University of Duhok College of nursing

Lumbar Puncture

Prepared by students :Karwan AkbarKeser Soliman Mohammad Taha

Anatomy What is the Lumbar Spine?

The lumbar spine - or low back - is the third major region of the spine . Most people have five bones or vertebrae in the lumbar spine, although it is not unusual to have six. Each vertebra is stacked on top of the other and between each vertebra is a gel-like cushion called a disc (intervertebral disc). The discs help to absorb pressure, distribute stress, and keep the vertebrae from grinding against each othe

Lumbar Puncture

Definition :Lumbar puncture is the insertion of a specialized needle into the lumbar subarachnoid space to gain access to the cerebrospinal fluid.

Indication and rationale for lumbar puncture

1-to obtain a sample of cerebrospinal fluid for investigative and diagnostic purposes, e.g.:

--bacteriological investigation for patients suspected of having meningitis or encephalitis

--cytological investigation for patients suspected of having a malignant tumors

2-to identify the presence of blood in the cerebrospinal fluid following (trauma or a suspected subarachnoid hemorrhage)

3-to introduce radio-opaque fluid into the subarachnoid space

(For radiographic investigation)4-to identify raised intraspinal /intracranial

pressure and provide relief (if appropriate, by removing some of the cerebrospinal fluid)

5-to introduce intrathecal medication such as (cytotoxic agents or antibiotics

Indication and rationale for lumbar puncture

Cerebrospinal fluid

CSF is derived from blood and is produced in the ventricles of the brain. It passes to the subarachnoid space through tiny canals. In the subarachnoid space it flows down the spinal cord and returns to the space surrounding the brain.

CSF functions

1) Acts as a shock absorber, protecting the central nervous system (the brain and cord) against trauma;

2) Helps to compensate for pressure changes within the skull (for a limited time), for example when a space occupying lesion (SOL) develops – this is achieved through changing in the rate of CSF production or absorption;

3) Helps to keep the brain’s biochemical environment stable by providing some nutrition and removing waste metabolites for excretion.

Normal values

Normal CSF is mostly water, but it also contains:

A. Protein (15-45mg per 100ml); B. Glucose (40-80mg per 100ml); C. Lactate (1.1-1.9mmol/l); D. Lymphocytes (0-5 cells per mm3). E. Normal CSF pressure measured with a

manometer is 60-160mm of water.

Indications

1) Primary indication for emergency spinal top is possibility of CNS infection

2) The second indication for on emergency spinal puncture is suspected spontaneous subarachnoid hemorrhage

3) To measure the pressure of CSF the pressure range is 60/180 mm/H2O

4) To inject dye or air in to subarachnoid space preparatory to toke X-ray of brain and spinal cord

5) To inject medication or anesthetic directly in to subarachnoid space

6) To remove CSF to relive under pressure

Contraindication

1) Obsolete contraindication in the presence of infection in the tissues near the puncture site

2) Relatively contraindication in presence of SOL or increased LCP

3) Caution sdvisecal when lateralizing signs or signs of uncle herrniation

Complications

1. Headache2. Meningitis3. Epidural or subdural abscess4. Bleeding into the spinal canal5. C.S.F leakage 6. Local pain caused by nerve root irritation 7. Edema and hematoma of the puncture site 8. Fever 9. Tonsil or herniation and modularly compression

Equipments

o Trolleyo Sterile dressingo Sterile drapeso Sterile surgical gloves for the medical practitionero Lumbar puncture needles of appropriate sizeo Spinal manometero Two-way tapo Alcohol-based antiseptic lotion for cleansing the

skin

o Local anesthetic and equipment for its administrationo Syringe and needle for administering the local anesthetico Sterile dressing ,e.g. Airstrip or plastic sealant sprayo Three sterile specimen containers appropriately labeled

1,2 and 3, completed laboratory forms, and a plastic specimen bag for transportation .These may be required for three separate samples of cerebrospinal fluid for microbiological ,biochemical and cytological investigation

o Receptacle for disposable itemso Sharps box.

Equipments

Preprocedure

1. Determine whether written consent for the procedure has been obtained

2. Explain the procedure to the patient and describe sensation that are likely during the procedure (ie, a sensation of cold as the site is cleansed with solution ,a needle prick when local anesthetic is injected)

3. Determine whether the patient has any questions or misconception about the procedure; reassure the patient that the needle will not enter the spinal cord or cause paralysis.

4. Instruct the patient to void before the procedure.

 Procedure

o The patient is positioned on one side at the edge of the bed or examining table with back toward the physician ; the thighs and legs are flexed as much as possible to increase the space between the spinous processes of the vertebrae ,for easier entry into the subarachnoid space

o A small pillow may be placed under the patients head to maintain the spine in a horizontal position; a pillow may be placed between the leg to prevent the upper leg from rolling forward.

o The nurse assists the patient to maintain the position to avoid sudden movement, which can produce a traumatic (bloody)tap.

o The patient is encouraged to relax and is instructed to breathe normally, because hyperventilation may lower an elevated pressure.

o The nurse describes the procedure step by step to the patient as it proceeds.

o The physician cleanses the puncture site with an antiseptic solution and drapes the site.

 Procedure

o The physician injects local anesthetic to numb the puncture site, and then inserts a spinal needle into the subarachnoid space through the third and fourth or fourth and fifth lumbar interspace.

o A specimen of CSF is removed and usually collected in three test tubes, labeled in order of collection. A pressure reading may be obtained .The needle is withdrawn.

o The physician applies a small dressing to the puncture site.

o The tubes of CSF are sent to the laboratory immediately.

 Procedure

Post procedure

o Instruct the patient to lie prone for 2 to 3 hours to separate the alignment of the Dural and arachnoid needle punctures in the meanings, to reduce leakage of CSF.

o Monitor the patient for complications of lumbar puncture; notify physician if complications occur.

o Encourage increased fluid intake to reduce the risk of post-procedure headache. And protein testing the specimens should be sent to the laboratory immediately because changes will take place and alter the result if the specimens are allowed to stand.

References Internet sites http:// www.google.com http:// www.wekipedia.org

Books1.book: Brunner and suddarths text book of medical-surgical nursing edited by :Suzanne c.smeltzer Brenda G.Bare Janice L.Hinkle Kerry H.cheever pages: unit14 ,chapter60 ,page 2157

References2. Book: Clinical nursing practices Edited by: Elizabeth M.jamieson Lesley A. Whyte Janice M.mchal pages: practice 23,page( 199_201)

thanks for all