COMBINED (P.G.

) INSTITUTE OF MEDICAL SCIENCES &

RESEARCH
DEHRADUN, UTTARAKHAND

Medical Surgical Nursing

Procedure
On
Lumber Puncture
Submitted To Submitted By
Mohamad Dildar
M.Sc Nursing 1st Year

Submitted On
 Lumbar puncture, assisting
Introduction

Lumbar puncture involves the insertion of a sterile needle into the subarachnoid space
of the spinal canal, usually between the third and fourth lumbar vertebrae. This
procedure is performed to help determine the presence of blood in cerebrospinal fluid
(CSF), obtain CSF specimens for laboratory analysis, inject dyes for contrast in
radiologic studies, or administer drugs or anesthesia. The procedure also involves
measuring the pressure of CSF, which flows freely between the brain and the spinal
column.

Performed by a practitioner with a nurse assisting, lumbar puncture requires sterile

technique and careful patient positioning. This procedure is contraindicated in patients
with increased intracranial pressure with mass effect, lumbar deformity, a platelet count
less than 50,000/mm3, or an International Normalized Ratio greater than 1.5 as well as
in those who are receiving anticoagulants 1  or who have an infection at the puncture
site. 2

Equipment
 Overbed or procedure table

 Sterile gloves

 Cap

 Mask with face shield or mask and goggles

 Sterile gown

 Antiseptic solution

 Sterile gauze pads

 Antiseptic pads

 Sterile fenestrated drape

 Syringe

 Sterile needle

 Local anesthetic (usually 1% lidocaine without epinephrine)

 Spinal needle with stylet 3

  Three-way stopcock

 Manometer

 Small adhesive bandage

 Four sterile collection tubes with caps

 Labels

 Light source

 Sterile marker

 Sterile labels

 Laboratory transport bag

 Optional: patient-care reminder, prescribed analgesia or anxiolytic, laboratory

request form

Disposable lumbar puncture trays contain most of the needed sterile equipment.

Implementation
 Verify the practitioner's order.

 Gather the equipment and take it to the patient's bedside.

 Confirm that the practitioner has obtained written informed consent and that the
signed consent form is in the patient's medical record.

 Perform a preprocedure verification to make sure that all relevant

documentation, related information, and equipment are available and correctly
matched to the patient's identifiers.
 Verify that ordered preprocedure laboratory and imaging studies are complete
and that the results are in the patient's medical record. Notify the practitioner of
any unexpected results.

 Perform hand hygiene.

 Confirm the patient's identity using at least two patient identifiers

 Provide privacy.

 Explain the procedure to the patient to ease anxiety and ensure cooperation.
 Inform the patient that he may experience a headache after lumbar puncture,
but reassure him that his cooperation during the procedure minimizes this effect.

 Check the patient's history for allergies to the local anesthetic, antiseptic
solution, analgesia, or sedation.

 Instruct the patient to void before the procedure.

 If prescribed, administer analgesia or anxiolytic medication using safe medication

practices to promote comfort and decrease anxiety so that the patient can
maintain proper positioning during the procedure.
 Perform hand hygiene.

 Open the equipment tray on an overbed or procedure table, being careful not to
contaminate the sterile field when you open the wrapper.

 Label all medications, medication containers, and other solutions on and off the
sterile field.

 Provide adequate lighting at the puncture site.

 Raise the patient’s bed to waist level when providing patient care to prevent
caregiver back strain.
 Position the patient in a sidelying or sitting position according to the
practitioner's preference. 

 For a sidelying position, have the patient lie on his side at the edge of the bed,
with his chin tucked to his chest and his knees drawn up to his abdomen (as
shown). Make sure that the patient's spine is curved and his back is at the edge
of the bed. This position widens the spaces between the vertebrae, easing
insertion of the needle.  To help the patient maintain this position, place one of
your hands behind his neck and the other hand behind his knees, and pull
gently. Hold the patient firmly in this position throughout the procedure to
prevent accidental needle displacement. 
 For a sitting position, have the patient sit on the edge of the bed, leaning over
the bed table.

 Reemphasize the importance of remaining as still as possible to minimize

discomfort and trauma.
 Perform hand hygiene.

 Put on a cap, a mask with an eye shield, a sterile gown, and sterile gloves.

 The practitioner cleans the puncture site with antiseptic solution and allows it to
dry to prevent contamination by the body's normal skin flora.  He then drapes the
area with a fenestrated drape (as shown below) to provide a sterile field.  (If the
practitioner uses antiseptic sponges instead of sterile gauze pads, he may
remove his sterile gloves and put on another pair to avoid introducing antiseptic
solution into the subarachnoid space with the lumbar puncture needle. )
 

  Clinical alert:  Studies suggest that chlorhexidine is neurotoxic; its use as an

antiseptic agent for skin preparation before lumbar puncture is controversial.

 Conduct a time-out before starting the procedure to confirm that the correct
patient, site, positioning, and procedure have been identified, as applicable.
 If the equipment tray doesn't include an ampule of anesthetic, disinfect the
injection port of a vial of anesthetic with an antiseptic pad and then allow it to
dry completely. Then invert the vial 45 degrees so that the practitioner can insert
a 25G needle and syringe and withdraw the anesthetic for injection. 

  Clinical alert:  Dedicate multidose medication vials to one patient whenever

possible to reduce the risk of viral hepatitis transmission and other infections.

 Before the practitioner injects the anesthetic, tell the patient that he'll experience
a transient burning sensation and local pain. Ask him to report other persistent
pain or sensations because they may indicate irritation or puncture of a nerve
root, which requires repositioning of the needle.
 When the practitioner inserts the sterile spinal needle into the subarachnoid
space (usually between the third and fourth lumbar vertebrae, as shown),
instruct the patient to remain still and to breathe normally. If necessary, hold the
patient firmly in position to prevent sudden movement that may displace the
needle.
 Closely monitor the patient for adverse reactions, such as headache, nausea,
vomiting, elevated heart rate, pallor, and clammy skin. Immediately alert the
practitioner to any significant changes.

 If the practitioner is performing lumbar puncture to administer contrast media for

radiologic studies or spinal anesthesia, he injects the dye or anesthetic at this time.

 When the needle is in place, the practitioner attaches a manometer with a three-
way stopcock to the needle hub (as shown below) to read CSF pressure. If ordered,
help the patient extend his legs to provide a more accurate pressure reading.

 The practitioner then detaches the manometer and allows CSF to drain from the
needle hub into the collection tubes, collecting 2 to 3 mL in each tube. After collection,
mark the tubes in sequence, securely cap them, and label them in the presence of the
patient to prevent mislabeling. 15
 The practitioner removes the spinal needle and then applies a sterile occlusive
dressing to the puncture site.

 Discard used supplies in appropriate receptacles.

 Remove and discard your gloves and other personal protective equipment

 Perform hand hygiene.

 Return the patient's bed to the lowest position to prevent falls and maintain
patient safety.
 Place the CSF specimens in a laboratory transport bag and immediately send
them to the laboratory with the necessary completed laboratory request forms.
Do not refrigerate collected CSF specimens for later transport because
refrigeration alters the results. 37
 Perform hand hygiene.

 Document the procedure.

Special Considerations
 Monitor CSF test results and report critical results to the practitioner within the
time frame determined by your facility to prevent treatment delays.

 Be aware that, after the procedure, the practitioner may order the patient to
remain flat or at a 30-degree angle for 30 minutes to up to several hours. Check
the practitioner's orders for the specific position and duration.

 Encourage the patient to drink fluids after the procedure to restore spinal fluid
volume and reduce the risk of headache.
 Check the puncture site for redness, swelling, and drainage every hour for the
first 4 hours and then every 4 hours thereafter for the first 24 hours.

 If CSF pressure is elevated, assess the patient's neurologic status every 15

minutes for 4 hours. If he remains stable, assess him every hour for 2 hours and
then every 4 hours thereafter, or according to the pretest schedule. Notify
practitioner of changes in neurologic status. 

 For patients who are obese, the practitioner may use ultrasound during the
procedure to help determine accurate needle placement.

Complications
Headache is the most common adverse effect of lumbar puncture. 2  Other adverse
effects may include a reaction to the anesthetic, meningitis, epidural or subdural
abscess, bleeding into the spinal canal, CSF leakage through the dural defect remaining
after needle withdrawal, local pain caused by nerve root irritation, edema or hematoma
at the puncture site, transient difficulty voiding, and fever. The most serious
complications of lumbar puncture, although rare, are tonsillar herniation and medullary
compression.

References

(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)

1. Siegel, J. D., et al. (2007). "2007 guideline for isolation precautions: Preventing
transmission of infectious agents in healthcare settings" [Online]. Accessed
September 2016 via the Web
at http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf (Level II) 

2. Johnson, K. S., & Sexton, D. J. (2016). Lumbar puncture: Technique, indications,

contraindications, and complications in adults. In: UpToDate, Aminoff, M. J., &
Wilterdink, J. L. (Eds.). Accessed September 2016 via the Web
at http://www.uptodate.com/
UpToDate Full Text

3. Armon, C., & Evans, R. W. (2005). Addendum to assessment: Prevention of

post–lumbar puncture headaches. Neurology, 65, 510–512. Accessed September
2016 via the Web at http://www.neurology.org/content/65/4/510.abstract
Abstract | Complete Reference

4. The Joint Commission. (2016). Standard RI.01.03.01. Comprehensive

accreditation manual for hospitals.  Oakbrook Terrace, IL: The Joint
Commission. (Level VII) 

5. Centers for Medicare and Medicaid Services, Department of Health and Human
Services. (2015). Condition of participation: Patient's rights. 42 C.F.R. §
482.13(b)(2).

6. Accreditation Association for Hospitals and Health Systems. (2016). Standard

15.01.11. Healthcare Facilities Accreditation Program: Accreditation requirements
for acute care hospitals.  Chicago, IL: Accreditation Association for Hospitals and
Health Systems. (Level VII) 
7. The Joint Commission. (2016). Standard UP.01.01.01. Comprehensive
accreditation manual for hospitals.  Oakbrook Terrace, IL: The Joint
Commission. (Level VII) 

8. Accreditation Association for Hospitals and Health Systems. (2016). Standard

30.00.14. Healthcare Facilities Accreditation Program: Accreditation requirements
for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and
Health Systems. (Level VII) 

9. The Joint Commission. (2016). Standard NPSG.07.01.01. Comprehensive

accreditation manual for hospitals.  Oakbrook Terrace, IL: The Joint
Commission. (Level VII) 

10.Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene
in health-care settings: Recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene
Task Force. MMWR Recommendations and Reports, 51(RR-16), 1–45. Accessed
September 2016 via the Web
at http://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II) 

11.World Health Organization. (2009). "WHO guidelines on hand hygiene in health

care: First global patient safety challenge, clean care is safer care" [Online].
Accessed September 2016 via the Web
at http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf (L
evel IV) 

12.Accreditation Association for Hospitals and Health Systems. (2016). Standard

07.01.21. Healthcare Facilities Accreditation Program: Accreditation requirements
for acute care hospitals. Chicago, IL: Accreditation Association for Hospitals and
Health Systems. (Level VII)