PROCEDURE ON

LUMBAR PUNCTURE
SUBJECT: ADVANCED NURSING PRACTICE

SUBMITTED TO:

Mr. SRIDHARA P M
VICE PRINCIPAL and
PROFESSOR
KTG COLLEGE OF NURSING
BENGALURU
SUBMITTED BY:

Mr. LOKESHA P S
1ST YEAR MSc NURSING
KTG COLLEGE OF NURSING
BENGALURU

Date of submission:

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 INDEX

SL NO. CONTENT PAGE NO.

1 INTRODUCTION 2

2. DEFINITION 2

3. PURPOSES 2

4. CONTRAINDICATIONS 3-4

5. PRE REQUSITE-KNOWLEDGE AND SKILLS 4

6. NORMAL CSF VALUES 4

7. PREPARATION OF THE ARTICLES 5

8. PREPARATION OF THE PATIENT 6-7

9. PERFORMANCE PHASE 7-8

10. FOLLOW UP PHASE 8

11. COMPLICATIONS 9

12. CONCLUSION 9

13. BIBLIOGRAPHY 9

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 LUMBAR PUNCTURE

INTRODUCTION

Special neurologic procedures are essential for evaluating, planning and treating patients in
critical situations. The nurse is responsible for giving and reinforcing information concerning
these tests to the patient and family. The nurse is also responsible for correlating the patient’s
clinical status with the test results, planning patient care and identifying specific teaching needs.

DEFINITION

Lumbar puncture is a procedure in which a needle is inserted into lumbar subarachnoid space
usually between the third and fourth lumbar vertebrae and cerebrospinal fluid is withdrawn for
diagnostic and therapeutic purposes.

PURPOSES

 Obtaining CSF for examination (microbiologic, serologic, cytologic or chemical

analysis).
 Measuring cerebrospinal pressure and assisting in detection of obstruction of
cerebrospinal fluid circulation.
 Determining the presence or absence of blood in the spinal fluid.
 Aiding in the diagnosis of viral or bacterial meningitis, subarachnoid or intracranial
hemorrhages, tumors and brain abscesses.
 Administering antibiotics and cancer chemotherapy intrathecally in certain cases.

 Introduce spinal anesthesia for surgical or obstetrical procedures.

 Suspicion of central nervous system diseases such as Guillain-Barré syndrome and
carcinomatous meningitis.

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CONTRA INDICATIONS

 Absolute contraindications to lumbar puncture are as follows:

o Unequal pressures between the supratentorial and infratentorial compartments,

usually inferred by characteristic findings on the brain CT scan:
 Midline shift
 Loss of suprachiasmatic and basilar cisterns
 Posterior fossa mass
 Loss of the superior cerebellar cistern
 Loss of the quadrigeminal plate cistern
o Infected skin over the needle entry site
 Relative contraindications to lumbar puncture are as follows:
o Increased intracranial pressure (ICP)
o Coagulopathy
o Brain abscess
 Indications for brain CT scan prior to lumbar puncture in patients with suspected
meningitis include the following:4
o Patients who are older than 60 years
o Patients who are immunocompromised
o Patients with known CNS lesions
o Patients who have had a seizure within 1 week of presentation
o Patients with abnormal level of consciousness
o Patients with focal findings on neurological examination
o Patients with papilledema seen on physical examination with clinical suspicion of
elevated ICP

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  Indications for CT scan prior to lumbar puncture in patients with suspected
subarachnoid hemorrhage (SAH)
o Cranial CT should be obtained before lumbar puncture in all patients with
suspected SAH in order to diagnose obvious intracranial bleed or any significant
intracranial mass effect that might be present in awake and alert SAH patients
with a normal neurologic examination.

PRE-REQUISITE KNOWLEDGE AND SKILLS

Before assisting for lumbar puncture, the nurse should understand;

a) Anatomy and physiology of the spinal column and CSF circulation

b) The anticipated dynamic response following CSF removal.
c) Potential risks and benefits of the procedure.
d) Principles of asepsis.
NORMAL CSF VALUES

PARAMETER NORMAL VALUES

Specific gravity 1.007

PH 7.35
Appearance Clear, colorless
RBCs None
WBCs 0-8mcl (0-0.008/L
PROTEIN
Lumbar 15-45 mg/dl
Cisternal 15-25mg/dl (0.15-0.25 gm/l)
Ventricular 5-15mg/dl (0.05-0.15gm/dl)
Glucose 45-75mg/dl
Micro organisms None
Opening pressure with lumbar puncture 60-150mm H2O

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PREPARATION OF THE ARTICLES

A tray containing;
 Sterile gloves, gown
 Face mask
 Spinal needle with stylet (20 or 22 gauge)
 Sterile gauze pads
 Povidone-iodine solution
 Three ways stop cock
 Manometer
 Sterile fenestrated drape
 Small sterile specimen containers-4
 Lidocaine 2%
 2cc syringe with needle
 Sterile dressing
 Adequate light source
 Two over bed tables
 Rolled towel or small pillow
 Crash cart

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PREPARATION OF THE PATIENT

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  Explain the procedure to the patient
 Obtain an informed consent
 Have the patient empty the bladder
 Position the patient in lateral decubitus (fetal) position with neck and head flexed and
knees up toward chest
OR
Instruct the patient to arch the lumbar segment of back and draw knees upto abdomen,
chin to chest, clasping knees with hands.
 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.

PERFORMANCE PHASE

 Wash hands
 Provide privacy for the patient
 Ensure correct position of the patient
 Prepare the skin with povidone iodine solution
 Drape the area
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  Administer local anesthesia
 Assist the physician in introducing the spinal needle at L3-L4 interspace. The
needle is advanced until the give of the ligamentum flavum is felt and the needle
enters the subarachnoid space.
 Monitor the patients neurologic, respiratory and cardio vascular status during
procedure.
 Once the needle is in place instruct the patient to relax, breath normally and avoid
holding the breath.
 Using aseptic technique assist in attaching manometer to spinal needle via a three
way stop cock.
 Assist with the collection of CSF specimens in sterile tubes. About 2-3 ml of
spinal fluid is placed in each of three test tubes for observation, comparison and
laboratory analysis. Spinal fluid should be clear and colorless.
 Label each tube with type of specimen, patient name and order in which the
specimen was collected.
 Apply antiseptic and dressing to puncture site after physician removes the needle.

FOLLOW UP PHASE

 Reposition the patient.

 Advise the patient to remain flat in the bed for about 2hrs.
 Ensure adequate hydration with oral or parenteral fluids.
 Monitor for spinal headache, and observe for CSF leak.
 Discard the supplies and replace the articles.
 Wash hands.
 Record the procedure with date, time, status of the puncture sit and the amount of
CSF collected.

COMPLICATIONS

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  Change in the level of consciousness
 Head ache
 Stiff neck
 Photophobia
 Inability to void
 Pain and tingling in the lower extremity.

CONCLUSION

A lumbar puncture is considered as an invasive, traumatic and somewhat painful

procedure. A proper explanation should be given to the patient to get co-operation. The nurse
should follow strict aseptic technique and continuous monitoring of the patient is mandatory.

BIBLIOGRAPHY

1. Sandra MN. The Lippincott manual of nursing practice. 7 th ed. Jaypee brothers:
Lippincott; 2003. P. 441-45.
2. Rochele LB, Maribeth. American association of critical care nurses, procedure
manual of critical care. Philadelphia: WB Saunders company; 1993. P.505-11.
3. Lewis, Heitkemper, Dirsken, O’Brien, Bucheri. Medical surgical nursing. 7 th ed.
New Delhi: Elsevier publishers; 2008. P. 1461-62.

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