LICEO DE CAGAYAN UNIVERSITY

Paseo del Rio Campus, Macasandig, Cagayan de Oro City

COLLEGE OF NURSING
1st Semester, Academic Year 2025-2026

Lumbar Puncture (Spinal Tap)

A Ward Class Topic Presented to the Faculty of the College of Nursing, Liceo de Cagayan University
In partial fulfillment of the Requirements for:

NCM 112: Care of Clients with Problems in Oxygenation, Fluid and Electrolyte, Infectious,
Inflammatory, Immunologic Response, and Cellular Aberration (Acute and Chronic)

Submitted by:
AMINODEN, Ameera Hosna M.
AMPASO, Shahraina A.
ARADO, Derzy Nicadel
BANGAYAN, Deniza Dianne S.
BARODI, Sorhayla P.
BELLO, Grathea Coleene S.
BORJA, Raven Jose
DEBILDOS, Julianne P.
DELA CRUZ, Mikaela Andrea A.
DIMAPORO, Fatima Jannah A.

Submitted to:
ABAO, ALYANNA
ACTUB, APRIL RAY
ACTUB, RULINE
AGCOPRA, RIBLI
BALA, MIA MAY L.
BALUYOS
ELTANAL, SHAIRA MAE
GALLOFIN, SHEENA MAY
JAPSON, GIOVANNIE

JULY 2025
 NCM 112 RLE WARD CLASS | PRELIMS
Lumbar Puncture Topic Outline:
I.​ Introduction​………………………………………………………………………..3
A.​ Definition and Overview of Lumbar Puncture​……………………………...3
B.​ Purposes of Lumbar Puncture​………………………………………………5
C.​ Principles of Lumbar Puncture​……………………………………………...5
D.​ Indications of Lumbar Puncture​…………………………………………….6
E.​ Contraindications of Lumbar Puncture​……………………………………..6

II.​ Equipment and Supplies​…………………………………………………………..7

III.​ Overview of the Procedure​……………………………………………………….11

A.​ Step-by-Step Procedure​…………………………………………………….11

IV.​ Risks and Complications​………………………………………………………….15

A.​ Post-Lumbar Puncture Headache​…………………………………………...15
B.​ Herniation of Intracranial Contents​…………………………………………15
C.​ Spinal Epidural Abscess​……………………………………………………16
D.​ Spinal Epidural Hematoma​…………………………………………………16
E.​ Meningitis​…………………………………………………………………..17
F.​ Other Complications​………………………………………………………..17

V.​ Nursing Management​……………………………………………………………..19

A.​ Before the Procedure…………………………………………………………..20
B.​ During the Procedure….……………………………………………………….21
C.​ After the Procedure…………………………………………………………….21

VI.​ Conclusion………………………………………………………………………….22

VII.​ References…………………………………………………………………………..23
 INTRODUCTION
A.​ Definition and Overview of Lumbar Puncture
a.​ Definition
A lumbar puncture, also referred to as a spinal tap or rachicentesis, involves the
insertion of a needle into the lumbar subarachnoid space to collect cerebrospinal fluid (CSF).
This procedure may be conducted to analyze CSF, measure and alleviate CSF pressure, check
for blood in the CSF, or deliver medications directly into the spinal canal (Hinkle & Cheever,
2018, p. 5162).
Typically, the needle is inserted into the subarachnoid space between the third and
fourth or the fourth and fifth lumbar vertebrae. Since the spinal cord terminates at the first
lumbar vertebra, inserting the needle below the third lumbar vertebra helps avoid damaging
the spinal cord.

For a lumbar puncture to be successful, it is essential for the patient to be relaxed;

anxiety can lead to tension, which may elevate the pressure readings. The patient is typically
positioned on their side with their head bent toward their chest, knees drawn up to their
abdomen, and their back positioned at the edge of the bed or examination table. This posture
helps to arch the back, creating more space between the vertebrae, thereby facilitating the
insertion of the spinal needle.
 During a lumbar puncture, the primary care
provider often measures cerebrospinal fluid (CSF)
pressure using a manometer, which is a glass or
plastic tube marked in millimeters (Berman et al.,
2021, p. 827). When the patient is in a lateral
recumbent position, the normal CSF pressure ranges
from 80 to 100 mm H2O or 8 to 14 mm Hg (Hickey,
2014).

A lumbar puncture can pose risks when there

is an intracranial mass lesion, as the removal of
cerebrospinal fluid (CSF) can lower intraspinal
pressure, potentially leading to downward herniation
of the brain through the foramen magnum.

b.​ Brief History

Domenico Cotugno (1736-1822)

Cotugno, an Italian physician, made a significant contribution to the discovery of
cerebrospinal fluid (CSF) in 1764. He identified a water-like fluid surrounding the spinal
cord, which had been previously overlooked by anatomists. His research laid the groundwork
for understanding CSF, although his findings did not gain widespread recognition until much
later.

François Magendie (1783-1855)

François Magendie played a crucial role in reviving interest in the findings of
Antonio Cotugno regarding CSF in the 19th century. He acknowledged Cotugno’s priority in
the discovery of CSF and advanced the anatomical and physiological understanding of this
vital fluid, which set the stage for future research in the field.

Walter Essex Wynter (1860-1945)

In 1891, Walter Essex Wynter performed the first lumbar puncture in Britain, aiming
to relieve cerebrospinal fluid pressure in patients suffering from meningitis. Although his
initial attempts provided only temporary relief and all patients ultimately succumbed to their
illnesses, Wynter's work marked the beginning of lumbar puncture as a clinical procedure.

Heinrich Quincke (1842-1922)

Heinrich Quincke, working independently of Wynter, introduced lumbar puncture in
Germany in the same year, 1891. His technique closely resembled modern methods, and he
successfully utilized lumbar puncture to treat conditions such as hydrocephalus. Quincke’s
contributions were instrumental in establishing lumbar puncture as a recognized medical
intervention.

Hans Queckenstedt (1876-1918)

Hans Queckenstedt is known for his studies on cerebrospinal fluid dynamics. He
identified the diagnostic utility of lumbar puncture in detecting spinal cord obstructions. In
 his 1916 report, he detailed his now-famous test, which involved compressing the jugular
veins to diagnose blockages in the spinal cord.

Further Developments
Following the pioneering work of these individuals, lumbar puncture evolved
significantly. Advances in chemical, cytological, and bacteriological analyses have greatly
aided in the diagnosis of various conditions, including meningitis and neurosyphilis. The
foundational contributions of these early researchers laid the groundwork for the modern
application of lumbar puncture in neurology.

B.​ Purposes of Lumbar Puncture

1.​ To facilitate both diagnostic analysis of cerebrospinal fluid and the

measurement, and subsequent reduction, of its pressure.

●​ A lumbar puncture (LP) is performed to obtain cerebrospinal fluid (CSF) for examination.
Analyzing the CSF can help healthcare professionals diagnose infections, central nervous
system disorders, and inflammatory conditions.

2.​ To identify whether blood is present within the cerebrospinal fluid.

●​ The presence of blood in the cerebrospinal fluid (CSF) could suggest bleeding due to a
traumatic injury, a brain hemorrhage, or other vascular problems. Analyzing the CSF for
blood can help inform subsequent treatment and management decisions.

3.​ To deliver therapeutic agents directly into the spinal canal.

●​ Certain medications, such as chemotherapy, antibiotics, or anesthesia, can be administered

directly into the CSF through a lumbar puncture. This method, known as intrathecal
administration, ensures that the medication reaches the brain and spinal cord directly,
bypassing the blood-brain barrier.

C.​ Principles of Lumbar Puncture

1.​ Maintain aseptic technique. Strict adherence to sterile procedures is essential to
prevent infection.

2.​ Proper Positioning

●​ Lateral Recumbent Position: Commonly used for adults, the patient lies on their
side in a fetal position, which aids in accurate needle placement and enhances
comfort.
●​ Sitting Position: Often used for infants, where the infant is held upright with head
support, keeping the spine straight for easier needle insertion.

3.​ Accurate landmark identifications

Assessment: Locate the L3-L4 interspace by feeling for the right and left posterior
superior iliac crests and then moving your fingers inward toward the spine. Assess
the L3-L4 interspace, as well as the one above (L2-L3) and the one below
 (L4-L5), to determine which is the widest.

4.​ Proper needle insertion

The needle should be positioned along the midline to prevent any tearing of the
dural membrane and reduce the risk of complications.

D.​ Indications of Lumbar Puncture

●​ Assess the pressure of cerebrospinal fluid (CSF).
●​ Assist in the diagnosis of potential CNS infections, such as bacterial or viral
meningitis, meningoencephalitis, intracranial or subarachnoid hemorrhage, and
certain malignant conditions.
●​ Analyze and identify demyelinating or inflammatory CNS disorders, including
Multiple Sclerosis, Guillain-Barré Syndrome (GBS), and Acute Disseminated
Encephalomyelitis (ADEM).
●​ Administer medications, which may include spinal anesthesia prior to surgery,
contrast agents for diagnostic imaging like CT-myelography, and chemotherapy
directly into the spinal canal.
●​ Manage conditions such as normal pressure hydrocephalus, cerebrospinal fistulas,
and idiopathic intracranial hypertension (IIH).
●​ Insert a lumbar CSF drainage catheter.

E.​ Contraindications of Lumbar Puncture

●​ Increased intracranial pressure caused by a brain tumor. Withdrawal of CSF fluid may
lead to cerebral or cerebellar herniation, resulting in severe neurological decline.
●​ Skin infection at the puncture site. An existing skin infection near the lumbar
puncture area heightens the risk of contaminating the CSF with infected material.
●​ Advanced degenerative vertebral joint disease. This condition can make it
challenging to insert the needle through the arthritic interspinous space.
●​ Severe coagulopathy. There is a significant risk of developing an epidural hematoma
in such cases.
 EQUIPMENT AND SUPPLIES
Prepackaged lumbar puncture kits are available that contain all the equipment needed to
perform the procedure. The kits should include the following essential items:

EQUIPMENT AND IMAGE USES

SUPPLIES

Fine, hollow needles designed

to penetrate the dura mater and
Spinal needles, 22- access cerebrospinal fluid
(CSF); the stylet prevents tissue
and 25-gauge, with blockage within the needle.
stylet

A short needle used to numb

the skin with local anesthesia
before inserting the spinal
needle.
25-gauge, ½-inch needle

A longer needle used to deliver

anesthesia deeper into the
tissues for more effective pain
control.
22-gauge, 1½-inch needle

A small syringe used to

accurately draw and administer
local anesthetic to the patient.

5-mL syringe
 A numbing medication
combined with epinephrine to
extend the anesthetic effect and
reduce bleeding by narrowing
1% lidocaine with epinephrine blood vessels.

Devices used to measure

cerebrospinal fluid pressure and
Three-way stopcock and control the flow of CSF during
the procedure.
manometer

Sterile containers used to

collect CSF samples for various
lab tests like glucose, protein,
culture, and cell count.
Sterile collection tubes
(minimum of four)

A barrier around the puncture

site to keep the area sterile and
Sterile towel and barrier reduce infection risk.
 Absorbent pads used to clean
the site and soak up any fluids
that may leak during the
procedure.
Sterile gauze sponges

Personal protective equipment

(PPE) worn by the healthcare
Mask, protective eyewear, and provider to prevent
contamination and ensure
sterile gloves
safety.

Antiseptic solution and tools

used to clean the patient’s skin
Povidone-iodine solution and and minimize the risk of
infection.
materials for skin cleansing

A sterile covering placed over

the puncture site after the
procedure to protect it and
absorb any residual fluid.
Self-adhesive bandage

Kidney Basin A curved basin used to collect

waste materials like used gauze
or discarded instruments during
the procedure.
 Sterile Bowl A clean container used to hold
disinfectant or sterile fluids
needed throughout the
procedure.

A surgical clamp used to secure

drapes or towels in place,
keeping the sterile field intact.

Backhaus towel clamp

Forceps A tweezer-like instrument used

to handle sterile items without
direct hand contact, preserving
cleanliness.
 OVERVIEW OF THE PROCEDURE
A.​ Step-by-Step Procedure (Lumbar Puncture)
1.​ Check the physician's order and secure consent. Verify the client's identity,
introduce self, and explain procedure to the client.
Rationale: Verifying the physician's order ensures that the procedure is
appropriate and authorized. Securing informed consent respects the patient's
autonomy and ensures understanding. Introducing oneself and explaining the
procedure promotes trust and cooperation, reducing anxiety and gaining patient
compliance.
2.​ Secure equipment from the CSR and bring it to the bedside.
Rationale: Having the necessary equipment ready minimizes delays, ensuring the
procedure is conducted efficiently and aseptically.
3.​ Obtain baseline vital signs. Have the client empty their bladder.
Rationale: Baseline vitals provide a reference for detecting post-procedure
changes. Emptying the bladder enhances comfort and reduces the risk of
involuntary voiding during the procedure, which could complicate positioning.
4.​ Provide privacy to the client and assist the client to move nearer to the side of bed
closer to you.
Rationale: Maintaining privacy preserves patient dignity. Moving the client
closer to the edge of the bed ensures easy access to the lumbar area, facilitating
proper positioning for the procedure.
5.​ Place the client in a side lying position. Instruct the client to arch the lumbar
segment of their back, and draw up knees to their abdomen, clasping knees with
their hands and with their chin touching the chest.
Rationale: This position maximally widens the intervertebral spaces, making it
easier for the needle to access the subarachnoid space. Flexion of the spine
increases the space between vertebrae and optimizes needle placement.
●​ Obese Client: Have the client straddle on a straight back chair (facing the
back) and rest their head against the arms which are folded on the back of
the chair.
Rationale: Obese clients may have difficulty assuming the side-lying
position. The sitting position improves access to the lumbar area by
straightening the spine, allowing better palpation of the interspaces.
●​ Pedia (Child): The child may be held across the front of the nurse, with
legs secured on one arm, with head and arms secured on the other arm.
Rationale: Proper restraint minimizes movement during the procedure,
ensuring safety and preventing complications like needle displacement or
traumatic tap.
●​ Infant: The very young infant may be placed in a sitting position, with the
head allowed to fall forward, thus arching the back. The nurse holds the
hands and feet with one hand and steadies the body with her other hand.
Rationale: This positioning helps maximize the separation between the
vertebrae, allowing easier access to the subarachnoid space, and keeps the
infant still during the procedure, minimizing the risk of injury from sudden
movements.
6.​ Expose the lumbar area. Do skin preparation. Disinfect the area using cotton balls
with betadine cleanser and wipe dry with sterile gauze/towel.
Rationale: Cleaning the lumbar area reduces the risk of infection by removing
surface bacteria, ensuring a sterile field for needle insertion.
7.​ Paint the lumbar area with betadine solution, in a circular motion, outward stroke.
Cover the area with sterile drape towel (eye sheet) by using picking forceps, if the
physician is not yet ready.
Rationale: Betadine provides long-lasting antiseptic action, and the outward
circular motion ensures contaminants are pushed away from the puncture site.
Sterile draping maintains asepsis until the physician is ready.
8.​ Open the tray aseptically and position it within physician's reach.
Rationale: Maintaining asepsis of the tray prevents contamination of instruments
that will be used in the sterile procedure.
9.​ Alcoholize the rubber cap of the Xylocaine vial and offer it to the physician.
Rationale: Disinfecting the rubber cap reduces the risk of introducing
contaminants into the anesthetic, ensuring a sterile injection. Administering
Xylocaine reduces pain and discomfort at the puncture site by blocking nerve
signals in the skin and underlying tissues. This allows the physician to perform
the procedure with minimal discomfort for the patient, increasing the likelihood of
cooperation and reducing anxiety.
10.​Prepare the sterile gloves for the physician.
Rationale: Sterile gloves are necessary to maintain asepsis when handling
instruments and touching the sterile field.
11.​Provide a stool. Assist the physician (throughout the procedure) in maintaining
the client's position, by supporting behind the knees and the neck of the client.
Rationale: Supporting the client helps maintain proper alignment and minimizes
the risk of sudden movements, which could result in a traumatic tap or needle
misplacement.
12.​Assist the physician as necessary.
Rationale: Ensuring the physician has necessary assistance improves the flow
and safety of the procedure, reducing the likelihood of complications.
a.​ Putting on gloves.
Rationale: Sterile gloves are necessary to maintain asepsis when handling
instruments and touching the sterile field.
b.​ Anesthetizing the area.
Rationale: Using a local anesthetic minimizes infection risk and ensures
patient comfort by numbing the area.
c.​ Inserting of the spinal needle which should be introduced at the L2 - L4
interspace. The needle is advanced until the "give" of the ligamentum
flavum is felt, and the needle enters the subarachnoid space.
Rationale: Inserting the needle below L2 reduces the risk of damaging the
spinal cord, which terminates around this level. The "give" indicates
correct needle placement in the subarachnoid space.
 d.​ After the needle enters the subarachnoid space, help the client to slowly
straighten their legs.
Rationale: Straightening the legs relieves abdominal pressure, which
could artificially raise intraspinal pressure readings.
e.​ Instruct the client to breath quietly (not to hold his breath or strain) and not
to talk.
Rationale: Straining or holding the breath can increase cerebrospinal fluid
(CSF) pressure, leading to inaccurate pressure readings.
f.​ The initial pressure reading is obtained, by measuring the level of the fluid
column after it comes to rest.
Rationale: This provides the opening pressure of the CSF, which can help
diagnose conditions like hydrocephalus or increased intracranial pressure.
g.​ About 2-3 ml of spinal fluid is collected on each 3 sterile specimen
containers: for observation, for comparison, and for laboratory analysis.
Rationale: The multiple samples allow for comparison, reducing the
chance of misdiagnosis due to contamination or traumatic tap. CSF should
be clear and colorless; any abnormality suggests pathology.
13.​Receive the specimen containers with CSF from the physician and label
accordingly.
Rationale: Receiving the specimen containers with cerebrospinal fluid (CSF)
from the physician and labeling them accordingly ensures accurate identification
and proper handling of the samples.
14.​Cleanse the punctured site and apply a sterile dressing when the spinal needle is
removed.
Rationale: Cleaning and dressing the site prevents infection and promotes healing
at the puncture site.
15.​Instruct the client to lie flat on bed for at least 4 - 6 hours.
Rationale: Lying flat helps prevent post-lumbar puncture headache, which can
occur due to CSF leakage.
16.​Make the client comfortable and observe for any untoward reactions. Take and
record vital signs.
Rationale: Monitoring ensures early detection of complications, such as changes
in neurological status or signs of infection.
17.​Send the labeled specimen containers to the laboratory with request form as soon
as possible.
Rationale: Prompt delivery of the CSF sample ensures accurate and timely
analysis, critical for diagnosing conditions like meningitis or hemorrhage.
18.​Do aftercare of the equipment and discard used gloves accordingly. Wash hands
aseptically.
Rationale: Proper disposal of materials and handwashing prevent
cross-contamination and maintain hygiene.
19.​Chart:
●​ Procedure done
●​ Date and Time
●​ Name of the physician and nurse
 ●​ Clients' response
●​ Number of specimen containers sent to the laboratory; color, consistency,
and any other characteristics of the CSF.
Rationale: Documentation provides a legal record of the procedure and ensures
continuity of care by informing the healthcare team of key findings and any client
reactions.
 RISKS AND COMPLICATIONS
A.​ Post-Lumbar Puncture Headache

A post–lumbar puncture headache, patients may experience a post-lumbar

puncture headache, varying in intensity from mild to severe, which typically manifests
within hours to several days following the procedure. This headache is characterized by a
deep, dull, throbbing pain, often localized to the bifrontal or occipital regions. Its severity
is notably increased by sitting or standing, but it tends to diminish or resolve when the
individual lies flat.
The headache results from cerebrospinal fluid (CSF) leaking at the puncture site.
The fluid continues to seep into the surrounding tissues along the needle track from the
spinal canal. This leakage leads to a reduction in the CSF supply within the cranium,
resulting in inadequate mechanical support for the brain. When the patient is in an upright
position, this causes tension and stretching of the venous sinuses and other pain-sensitive
structures, leading to discomfort.To help prevent headaches following a lumbar puncture,
it's recommended to use a fine needle and keep the patient lying face down immediately
afterward. After that, the patient should lie on their back for 4 to 8 hours. If a headache
does develop, it’s typically treated with rest in bed, pain relievers, and plenty of fluids.

B.​ Herniation of Intracranial Contents

Pre-procedural imaging, such as a CT scan or MRI, is often conducted to mitigate

the risk of brain herniation, a significant concern prior to lumbar puncture. Conditions
like bacterial meningitis, intracranial bleeding, tumors, or abscesses frequently present
with cerebral edema and elevated intracranial pressure (ICP). Performing a lumbar
puncture in the presence of high ICP can precipitate cerebral herniation, potentially
leading to severe neurological impairment or even fatality. This herniation is thought to
result from a rapid reduction in spinal cord pressure following the withdrawal of
cerebrospinal fluid (CSF) during the procedure, causing the brain to shift downwards and
potentially compress the brainstem. Should herniation manifest, characterized by acute
neurological decline including altered mental status, irregular respiration, pupillary
changes, or loss of consciousness, immediate medical intervention is imperative. This
includes halting the lumbar puncture, elevating the patient's head, and initiating measures
like hyperventilation or hyperosmolar therapy to lower ICP.

Cerebral herniation is a rare yet serious complication associated with lumbar

puncture, occurring in an estimated 0.1–3% of the general population. In patients with
acute bacterial meningitis, the incidence of herniation rises to about 5%, contributing to
approximately 30% of related fatalities. For high-risk individuals—such as those
exhibiting papilledema, space-occupying lesions, or signs of increased intracranial
pressure—the risk is approximately 1%. Herniation can develop within hours following
the procedure, highlighting the importance of thorough assessment and neuroimaging
before performing a lumbar puncture in at-risk patients.
C.​ Spinal Epidural Abscess

Spinal epidural abscess is characterized by swelling and inflammation, along with the
accumulation of infected material (pus) and microorganisms in or around the spinal cord. The
pus is composed of:
➔​ White blood cells
➔​ Fluid
➔​ Live and dead bacteria or other microorganisms
➔​ Damaged tissue cells
Typically, the pus is encased in a lining or membrane that forms around its edges, leading
to pressure on the spinal cord. This infection is primarily caused by bacteria, often stemming
from a staphylococcus infection that spreads through the spine. Risk factors for developing a
spinal epidural abscess include poor aseptic technique, immunocompromised states, and
pre-existing infections. Patients may present with fever, localized back pain, and tenderness at
the puncture site. Over time, spinal cord compression can lead to neurological deficits such as
numbness, weakness, or incontinence.
Spinal epidural abscess (SEA) is a rare but serious complication of lumbar puncture and
other spinal procedures, occurring in approximately 15–20% of SEA cases due to direct
inoculation from procedures like lumbar punctures, epidural injections, or surgeries. The overall
incidence of SEA ranges from about 0.2 to 8 cases per 10,000 hospital admissions, with rates
increasing in recent decades due to a rise in invasive spinal procedures and intravenous drug use.
SEA most commonly affects individuals in their 50s and 60s, with a higher prevalence in males.
Mortality rates vary between 2% and 20%, and less than 6.6% of survivors experience
recurrence.
To prevent this complication, it is crucial to strictly adhere to aseptic techniques during
the procedure, including proper sterilization of the site and sterile handling of equipment.
Treatment may involve urgent antibiotics and possibly surgical drainage, as delayed intervention
can result in permanent neurological damage.

D.​ Spinal Epidural Hematoma

A spinal epidural hematoma is a rare yet serious complication that can arise after a
lumbar puncture, a procedure typically performed to collect cerebrospinal fluid or administer
medication. This condition involves bleeding in the epidural space, which can result in
increased pressure on the spinal cord and nerve roots. Symptoms may include:
➔​ Sudden onset of severe back pain
➔​ Neurological deficits, such as weakness or numbness in the legs
➔​ Bowel or bladder dysfunction
Risk factors for developing a hematoma include anticoagulant therapy, underlying
coagulopathy, and trauma. Timely diagnosis and treatment are essential, often necessitating
surgical intervention to relieve pressure and prevent permanent neurological damage.
The incidence of spinal epidural hematoma following lumbar puncture is estimated to
be between 0.15% and 0.23% (approximately 1 in 500 to 650 procedures). A Danish study
involving over 83,000 lumbar punctures indicated that the risk is slightly elevated in patients
with coagulopathy and in males aged 41 to 80. Although these cases are uncommon,
symptomatic instances frequently require urgent surgical decompression, with outcomes
closely linked to the promptness of the intervention.

E.​ Meningitis

Meningitis is a rare complication of lumbar puncture that can occur if bacteria or

other pathogens are introduced into the spinal canal during the procedure. Inadequate skin
sterilization or breaches in sterile technique can lead to infection. Furthermore, it is
important to emphasize that lumbar punctures are generally safe, and serious complications
such as meningitis are quite uncommon when performed by experienced practitioners but if
there is a pre-existing infection in the body, the procedure may facilitate the spread of
pathogens to the central nervous system.

Lumbar puncture is crucial for diagnosing meningitis and has significant diagnostic
and clinical implications. In emergency settings, approximately 8.5% of lumbar punctures
identify aseptic meningitis, while 2.4% confirm bacterial meningitis among all suspected
cases. In adult intensive care units, 30% of lumbar punctures confirmed meningitis, and in
3% of cases, a specific bacterial pathogen was identified, which influenced patient
management. In cases of acute meningitis, about 77% of patients undergo lumbar puncture,
with positive cerebrospinal fluid cultures found in 21.5% of those tested. Overall, the
sensitivity of CSF culture or PCR during the initial lumbar puncture is approximately 85%
(95% CI: 77–90%) in cases without typical inflammatory markers. These findings underscore
the diagnostic yield of lumbar puncture, which ranges from 21% to 30% for detecting
meningitis, and its critical role in confirming infection and guiding treatment decisions.

F.​ Other Complications

●​ Stiffness of the Neck
Some patients may experience mild neck stiffness, particularly if there was difficulty
during needle insertion, which might irritate the muscles and tissues in the neck area. This
stiffness is often a transient response, typically resolving shortly as the body recovers from the
procedure. Neck stiffness occurs infrequently after lumbar puncture; in a study of 1,702 lumbar
punctures for Alzheimer’s evaluation, only 2 events (0.12%) were reported as stiff neck. Among
patients who developed post-dural puncture headache (PDPH), isolated neck stiffness was noted
in 4% of cases (2 out of 48).
●​ Slight Elevation of Temperature
Some patients may experience a mild increase in body temperature. This slight fever is
typically a transient, benign reaction to the body’s response to the procedure, often resulting from
minor inflammation around the puncture site. The body may mount a mild immune response as it
heals, leading to a low-grade fever that usually subsides within 24 to 48 hours. Slight
temperature elevations occur in a small proportion of patients—typically between 5% and
15%—and are generally transient, reflecting mild aseptic inflammation rather than infection.
Serious febrile responses suggesting an infectious complication, such as meningitis, are rare
(under 1%).

●​ Backache or Spasm
Mild to moderate back pain or muscle spasms may develop after a lumbar puncture.
This discomfort typically arises from irritation or minor trauma to the soft tissues, ligaments, or
muscles surrounding the puncture site, as the procedure involves inserting a needle through
multiple tissue layers to reach the spinal canal. Back pain or spasms following a lumbar puncture
are relatively common. In a prospective study of 112 children and adolescents, 40% experienced
postoperative backache within two days, which resolved within a week. Among adults
undergoing lumbar puncture in memory clinics, 17% reported back pain—13.3% with mild
discomfort and 3.7% experiencing pain lasting several days. These findings highlight back pain
as a notable but typically self-limiting complication following lumbar puncture.
●​ Temporary Voiding Problems
​ After a lumbar puncture, some patients may experience difficulty urinating, which
can range from mild hesitancy to a temporary inability to fully empty the bladder. This issue
arises from potential irritation or mild trauma to the nerves in the lower spine, particularly those
involved in bladder control (sacral nerves). Temporary urinary retention occurs in about 10–12%
of patients following lumbar puncture or spinal anesthesia, often due to nerve blockade, with
higher rates observed in individuals on prolonged bed rest.
 NURSING MANAGEMENT
A.​ Before the Procedure
1.​ Initiate a comprehensive pre-procedural verification, ensuring all pertinent
documentation, patient data, and necessary equipment are readily accessible and
accurately correlated with the patient's identity.
2.​ Determine whether written consent for the procedure has been obtained.
3.​ Confirm the patient’s identity using at least two patient identifiers according to
your facility’s policy.
4.​ Provide a thorough explanation of the lumbar puncture process to the patient,
detailing the sequence of events and describing the sensations they are likely to
experience, such as the cool feeling from antiseptic solution or a brief stinging
sensation upon local anesthetic administration.
5.​ Advise the patient regarding the potential of a post lumbar puncture headache,
while simultaneously reassuring them that their active cooperation throughout the
procedure can significantly reduce the risk.
6.​ Actively ask questions or clarify potential misconceptions the patient may harbor
concerning the procedure. Reassure them explicitly that the spinal needle’s
insertion point is below the termination of the spinal cord, thus precluding the risk
of paralysis.
7.​ Check the patient’s history for hypersensitivity to local anesthetic.
8.​ Provide privacy and instruct the patient to empty the bladder and/or bowel before
the procedure.
9.​ Assist the patient into the lateral recumbent position, ensuring they are positioned
at the bed's edge. Guide them to flex their spine maximally by bringing their chin
to their chest and drawing their knees towards their abdomen. This specific
posture is critical as it effectively widens the intervertebral spaces, thereby
facilitating easier needle insertion.
10.​To optimize spinal alignment, a small pillow may be positioned beneath the
patient's head. Additionally, a pillow can be placed between the patient's legs to
stabilize the upper leg and prevent anterior rotation.
11.​Alternately, for sitting position, have the patient straddle a straight-back chair
(facing the back) and rest head against arms, which are folded on the back of the
chair.
12.​Encourage the patient to remain relaxed and to maintain a normal breathing
pattern, as hyperventilation has the potential to artificially decrease an elevated
cerebrospinal fluid pressure reading.
13.​Aseptically open the equipment tray on an overbed table, exercising extreme
 caution to prevent contamination of the sterile field during wrapper removal.
Ensure all medications, their respective containers, and any other solutions are
clearly labeled both within and outside the sterile field.
14.​Ensure sufficient illumination at the puncture site. Adjust the patient's bed height
to an ergonomic level that facilitates comfortable and precise performance of the
procedure by the physician.
15.​Ensure that the puncture site is well-lit and adjust the patient's bed height to
enable the doctor to carry out the procedure comfortably.
16.​Conduct a time-out before starting the procedure to determine that the correct
patient, site, positioning, and procedure are identified and confirmed as
applicable.

B.​ During the Procedure

1.​ The nurse describes the procedure step by step to the patient as it progresses. This
helps to alleviate anxiety and ensures the patient understands what to expect.
2.​ Before the doctor injects the anesthetic, inform the patient that he will experience a
transient burning sensation and local pain. Encourage him to report any persistent
pain or unusual sensations, as these may indicate irritation or puncture of a nerve root,
which would require repositioning of the needle.
3.​ When the doctor inserts the sterile spinal needle into the subarachnoid space between
the third and fourth lumbar vertebrae, instruct the patient to remain still and breathe
normally. If necessary, hold the patient firmly in position to prevent sudden
movements that could displace the needle.
4.​ Once the needle is in place, the doctor attaches a manometer with a three-way
stopcock to the needle hub to measure cerebrospinal fluid (CSF) pressure. If ordered,
assist the patient in extending his legs to provide a more accurate pressure reading.
5.​ Label the specimen containers in the presence of the patient to prevent any
mislabeling, ensuring accurate identification of samples.
6.​ If the doctor suspects an obstruction in the spinal subarachnoid space, he may check
for Queckenstedt’s sign. After taking an initial CSF pressure reading, compress the
patient’s jugular vein for 10 seconds, as ordered. This maneuver increases intracranial
pressure (ICP) and, if no subarachnoid block exists, should cause CSF pressure to rise
as well. The doctor will then take pressure readings every 10 seconds until the
pressure stabilizes.
7.​ During the lumbar puncture, closely monitor the patient for signs of adverse
reactions, such as elevated pulse rate, pallor, and clammy skin. Immediately alert the
doctor about any significant changes in the patient's condition.
C.​ After the Procedure
1.​ After the doctor collects the specimens and removes the spinal needle, clean the
puncture site with an antiseptic solution and apply a small adhesive bandage to
protect the area.
2.​ Place the cerebrospinal fluid (CSF) specimens in a laboratory biohazard transport bag
and send them to the laboratory immediately, accompanied by completed laboratory
request forms. It is crucial that collected CSF specimens are sent to the laboratory
without delay, as they cannot be refrigerated for later transport.
3.​ After the procedure, instruct the patient to lie prone for about 2 hours. This position
helps separate the alignment of the dural and arachnoid needle punctures in the
meninges, thereby reducing the risk of CSF leakage.
4.​ Monitor the patient for any complications arising from the lumbar puncture. Notify
the primary provider if any complications occur. Check the puncture site for signs of
redness, swelling, and drainage every hour for the first 4 hours, and then every 4
hours for the first 24 hours.
5.​ Ensure the patient maintains adequate hydration with oral or parenteral fluids to help
restore spinal fluid volume and reduce the risk of post-procedure headaches.
6.​ Monitor the patient for signs of spinal headache and observe for any CSF leaks.
7.​ Document the procedure thoroughly. Record the initiation and completion times of
the procedure, the patient’s response, administration of any drugs, the number of
specimen tubes collected, the time of transport to the laboratory, and the color,
consistency, and any other characteristics of the collected specimens. Additionally,
document any patient teaching provided during the process.
 CONCLUSION
LUMBAR PUNCTURE

The lumbar puncture, often referred to as a spinal tap, stands as a frequently performed and

diagnostically invaluable procedure. Its significance is particularly pronounced in the timely

identification of critical and potentially life-threatening conditions, such as central nervous system

infections like meningitis or acute intracranial hemorrhages. The successful and safe execution of

this invasive procedure hinges critically on meticulous preparation, adherence to precise technical

guidelines, and comprehensive post-procedural care. By diligently observing these principles, the

potential for adverse events and complications can be substantially reduced. Furthermore, a key

element contributing to procedural success involves the practitioner's ability to mentally visualize

and accurately identify the relevant anatomical landmarks before the spinal needle is introduced.

Beyond the technical aspects, fostering a patient-centered approach is paramount. This includes

engaging in thorough, informed decision-making processes and openly discussing the inherent risks

and anticipated benefits of the lumbar puncture with the patient. Such transparent communication

not only empowers the patient but also serves to significantly mitigate anxiety, ultimately paving the

way for more favorable clinical outcomes.

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