
analgesia at that interspace.

Introduce the spinal needle in the exact midline


between the 2nd and 3rd lumbar vertebrae and
into Subarachnoid space. The needle should
be 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.

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Procedure Rationale
Following three failed attempts, the practitioner To minimise the patient’s discomfort
should discontinue the procedure and refer to and anxiety.
the patient’s doctor.

Measuring the pressure


The manometer is attached to the hub of the Normal pressure is 11-16 cm H2o
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 cerebral- To establish diagnosis.


spinal fluid (see notes for amounts required)

Closing pressures should be measured before To maintain sepsis and stop fluid leak
withdrawal of the needle. After withdrawal, the
needle puncture point should be briefly To prevent infection
massaged with a sterile piece of gauze and a
plaster applied

The patient can rest for as long as they wish or Research shows that bed rest is not
alternatively the patient can get straight up. necessary and will not influence
whether a patient complains of a post
lumbar puncture headache.

Remove and dispose of sharps as appropriate. Refer to STH Trust Policy as removal
of sharps and waste.

Document the procedure:


(a) Complexity of procedure Provide accurate record of procedure.
(b) Amount of local anaesthetic used
(c) Opening pressure
(d) Closing pressure
(e) Colour of CSF
Ensure that specimens are labelled To ensure correct patient results.
appropriately and sent with correct forms.

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Procedure Rationale
Special procedures for suspected Normal Symptoms of Normal Pressure
hydrocephalus: hydrocephalus include apraxia and
decline in cognitive function.
Ensure patient understands purpose of
procedure. Before undertaking lumbar Aim of the procedure is to determine if
puncture undertake 10 metre timed walk, mini patients neurological status improves
mental test and any other assessment detailed temporarily after removal of 20-30ml
by referring consultant. of CSF.

Undertake LP, removing 20-30ml CSF.

Wait 30-60 minutes

Repeat timed walk, mini mental test and any


other assessment

Document the procedure in the notes.

POTENTIAL PROBLEMS

PROBLEM CAUSE ACTION


Pain down one leg during The spinal needle may a. Reposition the needle.
the procedure. have touched a dorsal b. Reassure the patient
nerve root.
Headache may develop up Removal of a) Reassure patient
to 24 hrs following cerebrospinal fluid. b) Relieve by lying flat
procedure. c) Encourage increased
fluid intake
d) Take analgesia
e) If severe and increasing
inform G.P

Backache a) Insertion of needle a) Reassure patient


b) Position required to b) Lie flat
procedure c) Take analgesia
Leakage a) Leakage of cerebro- a) No further action required
spinal fluid. b) Report immediately if
associated with other
symptoms
Deterioration in neurological Presence of space Summon medical assistance
status occupying lesion in the immediately.
brain not appreciated

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ASSESSMENT

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MANAGEMENT OF PATIENTS UNDERGOING A LUMBAR PUNCTURE.

Performing a Lumbar Puncture

Aim: To understand the procedure of Lumbar Puncture.

Range: Qualified Nurses

ASSESSMENT SPECIFICATION:
The Employee is required to meet all the performance indicators at least once
to indicate completion. This may be achieved through a number of any of the
following methods of assessment, however, the observation of real work.
Followed by questioning to check underpinning knowledge is preferable in the
first instance.

Assessment method key Index


D/O: direct observation Q&A: Question and answer
T: Testimony of others. S: Simulation

Evidence of performance Assessment Method of Date


assessment completed

1. Accurately identify rationale for the


procedure.
3. Can explain related anatomy and
physiology.
4. Can describe patient’s condition
and relevant history
4. Provide the appropriate information
related to the procedure to the
patient and discuss the term
‘informed consent’.
5. Ensure that the patient has
completed the consent form and is
happy for the practitioner to
perform the procedure.
6. Checks that the patient has a
recent MRI or CT scan to exclude
space occupying lesion.
7. Can discuss the nurses role
regarding accountability and legal
issues

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Evidence of performance Assessment Method of Date
assessment completed

8. Can explain what is meant by the


term “Scope of Professional
Practice”.
9. Complete the patient assessment
form and demonstrate knowledge of
the contra-indications to performing
the procedure.
10. Position the patient correctly on
the bed, ensuring that the patient is
protected from potential risk of
falling or injury.
11. Ensure that Universal Precautions
are adhered to.
12. Demonstrate an understanding of
the potential risk to the practitioner
and ensure adequate safeguards
are in place.
13. Demonstrate appropriate
preparation and cleaning of the
site.
14. Discuss the potential
complications resulting from
inadequate skin preparation.
15. Can explain selection of correct
equipment and prepares trolley
and equipment as per local policy
16. Understands the rationale for not
undertaking the procedure
17. Can discuss potential
complications of the procedure
18. Is able to identify correct route of
entry.
19. Demonstrates safe administration
of local anaesthetic.
20. Demonstrates the safe insertion of
the lumbar puncture needle.

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Evidence of performance Assessment Method of Date
assessment completed

21. Demonstrates the correct


measurement of the CSF pressure
and can discuss the normal values
and significance of altered
pressures.
22. Obtains the necessary CSF
samples and labels the bottles
appropriately.

23. Demonstrates the safe removal of


the lumbar puncture needle and
manages the puncture wound
appropriately.

24. Disposes of equipment


appropriately are according to
local policy.

25. Can perform post-procedure


observations and record as
appropriate.

26. Accurately records the procedure


in the patient’s records.

Methods of attainment of competence.

• Observation of procedure carried out by medical staff


• Observation of procedure carried out by Nurse observed by senior
medical staff
• Observation of procedure by junior medical staff
• Independent performance with medical staff nearby
• Independent performance

The timescale will be dependent on the attainment of confidence and


competency.

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APPENDICES

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Appendix 1

COMPETENCE WITHIN THE PRACTISE OF


A LUMBAR PUNCTURE

Historically, nursing practise has always been a combination of


theoretical knowledge and experience. The knowledge embedded in clinical
expertise and practise is central to the advancement of nursing practise and
the development of nursing science. As nurses have continued to examine
the nature of nursing within personal portfolios, through examples of good
practise and reflective practise, the competencies defining skilled nursing
practise founded by Benner (1984) and later, re-examined by authors such as
Fearon (1998), are continually reclassified.

The introduction of the Scope of Professional Practise (UKCC 1992) again


raised the issue of competence within clinical nursing practise putting an end
to the extended role as it was previously known by allowing nurses to develop
their skills, examine their own competence to practise and determine the
extend to which these competencies continue to be achieved and maintained
at a satisfactory level. For nurses familiar with the mandatory requirements to
maintain professional knowledge and competence (PREP UKCC 1995) a
clinical competency framework seemed a viable concept to assist the process
and provide a framework to support changes within their practise.

Since then, there have been numerous references within later UKCC
documents and more recently within the Making A Difference: A strategy for
Nursing Document (DOH 1999:) and the new NMC Code of Professional
Conduct (NMC 2002).

Discussion of competence is not a new phenomenon. All nursing curricula of


the 1990’s describe competencies and learning outcomes for students. The
NVQ system provided a standard set of competencies nationwide, whilst all
nurses and midwives wanting admission to part or parts of the register
needed to achieve the statutory requirements of the Nurses, Midwives and
Health Visitors Acts of 1979 and 1992. Rules therein specify competencies of
which the practitioner must demonstrate achievement.

True competency – based learning situations require performance criteria and


the fair assessment of evidence (indication of performance) of learning
through a range of practical tasks and recollection of theoretical concepts
which underpin the practise. Attainment of competencies via a structured
framework allows for both experienced and less experienced practitioners to
develop safe, effective practise within a supportive, reflective environment.

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Since nursing and midwifery is a mixture of practical skill and theoretical
knowledge, competencies should identify the skills, knowledge aptitude and
attitude needed to perform as particular skill, task or activity in any clinical
setting.

Competencies therefore need to be realistic, achievable and reflective of


current activity and yet allow for action planning for skills, which may require
refinement. They need allow for acknowledgement of prior learning,
experiences and expertise, whilst providing a framework to ensure that upon
completion, practitioners all possess the agreed level of competence.

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Appendix 2
DISCUSSION / ACTION PLAN

Please use this part of the document to record meetings relating to the
proposed achievement of elements of the clinical competencies.

Date: Assessor:

Elements Discussed:

Planned method of attainment of


skills and assessments
Target date:
If the action plan has not been achieved please state as to the reason
why:

Date: Assessor:

Elements Discussed:

Planned method of attainment of


skills and assessments
Target date:
If the action plan has not been achieved please state as to the reason
why:

Date: Assessor:

Elements Discussed:

Planned method of attainment of


skills and assessments
Target date:
If the action plan has not been achieved please state as to the reason
why:

Signature of Assessor: Signature of Learner:

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Appendix 3
COMPETENCY TO PRACTICE DECLARATION

The professional position

In order to bring into proper focus the professional responsibility and


consequent accountability of individual practitioners, it is the council’s
principles rather than certificates that for which should form the basis for
adjustments to the scope of practice. (UKCC, 1992).

Implications for employers

This change has consequences for managers of clinical practice and


professional leaders of nursing, midwifery and health visiting, who must
ensure that local policies and procedures based upon the principles set out in
this paper an in the councils Code of professional Conduct. Any local
arrangements must ensure that registered nurses midwives and health
visitors are assisted to undertake, and are enabled to fulfil any suitable
adjustments to their scope if practice (UKCC, 1992).

These requirements are met by:

• A position paper on the scope of professional practice for nurses,


midwives and Health Visitors
• A signed Competency Statement detailing preparation nurses have
received to practice
• A standard education package for specific areas for practice
development

The Trust requires the nurse to:

• Read the position paper notes above


• Satisfy themselves that preparation they have received matches the
Neurology standard
• Undertake the education package if the y are undertaking a new skill or
role.
• Refresh their competency to practice by reading updated policies and
procedures as they are issued
• Recognise when their competency requires a refresher due to the lack of
opportunity to use the skill
• Read nursing matters that will highlight significant changes in practice.

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Appendix 4
COMPETENCY TO PRACTICE DECLARATION

I confirm that I am competent to practice ……………………………..(specify


skill/task) and understand that I am responsible and accountable for my own
practice.

I have:

• Undertaken supervised practice (new skill) or demonstrated competent


practice (transferred skill).
• Read the accountability documents and policies and procedures
identified in the package
• Completed the education package (or a similar preparation)

I understand that I am responsible and accountable for keeping my practice


up-to-date, that I am advised to read policies and procedures annually as they
are reviewed and seek to update my practice as necessary.

Authorised by …………………

Clinical Director

Signed …………………….. Date …………………………


Print Name …………………

Director of Nursing

Signed ……………………… Date ………………………..


Print Name …………………

Matron

Signed ……………………… Date ………………………..


Print Name …………………

Signed ………………………… Date ……………………………..

Print Name ……………………

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References

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

Department of Health (1999). Making a Difference: Strengthening the nursing,


midwifery and health visiting contribution to health and health core.
Department of Health. London.

Hickey, J. (1997). The Clinical Practice of Neurology and Neurosurgical


nursing 4th ed. J.B Lippincott. Philodelphia.

NMC (202). Code of Professional Practice, London: United Kingdom Central


Council for Nursing, Midwifery and Health Visiting.

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

Weldon, K. (1988). Anatomy and Physiology of the Nervous system.pp 1-28,


in Neuro-oncology for nurses – Whurr, London.

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