LUMBER PUNCTURE:
Introduction: The cerebrospinal fluid is formed through the chorio villi, in each of the four ventricles of the brain and it circulates freely
through the ventricles , the subarachnoid space and the central canal of the spinal cord . It is then absorbed into the venous circulation via
superior sagittal sinus.
During development the vertebral column outgrows the spinal cord. In adult, the spinal cord ends at the lower border of the first lumber vertebra;
but in the newborn infant it ends slightly at the lower level at the level of the third lumber vertebra . the dural and arachnoid sacs extends up to the
level of the second sacral vertebra and is cavity the CSF. Thus the region between the second lumber vertebra and the second sacral vertebra is
suitable for the withdrawal the CSF , as there is no danger of injury to the spinal cord.
Definition: A lumber puncture is the insertion of a needle into the lumber region of the spine, in such a manner that the needle enters the
lumber arachnoid space of the spinal canal below the level of the spinal cord , so that the cerebrospinal fluid can be withdrawn or a substance can
be therapeutically or diagnostically injected.
Purpose of lumber puncture:
To administered spinal anesthesia before surgery in the lower half of the body.
To administered medication into the spinal cord as in the case of meningitis.
To remove fluid(CSF, blood ,pus, etc) contained in the subarachnoid space, thereby reducing the intracranial pressure.
To remove a sample of CSF for laboratory exam inations order to diagnose disease.
To measure the pressure of CSF and to determine whether the lumber sub arachnoid space is in communication with the ventricles of
brain.
To remove CSF and to replace it with air, oxygen or radio opaque substances for diganostic X- rays in order to locate tumors or other
brain disorders.
Complication:
Injury to the spinal cord and spinal nrves.
Infection introduced into the spinal cavity which may give rrise to meningitis.
Leakage of CSF through the puncture site and lowering the intracranial pressure and may cause post puncture
headaches.
Damage to the intervertebral disks.
Local pain , edema and hematoma at the puncture site.
Temperature elevation .
Rapid reduction in the intracranial space.
Site of the lumber puncture and the Positioning of the patient:
In lumbar puncture a needle is inserted into the lumbar area (L3-4) is the preferred.
Patient Positioning
The spinal cord ends at L1/L2 level in adults.
Place one hand on each ASIS and move medially to the midline, locating the spine. This is L4 and LP may be
performed through the 2 spaces above (L3/L4 or L2/L3) or one space below (L4/L5).
LP can be performed with the patient either lying down or sitting up. Choose the position that you and the patient are
most comfortable with.
Optimise patient position to increase the interspinous distance as much as possible: flex the spine and hips.
Perform LP on infants and unconscious patients, with the patient lying down, and an assistant maintaining spinal
flexion.
Sitting
This position generally makes it easier to identify anatomical landmarks and planes.
Sit the patient on a firm surface.
Patient should lean forward, and can hug a pillow on a table at the right height to flex (not extend) the back.
Lift the patient’s legs by putting their feet on a stool or chair and flex the hips to above 90 degrees.
If pressure measuring is required, lie the patient on their side (after successful needle insertion) with assistance and then
open the tap to measure the pressure.
Lying down
Patient should be lying in the lateral decubitus position.
Ensure the vertical plane of the patients back is perpendicular to the bed.
Flex knees and hips so that knees are close to the chest.
While flexion of the neck is often taught as important, evidence suggests that this has no effect of the size of the
interspinous opening and may be uncomfortable for the patient.
Postioning correctly is all about increasing the interspinous distance as much as possible.
Preparation of Articles:
A sterile tray containing:
LP needles- 2 sizes with the their stilette.- to aspirate the fluid
Sponge holding forceps.-to clean the area of body
Syringes ( 5ml) with needles to give anaesthesia.-to give anesthesia
Small bowl- to take cleaning lotion.
Specimen bottle-to collect the fluid
Cotton balls, gauze pieces and cotton pads- to cover the the puncture area
Gloves , gown and masks-to maintain the aspectic technique
Dressing towels or slit towel- to maintain the aspectice technique
Three way adapter , manometer and tubing to measure the pressure of the CSF if required.
An unsterile tray containing:
Mackintosh and towel.
Kidney tray and paper bag.
Spirit , Iodine, tr. Benzoin, etc
Lignocaine 2 percent
Sterile normal saline to fill in the manometer.
Adhesive plaster and scissors.
.Instructions:
1. Strict aseptic techniques are to be followed.
2. Patient should be placed in a position that will widen the intervertebral.
3. Uncooperative patients and children are to be restrained during the procedure.
4. The patient should be placed near the edge of the bed.
5. The LP needles should be sharp, small in size and not curved.
6. After the lumber puncture,the patient should lie flat on the bed.
7. The CSF collected should be sent to the laboratory without any delay.
8. Drugs to be injected must be warmed to body temperature and it should be injected very
slowly.
9. Local anaesthesia may be given subcutaneously at the injection site prior to the
procedure or a patch impregnated with lidocaine is applied to the skin 3 hours before
the procedure.
NURSING RESPONSIBILITY FOR LUMBAR PUNCTURE:
Preliminary assessment-
Assess the condition of the patient
Assess the vitals of the patient
Check the blood reports of the patient
Check the past history of the patient
Preparation of the patient:
Explain the procedure to the patients
Obtain informed consent.
Monitor vitals before the procedure.
Prepare the skin as for a surgical procedure. Skin is disinfected with spirit and iodine just
before doing the spinal puncture.
Put on clean and loose garments.
Arrange the articles at the bedsides table.
Fold back the upper garments above the waist line and the lower garments below the hip.
Protect the bed with mackintosh.
STEPS OF PROCEDURE
o The patient sits down on the edge of the table or lies down on the side, with the knees drawn up
to the chest.
o The doctor marks the area, where the puncture will be made (with a pen)
o The area is cleaned with some soap, before being draped with a sterile towel
o Anesthesia is applied on to the skin
o A long and thin needle is inserted in the spinal canal and the stylet is removed so that the fluid is
o collected. In some cases, the doctor may need to move the needle farther in or at a different
angle, to get the fluid in the spine.
o A device known as a manometer is connected to the needle, to measure the pressure of the fluid.
Patients who are lying down may be asked to straighten their legs at this point.
Once the fluid is collected, the final pressure reading is taken, the needle is removed and the site of
the puncture is cleaned and bandaged.
The samples of the fluid are collected, they are sent to a lab, to check for any abnormalities.EDURE
After care of the procedure:
As soon s the needle is withdrawn , Seal the puncture site to prevent leakage of CSF.
Place the child comfortable on the bed in a supine position for 12 to 24 hours.
If the patient develops post puncture headache , The following precaution are taken.
Darken the room.
Give plenty of oral fluids .
Administered analgesics.
Raise the foot end of the bed.
Watch for Patient’s color, Pulse , respiration, blood pressure and other signs of complication.
Record the procedure on the patient’s charts with date and time.
The specimens of CSF collected should be sent to the laboratory without any delay with proper labels
and requisition.
If there are no complication observed , the patient may be allowed to be upright after 8-12 hours.
AFTER PROCEDURE CARE OF ARTICLES
Replace the articles from patient side
Collect the sharp needles in the white container
Clean the articles with water and pack them for sterilization
NURSING DIAGNOSIS -:
Pre procedure diagnosis
Anxiety related to procedure
Lack of knowledge related to frequent questioning
Post procedure diagnosis
Acute pain related to lumber puncture as evidence by the verbalization of the patient
Impaired physical mobility related to puncture as evidence by less movements.
Risk for infection related to surgical procedure.
NURSING RESPONSIBILITY
Assess the condition of the patient .
Give the comfortable position to reduce the pain
Administer the analgesics as prescribed by doctor
Give the information regarding the procedure and reduce the anxiety by introducing with other
patient who had undergone the same procedure
Advice the patient to take small walks after the few hours of the procedure
Maintain the aseptic techniques during and after procedure .
BIBLIOGRAPHY
Ansari Javed, Comprehensive Medical Surgical Nursing ,published by Pee Vee, 2011 edition , page no-
573-586.
Suddarth’s & Brunner , textbook of medical surgical nursing , published by Lippincott Williams &
Wilkins , 11 edition, page no-853
Black M Joyce; Medical-Surgical Nursing; vol-II; Elsevier; 7th edition; pge no.- 1335-1355.
