Ateneo de Zamboanga University

College of Nursing

Nursing Skills Output (NSO)

Report no. 3

ASSISTING IN LUMBAR PUNCTURE

I. DESCRIPTION:

Lumbar puncture (LP) involves entering the subarachnoid space of the spinal
column with a hollow needle. It is normally performed at the level of the L3/4 or L4/5
inter-spinous space.

II. MATERIALS/EQUIPMENTS NEEDED:

 Sterile drape and sheet, gown, gloves

 Dressing pack
 Chlorhexidine antiseptic solution
 2 yellow top specimen tubes
 Calibrated spinal stylet needle (18-22 gauge)
 Spinal manometer

III. PROCEDURE

1. Review history of prior procedures with the patient and/or parents

2. Procedure and risks are explained and written or verbal consent obtained.
3. If there is any question of raised intracranial pressure (ICP) a careful fundoscopic
and neurological examination is required to rule out papilledema or focal
neurologic deficit. If there is any doubt that raised ICP exists, a CT scan and
neurosurgery consultation should be obtained.
4. Proper positioning is the most crucial step to ensure success:

The lateral decubitus position is preferred in most circumstances. The patient is

placed curled on his side, on a firm surface, with his knees flexed up to the chest
and neck flexed forward. The lumbar region should be close to the edge of the
bed and the plane of the back and shoulders as perpendicular to the bed as
possible. An assistant may restrain the patient by placing one arm under the
flexed knees and the other arm around the neck and shoulders. In addition to
restraint, this will help maintain the lumbar spine in flexion, thereby widening
the spaces between the lumbar spinous processes.

5. Alternatively the patient may be placed in a seated position with neck and spine
maximally flexed, with arms resting on a bedside table (older child) or leaning
over a pillow and held against a seated assistant (younger child).
6. Drawing an imaginary line between the two posterior iliac crests will allow
identification of the L4-5 or L3-4 interspaces.
7. Using sterile technique done sterile gloves and clean, prep and drape the area.
Infiltrate skin and deeper tissues with 1% lidocaine. When experienced at

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 performing lumbar punctures it may be unnecessary to use lidocaine if EMLA
cream has been applied to the skin.
8. Review tray set-up, ensure lids of collecting containers are unscrewed and
containers are readily available.
9. Review patient position and restraint.
10. Identify L4-5 or L3-4 interspace and insert spinal needle, with stylet in place,
along the midline with bevel facing upwards (assumes lateral decubitus
positioning). Prior to insertion, do not handle the needle at any point other than
the hub to avoid possible contamination.
11. Proper alignment of the needle is aided by placing the thumb of the non-
inserting hand on the spinous process above the interspace being used.
12. Direct the needle slightly cephalad along an imaginary line towards the umbilicus
and advance it slowly. Resistance may be felt as the needle penetrates the
ligamentum flavum and further smaller “pop” may be felt as the needle
penetrates the dura. These changes are not always felt so the stylet should be
frequently withdrawn to look for the presence of CSF. If none is visible, rotate
the needle 90° to attempt to free the bevel of any occluding tissue. If no CSF is
forthcoming replace the stylet, advance the needle slightly and recheck.
13. If an opening pressure is required, once CSF is seen in the hub, attach the 3-
way stopcock and manometer to the needle hub. (Familiarize yourself with the
positions of the stopcock prior to starting the procedure.) Note the height of the
fluid column.
14. Collect approximately 0.5–1 cc of CSF sequentially in each of the sterile tubes to
be sent for appropriate chemical, cytologic and, microbiologic tests. The last tube
should be sent for cell count and differential, as it is least likely to be
contaminated with red cells.
15. Replace the stylet prior to removal of the needle as this may reduce incidence of
post-LP headache.
16. Remove LP needle and apply pressure over puncture site. The patient should be
kept recumbent in a semi-prone position for approximately 1 hour post
procedure.
17. The physician must label the specimens (hospital # and date of birth) before
they are taken out of the room.

IV. DIAGRAM AND ILLUSTRATIONS:

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V. NURSING RESPONSIBILITIES

Pre-procedure:

1.
Inform patient and significant others if applicable.
2.
Prepare equipment on trolley as for above.
3.
Ensure patient has an empty bladder.
4.
If monitoring is required ensure parameters are set appropriately.
5.
Ensure analgesia is provided if appropriate.
6.
Place patient in either lateral recumbent position with knees and head tucked
towards each other or sitting (leaning) over a bedside table.
7. Ensure patient is aware of the importance of positioning during the procedure.
 Compliance from the patient is necessary to maintain flexion of the lumbar region to
safely insert the needle

Procedure:

1. Remain and support patient through the procedure.

2. Assist with procedure as directed by Medical Officer.
 Monitor pressure (normal is 5-15mmHg).
 1/2mls 10drops into each specimen tube.
3. Band-Aid is applied over insertion site.

Post procedure:

1. Monitor vital signs hourly.

2. Administer analgesia as required/prescribed.
3. Check puncture site for leakage (especially if headache is severe).
4. Encourage fluid intake if applicable.
5. Maintain patient in supine position for 4 hrs.
6. Be aware of post LP complications such as:
 Headaches
 Infection
7. Maintain a quiet environment.
8. Ensure specimens are sent to appropriate laboratory for analysis.

REFERENCES:

 Bucher, L & Melander, S (1999) Critical Care Nursing. W.B. Saunders Company,
Philadelphia
 Hickey, J. V. (1999). Clinical Practice of Neurological and Neurosurgical Nursing.
Lippincott, Philadelphia
 http://www.bcchildrens.ca/NR/rdonlyres/6B320898-6521-4FEC-ABE3-
9D555B64C6C6/12799/LPs1.pdf

Date Clinical Instructor's Initial

Arnuco, Grant Wynn B.

BSN III- A

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