ASSIGNMENT

ON

LUMBAR PUNCTURE

Submitted by submitted to

Jinsi.P.G Dr.Sindhu .C.Philip

1st year MSc Nursing Associate Proffessor

TMM.College of Nursing TMM.College of Nursing

Submitted on:
LUMBAR PUNCTURE

Definition: -

Lumbar puncture is the introduction of a hollow needle into

the subarachnoid space of the spinal canal and usually in the

lumbar region.

Purposes:-

 To withdraw cerebrospinal fluid to relieve pressure.

 To secure specimens of C. S. F. for diagnostic purpose.

 To inject sera or drug in the treatment of the diseases.

 To inject spinal anesthetic.

 To introduce an opaque liquid or air or oxygen before taking

an X-ray for diagnosis of cord and brain lesions.

 To test the pressure of the spinal fluid under different

conditions.

When opaque substances are injected and X-ray pictures are

taken, it is known as MYELOGRAM. When air or oxygen is

injected the procedure is called Pneumoencephalogram.

Preparation of the patient:-

The lumbar region should be washed well with soap and

water (shaved if necessary) wiped and dried. Then apply some

antiseptics as Tincture iodine or spirit, and covered with sterile

towel and fix with binder. L. P. is done between the 2nd and 3rd or

4th and 5th intervertebral space because the spinal cord ends at the

level of the 1stlumbar vertebra.

Position of the Patient:-

Put the patient in right or left lateral position near the edge of

the bed (according to the convenience of the physician). Have his

back arched so that his head is almost touching his knees, instructs

the patient to draw his knees up towards the chest. In any way,

back should be arched to widen the intervertebral space. Nurse

should help him to lie in the proper position.

The treatment can be done in sitting position also. A table or

chair must be provided for the patient to lean on, so as to arch his

back and the nurse should support by standing in front of the

patient.
Requisites:-

A Screen to provide privacy.

Unsterile tray containing:

1) Small mackintosh and towel to protect the bed,

2) Bottles of Tincture iodine and spirit, or any antiseptic to clean

the skin, Tr. Benzoin

3) Bottles of local anesthetic as novacaine 1 percent.

4) Bottle of drug or serum in case of introduction into the spinal

column.

5) Kidney tray.

6) Sterile normal saline in a bottle.

Sterile tray containing:-

1) Sterile towels 2 (one to wipe hands of the Doctor and one

started towel for the patient)

2) Small bowls 2 (one for local anesthetic, and one for cotton

swabs)

3) 2cc syringe and needles for giving local anesthetic (if

necessary)

4) Spinal needles 2 (of different sizes) with fitting stiletto

 5) Sponge holding forceps.

6) Manometer (in case pressure is to be noted)

7) Three way adaptor -1

8) Sterile dressings to apply over puncture

9) Sterile bottles with cork (to obtain specimens) or test

tubes.

10) Sterile gloves and mask.

11) One syringe and needle in case drug has to be introduced.

Procedure:-
Explain the procedure to the patient.
Provide privacy.
Assemble the equipment to the bedside.

Protect the bed with mackintosh and towel.

Put the patient in position as explained before, at the edge of

the bed. Fold the clothing down to the hip so that the back is free

from clothes. Cover chest with a small blanket or towel. Explain

that there will be certain amount of pain which is unavoidable. He

should keep himself without shaking.

If the patient is in a sagging bed a board is placed under the

bed to get firmness and to get the correct spinal curvature. Doctor
gets ready (washing his hands thoroughly and dressed in sterile

gloves and mask). Provide a stool to sit if necessary. The skin area

at the lumbar region is cleaned and painted with Tincture iodine

using forceps, and the forceps is discarded in the kidney tray.

After the skin is prepared, cover the part with a' sterile towel

or a Fenestrated sheet (a sheet with a hole in the middle). Local

anesthetic is given sometimes with 2 cc syringe and needle by

injecting novocaine 1 percent.

Then the lumbar region is punctured with the spinal needle

usually done at the lumbar intervertebral space.

If specimen is to be collected it should be taken as soon as

begins to drop-from the needle, without touching the needle. If

pressure is to be noted, Manometer is attached to the needle, to

note the pressure. When a serum or any drug is to-be injected, the

same quantity of spinal fluid is withdrawn and an equal quantity

of drug is injected. Usually 20 to 50 cc of serum is injected.

After the removal of fluid or introduction of therapeutic

drug the needle is closed with the stilette (sometimes doctors use
their gloved hand to close the needle) and then the needle is

withdrawn and sterile dressing applied over the wound.

Throughout the procedure it is the nurse's duty to watch the

patient carefully. The color, pulse and respiration should be

watched. Any complaint that the patient made such as headache

or nausea, should be reported immediately to the surgeon. After

the treatment, the patient usually is put in the recumbent position

with the foot raised particularly if a serum or drug is introduced

or otherwise ordered by the physician. The patient should stay

in bed at least 24 hours after a lumbar puncture.

Any specimen taken should be labeled properly and send for

examination.

Record the treatment, date, time, amount, character of spinal

fluid withdrawn, its color (cloudy or bloody) whether it is drawn

with pressure and discomfort shown by the patient. Any drug or

serum injected into the spinal column, its quantity and nature,

whether the specimen has been sent to the laboratory for examin-

ation and by whom it was done.

N.B.If the patient is child or an infant it should be restrained

to prevent it from moving its limbs at the time of the procedure.

Sometimes the patient's B. P is to be checked at frequent intervals.

Normal C. S. F is clear, colorless. Usually 1 or 2 drops per

second flows from the needle. But under high pressure it may spurt

out. Pressure at the jugular veins causes increase in pressure.

Sometimes the first fluid flows from the needle may the blood

stained. In inflammation of the meninges, the C. S. F. may show an

increase in pressure. Normal pressure of spinal fluid is 100 to 130

mm of water and specific gravity is 1006.

In acute infections, the fluid may be cloudy or yellow in color

or turbid because of the presence of pus. Blood usually dark in

color may indicate injury to the spinal cord above the site of

puncture.

CONTRAINDICATIONS

Lumbar puncture should not be performed in the following

situations:

 Idiopathic (unidentified cause) increased intracranial

 pressure (ICP)

 Rationale: lumbar puncture in the presence of raised

ICP may cause uncal herniation

 Exception: therapeutic use of lumbar puncture to reduce

ICP,only if obstruction (for example in the third

ventricle of the brain) has been ruled out

 CT brain, especially in the following situations

 Age >65

 Reduced GCS

 Recent history of seizure

 Focal neurological signs

 Abnormal respiratory pattern

 Hypertension with bradycardia and deteriorating

consciousness

 Ophthalmoscopy for papilledema

 Bleeding diathesis (relative)

 Coagulopathy

 Decreased platelet count (<50 x 109/L)

 Infections
 Skin infection at puncture site

Vertebral deformities (scoliosis or kyphosis), in hands of an

inexperienced physician

ADVERSE EFFECTS

HEADACHE

Post spinal headache with nausea is the most common

complication; it often responds to pain medications and infusion of

fluids. It was long taught that this complication can be prevented

by strict maintenance of a supine posture for two hours after the

successful puncture

Contact between the side of the lumbar puncture needle and a

spinal nerve root can result in anomalous sensations (paresthesia)

in a leg during the procedure; this is harmless and people can be

warned about it in advance to minimize their anxiety if it should

occur.

OTHERS

Serious complications of a properly performed lumbar puncture are

extremely rare. They include spinal or epidural bleeding, adhesive

arachnoiditis and trauma to the spinal cord or spinal nerve roots

resulting in weakness or loss of sensation, or even paraplegia. The

latter is exceedingly rare, since the level at which the spinal cord

ends (normally the inferior border of , although it is slightly lower

in infants) is several vertebral spaces above the proper location for

a lumbar puncture . There are case reports of lumbar puncture

resulting in perforation of abnormal dural arterio-venous

malformations, resulting in catastrophic epidural hemorrhage; this

is exceedingly rare.

BIBLIOGRAPHY

1) Theresamma. CP., 2006 “Fundamentals of Nursing

Procedure manual for General nursing & Midwifery Course”.

1st Edition, Jaypee Brothers, Medical Publishers (p) Ltd.,

New Delhi.p:243-246.

2) Nancy Sr., 2002, “Principles & Practice of Nursing &

Nursing arts procedures”, 5th edition published & Printed by

N.R. Publishers, House, Indore.p:360-368.

3) LC Gupta US, Sahu, Priya Gupta, 2007 “Practical Nursing

Procedure”. 3rd Edition, Printed at Para Offset Pvt. Ltd. New

Delhi; p: 322-327.
4) Sagunthala Sharma ‘Birpuri’ 1997 “Principles and Practice

of Nursing” 1st edition Printed at Lordson Publishers (P) ltd.,

New Delhi. p. 401-403.

5) Brunner &Siddarths, 2001, “Text book of Medical- surgical

Nursing”- 12th edition, volume2, published by Wolters

Kluwer (India) pvt. Ltd New Delhi, Page No: 333-336

6) Lewis, collier, Heitkemper, 1996 “Medical–surgical

Nursing”, 4th Edition, Mosby year book- Inc USA, Page no:

471-478