Lumbar Puncture - Assisting Guidelines - Adult Only



Canberra Hospital and Health ServicesClinical ProcedureLumbar Puncture – Nurse Assisting Guidelines – Adults OnlyContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc468703009 \h 1Purpose PAGEREF _Toc468703010 \h 2Alerts PAGEREF _Toc468703011 \h 2Scope PAGEREF _Toc468703012 \h 2Section 1 – Assisting Lumbar Puncture PAGEREF _Toc468703013 \h 2Implementation PAGEREF _Toc468703014 \h 5Related Policies, Procedures, Guidelines, PAGEREF _Toc468703015 \h 5References PAGEREF _Toc468703016 \h 5Search Terms PAGEREF _Toc468703017 \h 6PurposeThe purpose of this Clinical Procedure is to outline the roles and responsibilities when assisting with a lumbar puncture procedure.A lumbar puncture is performed to collect and examine cerebrospinal fluid (CSF). CSF is collected by inserting a needle into the lumbar subarachnoid space and withdrawing the CSF. A lumbar puncture is performed for: Diagnostic purposesAdministration of intrathecal medicationsMeasuring CSF opening pressure with a manometerBack to Table of ContentsAlertsIf a lumbar puncture is performed for Creutzfeldt-Jakob Disease (CJD), single use drapes and equipment must be used. Refer to: Communicable Diseases Network Australia Creutzfeldt-Jakob Disease Guidelines 2013 located on the Policy Register. Back to Table of ContentsScopeThis document pertains to adult patients that require a lumbar puncture at Canberra Hospital.This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice:Medical OfficersRegistered Nurses and MidwivesStudent Nurses and Midwives working under supervisionBack to Table of ContentsSection 1 – Assisting Lumbar PunctureEquipmentDressing towels x 2Fenestrated drape and basic dressing packLumbar puncture set or, if preferred, a 22 gauge lumbar puncture needle, manometer, specimen jars x 3 and glucose tubeSpare lumbar puncture needlesGown & sterile glovesPersonal protective equipment (PPE): gown, protective glasses / goggles or face shieldDressing e.g. occlusive dressingLocal anaesthetic, lignocaine 1% ampoules x 2Drawing up needle x 2 10 ml syringe x 2Alcoholic chlorhexidine 2% skin preparationPatient identification labelsSedation and anti-emetic if requiredIV set-up kit if requiredUnderpad to protect bed linenSharps containerClinical waste binCytotoxic PPE and waste bin/sharps container if patient is receiving cytotoxic medications or chemotherapy ProcedureEnsure relevant admission process is completed by Clerical, Medical Office and Nurse if requiredPatient identification check and ID label secured, as per CHHS Patient Identification policyRecord baseline observations and neurological statusHave the patient empty their bladder before the procedure is performed Ensure privacyHave patient change into a hospital gownEnsure the medical officer explains the procedure to the patient, outlines possible post-procedure symptoms, and obtains verbal consent.Insert IV cannula if required for sedationPerform hand hygieneObtain a procedural trolley, clean all surfaces with detergent impregnated wipesPerform hand hygienePrepare equipment on the aseptic fieldPosition the patient in the left lateral position with flexed back close to the edge of the bed, knees flexed, neck flexed, and arms under knees, or position as requested by the medical officerArrange patient’s lower limb clothing to expose lower lumbar areaAdminister sedation if ordered by the medical officer and document in the patient’s medication chart. Patients pulse oximetry should be monitored and recorded if sedation is administered.Assist the medical officer as required during the procedureStand in front of the patient and reassure the patient during the procedure. Encourage the patient to breathe normally and relax as much as possible to prevent excessive muscle tension. Rationale: Excessive muscle tension may result in a false reading of CSF pressure Once the needle is in the subarachnoid space, assist the patient to relax and extend neck and legs, as directed by the medical officer. Otherwise, the patient must remain in the required position during the procedureThe nurse may occasionally be requested to apply pressure over the jugular veins for the Queckenstedt test during the procedure. This test is used to determine whether or not the flow of CSF is blocked in the lumbar subarachnoid space. It is performed by measuring the CSF pressure and observing the change in pressure after manual compression of the jugular veins. During the procedure continually observe patient's colour, respiration and level of consciousness. If multiple lumbar puncture attempts are required, it is advisable that patients’ blood pressure be monitored and recorded (e.g. 5 minutely or as directed by the medical officer). Note: During the procedure patients may experience backache (this can last several days) and shooting pain down the legs. It usually settles once the needle is removed Ensure sterile dressing is secured over the puncture site Ensure equipment is discarded appropriately Perform hand hygieneEnsure pathology request form is completed by the medical officer with the patient’s full name, date of birth and MRN. Ensure specimen labels are completed by the medical officer (as per Patient Identification procedure)and placed on the following specimens: CSF specimens x 3, glucose tube, along with any blood vials by the medical officer performing the procedureConfirm patients’ identification by verbal confirmation with patient, patient’s identification band, the Pathology Request form, and labelled specimens Assist the patient to a supine position with maximum one head pillow for the time prescribed by the medical officer Observe the puncture site half hourly for a minimum of one hour (or as time specified by consultant) for CSF leakage, swelling or bleeding. Notify the medical officer if signs are evidentIf patient required sedation, perform vital signs every 15 minutes for one hour post procedureAdminister analgesic and/or antiemetic as requiredEnsure documentation of the procedure is recorded in the patient's clinical record. Completed nursing documentation as required Provide post procedural patient education on potential side effects and management.Headache: Regular Analgesic, lying down and increase fluid. Rationale: headache is caused by leakage of CSF from puncture site. Headaches can be exacerbated by being in an upright position and is relieved by lying down.Nausea and Vomiting: Administer rm patient to seek medical advice if they experiences limb weakness or numbness, incontinence, draining of blood or persistence pain at insertion site, and persistence headaches. Back to Table of ContentsImplementation This procedure will be:Discussed at in-service educationDistributed to staff via emailAvailable on ACT Health Intranet Policies and ProceduresBack to Table of ContentsRelated Policies, Procedures, Guidelines, Policies and Standard Operating ProceduresCanberra Hospital and Health Services Standard Operating Procedure: Aseptic Non Touch Technique, Document Number CHHS14/011Canberra Hospital and Health Services Clinical Procedure: Healthcare Associated Infections, Document Number CHHS15/072Consent and Treatment PolicyCanberra Hospital and Health Service: Patient Identification and Procedure Matching, Document Number CHHS14/052Canberra Hospital and Health Services Clinical Policy: Medication Handling, Document Number CHHS15/086Canberra Hospital and Health Service Procedure: Code Blue Response Procedure- Adults, Paediatrics, Neonates, Document Number CHHS14/045 Back to Table of ContentsReferencesSmith, S F., Duell D J., Martin B C., (2004) Clinical Nursing Skills-Basic to Advanced, 6th Edition, Pearson Education, New Jersey, Chapter 21 Diagnostic Procedures, Fluid Analysis and Microscopic Studies, pages 689-690. Australian Government Department of Health, 2013, Infection Control guidelines for the prevention of transmission of Infectious Diseases in the healthcare setting. Accessed 5/7/16; <; John Hopkins Medicine, Health Library, Lumbar Puncture. Accessed on 4/7/16; < \l "Contents"Back to Table of ContentsSearch Terms Lumbar Puncture, needle, CJD, Queckenstedt test, CSF pressure, and CSF leak.Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 8 August 2016 ................
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