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GASTROINTESTINAL SYSTEM • Patients susceptible to accumulating respiratory
Preoperative
DEEP BREATHING EXERCISES
• Deep breathing and coughing exercises remove
secretions from the airways and facilitate
respiratory function.
• Voluntary coughing exercises in conjunction with
deep breathing facilitate the movement and
expectoration of secretion in the respiratory tract.
Frequent deep breathing automatically initiates
the cough reflex.
Types
DIAPHRAGMATIC
Technique: Place one hand on the abdomen, and the
other on the chest. Inhale deeply through the nose,
focusing on expanding the abdomen while keeping the
chest relatively still. Hold air in your lungs for five counts.
Exhale slowly, while the abdomen hand moves inward
and the chest hand remains still.
Effect: Stimulates the diaphragm to descend, promoting
deeper inhalation and increased oxygen intake. It can
help improve lung capacity and efficiency.
PURSED-LIP BREATHING
• Help maintain open airways by maintaining positive
pressure longer during exhalation.
Technique: Involves inhalation through the nose
followed by exhalation through pursed lips, as if blowing
out a candle. Exhalation is slower and more controlled
compared to inhalation.
Effect: Creates back pressure in the airways, preventing
them from collapsing too quickly. This reduces the effort
required to breathe out and helps alleviate shortness of
breath, particularly in individuals with obstructive lung
diseases like COPD.
OBJECTIVES
→ To facilitate a wide exchange of gases
→ To maximize the amount of oxygen available
→ To lower heart rate and and blood pressure
→ To decrease muscle tension
→ Strengthen the immune system
→ Activates the body's relaxation response
→ Reduces stress hormones
→ To make client relaxed
ASSESSMENT
1. Assess level of consciousness
2. Evaluate vital signs
3. Observe breathing pattern
4. Evaluate respiratory rate & pulse oximetry findings
5. Collect subjective data using interview questions
INDICATION
• Patients on bedrest or those who have undergone
any surgical procedure (e.g. abdominal or chest
surgery).
• Patients prone to pulmonary problems.
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problems.
• Patients who have had abdominal or chest surgery
need to perform deep breathing at least 3-4 turns
daily. Each session should include a minimum of 5
deep breaths.
• Deep breathing should be performed every hour
while awake.
• Deep breathing may be performed every hour,
especially by patients who are prone to pulmonary
problems.
EQUIPMENT
INCENTIVE SPIROMETER
o A medical device used to help patients improve the
functioning of their lungs.
o It consists of a clear plastic chamber connected to
a tube with a mouthpiece or a facemask. Inside the
chamber, there's a piston or a ball that moves up as
the patient inhales.
Uses:
o The primary purpose of an incentive spirometer is to
encourage deep breathing and to prevent lung
complications such as atelectasis (partial collapse
of the lung) and pneumonia, especially after surgery
or prolonged bed rest.
When is it used?
o Post-Surgery Recovery
o Respiratory Conditions
o Physical Rehabilitation
o Prevention of Respiratory Complications
NURSING CONSIDERATIONS
1) Encourage the client to do deep-breathing and
coughing exercises hourly, or at least every 2 hours,
during waking hours for the first few days.
2) Assist the client to a sitting position in bed or on the
side
3) Educate patients on the device's importance and
proper technique. Evaluate patients' suitability for
using incentive spirometry based on their condition
and capabilities
4) Assess the usage of the device and progress to track
improvements and address any issues.
5) Be vigilant for adverse effects and prompt
intervention are crucial to prevent complications.
EVALUATION
o Check for breath sounds after the procedure
o Check if the patient is feeling any dizziness,
lightheadedness or tingling sensations during and
after the procedure.
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DEEP BREATHING EXERCISE PROCEDURE

STEPS
1. Assist client to fowlers or sitting position
2. Have client place hands palm down, with middle
fingers touching, along lower border of rib cage
3. Ask client to inhale slowly through the nose, feeling
middle fingers separate. Hold breath for 2 or 3
seconds.
4. Have client exhale slowly through mouth. Repeat
three to five times
5. Instruct, reinforce, and supervise deep-breathing
exercises every 2-3 hours postoperatively.
6. Document procedure
RATIONALE
Upright position allows increased diaphragmatic excursion
secondary to downward shift of internal organs from gravity
This position allows client to feel movement of diaphragm,
indicating a deep breath.
Inhaling through the nose allows air to be filtered, warmed,
and humidified. Holding breath allows lungs to expand
fully.
Slow expulsion of air frequently initiates the coughing
reflex, which facilitates expectoration of mucus and
prevents hyperventilation.
Performing these exercises every two to three hours will
facilitate pulmonary ventilation and promote airway
clearance without overtiring the client
Maintains legal record and communicates with the
healthcare team.

COUGHING EXERCISE PROCEDURE

STEPS
1. Assist client to fowlers or sitting position
2. If adventitious breath sounds or sputum is present,
have client take a deep breath, hold for 3 seconds,
and cough deeply two or three times. Stand to the
client's side to ensure the cough is not directed at
you. Client must cough deeply, not just clear the
throat.
3. If the client has an abdominal or chest incision that
will cause pain during coughing, instruct the client to
hold a pillow firmly over the incision (splinting) when
coughing.
4. Instruct, reinforce, and supervise deep-breathing and
coughing exercises every 2 to 3 hours postoperatively
5. Document procedure.
RATIONALE
Upright position allows increased diaphragmatic excursion
secondary to downward shift of internal organs from gravity
Several consecutive coughs are more effective than one
single cough at moving mucus up and out of the respiratory
tract.
Coughing uses abdominal and accessory respiratory
muscles, which may have been cut during surgery.
Splinting supports the incision and surrounding tissues and
reduces pain during coughing.
Performing these exercises every 2 to 3 hours will facilitate
pulmonary ventilation and promote airway clearance
without overtiring the client
Maintains legal record and communicates with the
healthcare team.

USING AN INCENTIVE SPIROMETER

1. Hold or place the spirometer in an upright position. A tilted flow-oriented device requires less effort to raise the
balls or disks; a volume-oriented device will not function correctly unless upright.
2. Exhale normally.
3. Seal the lips tightly around the mouthpiece.
4. Take in a slow, deep breath to elevate the balls or cylinder, and then hold the breath for 2 seconds initially,
increasing to 6 seconds (optimal), to keep the balls or cylinder elevated if possible.
5. Remove the mouthpiece and exhale normally.
6. Cough after the incentive effort. Deep ventilation may loosen secretions, and coughing can facilitate their removal.
7. Relax and take several normal breaths before using the spirometer again.
8. Repeat the procedure several times and then 4 or 5 times hourly. Practice increases inspiratory volume, maintains
alveolar ventilation, and prevents atelectasis (collapse of the air sacs).
9. Clean the mouthpiece with water and shake it dry.

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WOUND CARE (DRESSING) EQUIPMENTS
• Wound dressings are materials applied to wounds to o Sterile forceps, Sterile Water, Pick up forceps, Kidney
promote healing, protect them from infection, and Basin, Sterile cotton balls, OS Micropore, Cidex
prevent further injury. Solution, Betadine, Hydrogen Peroxide, NSS Cotton
• They come in different forms and types; each with its applicator, Antibacterial ointment, Bandage scissors
purposes and benefits.
NURSING CONSIDERATIONS
2 TYPES OF SURGICAL WOUNDS o Assess the wound's size, appearance, and any
1. Incisional Wounds drainage.
• Are made by cutting through skin, muscle, and fat so o Choose the right dressing based on the wound's
that a body part can be repaired or removed. Small condition.
incisions are also created during laparoscopic and o Clean the wound using sterile techniques.
robotic surgery o Manage pain during and after wound care.
o Watch for signs of infection like redness or pus.
2. Excisional Wounds o Teach patients and caregivers how to care for the
• Are made for removal of cyst or other type of tissue wound.
o Check the wound regularly and adjust care as
2 TYPES OF DRESSING needed.
1. Primary Dressing o Ensure patient comfort during wound care
• Placed directly over the wound procedures.

2. Second Dressing EVALUATION

• Used to cover or hold a primary dressing in place 1) The client demonstrates progressive healing of
wound as evidenced by the ff:
KINDS OF DRESSING: o Wound edges closing together
Protective o Reduced swelling and redness of wound edges
→ Transparent Film, Silicone Dressing, Hydrogel o Reduction in amount and color of drainage
Dressing, Impregnated Gauze, Dry Gauze o Decreased wound pain
2) The client remains free of infection, with normal
Antibacterial temperature, WBC, absence of wound swelling,
odor, and purulent drainage, and no increase in pain.
→ Antibacterial Ointment, Iodosorb (cadexomer
3) The client practices self-care behaviors to promote
iodine), Silver Based Dressing
healing by the following:
o Washing hands appropriately
Absorbent
o Keeping hands away from the wound, wound
→ Foam Dressing, Alginate Dressing, Collagen
drainage, and dressing
Dressing, Hydrofiber
o Maintaining a well-balanced diet, as ordered
o The client verbalizes and demonstrates an
Debriding
understanding of wound and dressing care.
→ Hydrogel, Hydrocolloid

OBJECTIVES
→ To promote fast healing of the wound
→ To prevent debris/damaged cells
→ To prevent bacterial growth from mechanical injury
→ To absorb drainage or debride a wound or both

ASSESSMENT
1. Assess clients condition
2. Assess for signs of complication (hemorrhage,
infection, and dehiscence).
3. Assess wound appearance, drainage, swelling, odor,
dehiscence, and pain.
4. Gather data from patients about the level of comfort,
pain, and tenderness.

INDICATIONS
• Open wounds
• Infected wounds
• Removal of stitches, staples, or clips while
removing drains
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 RLE116GEP
PROCEDURE
STEPS RATIONALE
1) Assemble all equipment. This saves time and energy.

2) Verify the physician's order. This clarifies type of dressing.

3) Wash your hands. This deters the spread of microorganisms.
4) Identify the patient.
5) Explain the procedure to the patient, including the To gain client cooperation and to reduce apprehension
importance of not touching the exposed wound.
6) Provide privacy. Assist the patient to the most This provides for comfort.
appropriate position for the dressing change
7) Provide a clean area in performing the procedure
8) Place kidney basin/cuffed plastic bag near your work Soiled dressings may be placed in disposal plastic bag
area; Provide adequate lighting without contaminating outside surfaces of bag
9) Loosen tape on dressing and remove by holding down Pressing down on skin provides counter traction against
the skin and pulling the tape gently but firmly toward the pulling motion. Tape is pulled toward the incision to
the wound and the direction of hair growth. Use prevent strain on the sutures or wound. Using
adhesive remover if necessary. If tape is soiled, don solvents/adhesive remover lessens discomfort especially
gloves. on hairy areas.
10) Don clean disposable gloves, and remove soiled Using clean gloves protects the nurse when handling
dressings carefully in a clean to less clean direction. contaminated dressings. Cautious removal of dressing is
Do not reach over wound. Check position of drains more comfortable for patient and ensures that drain is not
before removing dressing. If dressing is adhering to removed if one is present. Sterile saline provides for easier
skin surface, it may be moistened by pouring a small removal of dressing
amount of sterile saline onto it. Keep soiled side of
dressing away from client's views.
11) Assess amount, color, consistency, odor of drainage Wound healing process or infection should be documented
12) Inspect the wound and surrounding skin for
appearance of the drainage and approximation of the
wound edges.
13) Discard dressings in plastic disposal bag. Pull off Proper disposal of dressings prevents spread of
glove inside out and drop it in bag/waste receptacle microorganisms by contaminated dressings
14) Using aseptic technique, open sterile dressings and Supplies are within easy reach, and sterility is maintained
supplies on work area
15) Don sterile gloves or may use sterile forceps Using sterile gloves/forceps maintains surgical asepsis
16) Clean wound or surgical incision.
17) Clean from top to bottom or from center outward a) Cleaning is done from least to most contaminated area
18) Use one cotton ball/gauze square for each wipe, b) Previously cleaned area is not re-contaminated
discarding each ball/gauze by dropping into plastic c) Movement in this manner ensures cleaning from least
bag. Do not touch disposal bag. to most contaminated area.
19) Clean around drain, if present, moving from center d) Moisture provides medium for growth of
outward in a circular motion. Use one cotton microorganisms. Growth of microorganisms may be
ball/gauze for each circular motion retarded and healing process improved
20) Dry wound using gauze sponge or cotton ball and
same motion
21) Apply antiseptic ointment, if ordered, using cotton
applicator.
22) Apply the sterile dressing, using aseptic technique. If Drainage is absorbed and wound is protected.
with drain, place 2 pre-cut sterile gauze under or
around drain.
23) Remove gloves from inside out, and discard
24) Apply tape to secure dressings Tape is easier to apply after gloves have been removed
25) Assist client to a comfortable position , Return
equipment, Perform handwashing
26) Record dressing change and appearance of wound, Accurate documentation of procedure ensures continuity
and describe any drainage in the chart. Check of care and provides information for future assessments.
dressing and wound site every shift

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 RLE116GEP
SURGICAL DRAINAGE
• Surgical drains are tubes placed near surgical
incisions in the post-operative patient, to remove
pus, blood, or other fluid, preventing it from
accumulating in the body.
• The type of drainage system inserted is based on
the needs of patient, type of surgery, type of
wound, amount of drainage expected and surgeon
preference
JACKSON-PRATT
• A soft pliable tube with multiple perforations and a
bulb that can recreate low negative pressure
vacuum, designed so that body tissues are not
sucked into the tube, decreasing risk of bowel
perforation.
OBJECTIVES
→ To make sure drains do not clot or clog.
→ To maintain proper hygiene.
ASSESSMENT
INITIAL PHASE
o Surgical drains should be assessed 1-4 hourly
throughout the shift.
o Assess drain insertion site for signs of fluid or air
leakage, redness or irritation to the skin.
o Document site conditions and notify the treating
team if any concerns arise.
o Assess if the drain is maintaining suction.
o Assess securement type and document on line
drains and airway (LDA).
o Assess patency of drain. Ensure drain is located
below the insertion site and free from kinks or knots.
o Document amount, output appearance, type of fluid
in drain bottle/receptacle and drain status on LDAs
ONGOING PHASE
o Monitor for infection.
o Signs of infection include redness, tenderness at
the drain site, warmth at the site, increased ooze, or
a change in collection fluid to purulent, or if the
patient is febrile.
o Drain patency and insertion site should be observed
at the beginning of your shift and before and after
moving a patient. A kinked, disconnected, dislodged
or blocked drain tube can lead to formation of
hematoma, increased pain and risk of infection.
o Drainage needs to be documented at a minimum 4
hours and more frequently if output is high. This
needs to be documented in flowsheets in the
sections “Output in previous hours” and “Chamber
reading” so an accurate fluid balance is maintained
o Suction needs to be assessed throughout the shift.
Suction will no longer be maintained once the drain
becomes full. This drain will need to be emptied,
changed or suction reapplied.
o Discuss removal plans with the treating team.
Drains should be removed as soon as practicable,
the longer a drain remains in situ, the higher risk of
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infection or development of granulation tissue. This
can cause pain and trauma upon removal.
o Pain should be assessed whilst the drain is in situ.
Appropriate analgesia should be provided when
necessary. Please refer to the pain assessment and
management guideline for more information.
EQUIPMENTS
o Measuring Container, Gloves, Alcohol Prep
PROCEDURE
1. Have all the supplies you need in front of you
2. Explain the procedure to the client.
To obtain trust and cooperation.
3. Perform proper hand hygiene
4. Milk the tubing before emptying the drainage bulb
Milking helps you move clots through your tubing and
keep drainage flowing.
5. Pinch the tubing close to where it goes to your skin.
6. With your thumb and forefinger of your other hand,
pinch the tubing below your other fingers.
7. Keeping your fingers pinched, slide them down the
tubing. Keep doing this until any clots are out of the
tubing into the bulb.
8. Unplug the stopper
9. Turn the bulb upside down and gently squeeze it,
pouring the contents into a measuring container.
10. With your thumb and forefinger of your other hand,
pinch the tubing below your other fingers.
11. Turn the bulb right side up and squeeze the bulb
enough.
For air to come out.
12. Keep squeezing the bulb until you plug in the stopper.
For the bulb to remain compressed.
13. Secure the drain, not letting it dangle.
14. Check the color and the amount of drainage in the
measuring container
15. Write both in the Jackson Pratt drainage record.
16. Note the measurements in the container are in
milliliters.
17. Empty the drainage down the toilet.
18. Do aftercare of equipment. Wash hands.
NURSING CONSIDERATIONS
1) Milking your tubing to help move clots.
2) Emptying your drains 2 times a day. Do this once in
the morning and once in the evening.
3) Write down the amount of drainage on your Jackson-
Pratt drainage log at the end of this resource. If you
have more than 1 drain, measure and write down the
drainage of each one separately. Do not add them
together.
4) Caring for your insertion site.
5) Checking for problems.
EVALUATION
The drain will remain patent, the wound is not
contaminated during care, no trauma is caused to the
wound, and the client did not experience pain or
discomfort.
 RLE116GEP
ABDOMINAL BINDER
• Application of Abdominal binder is the application of
support or protection to the abdomen
TYPES
Straight Abdominal Binder
• Is a rectangular piece of cotton or elasticized
material that has a long extension on each side to
surround the abdomen.
Scultetus (many-tailed) Binder
• Has many tails attached to the two longer sides to
provide support to the abdomen and retain
dressings.
OBJECTIVES
→ To support large abdominal incisions that are
vulnerable to tension or stress as the client moves or
coughs.
→ To hold dressing in place.
→ To apply pressure.
ASSESSMENT
• Observe clients with need for support of the thorax or
abdomen. Observe the ability to breathe deeply and
cough effectively.
• Review medical records if a medical prescription for
a particular binder is required and reasons for
application.
• Inspect skin for actual or potential alteration in
integrity. Observe for irritation, abrasion, skin
surfaces that rub against each other or allergic
response to adhesive tape used to secure dressing.
• Inspect any surgical dressing.
• Assess the client's comfort level, use analog scale of
0 to 10 and noting any OBJECTIVE signs and
symptoms.
• Gather necessary data regarding size of client and
appropriate binder.
INDICATIONS
o Abdominal binders are often recommended for
various conditions like post-surgery, hernias, or back
support.
o Indications for using one include providing support,
reducing pain, and promoting healing in the
abdominal region. Always follow your healthcare
provider's advice for proper usage.
NURSING CONSIDERATIONS
BEFORE:
o Assessment: Conduct a thorough assessment of
the patient's abdomen, including any wounds,
surgical incisions, or hernias. Assess for any
contraindications to using an abdominal binder,
such as compromised circulation or respiratory
issues.
o Patient Education: Educate the patient about the
purpose of the abdominal binder, how to properly
wear and adjust it, and potential complications to
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watch for. Emphasize the importance of reporting
any discomfort or changes in sensation promptly.
o Preparation: Ensure the appropriate size and type of
abdominal binder are selected based on the
patient's needs and condition. Prepare the
necessary supplies, including any additional
dressings or padding that may be required.
DURING:
o Application: Carefully apply the abdominal binder
according to the manufacturer's instructions and
the healthcare provider's recommendations.
Ensure proper alignment and snugness without
excessive tightness that could compromise
circulation or breathing.
o Assessment: Continuously assess the patient's
comfort, breathing, and skin integrity while wearing
the binder. Monitor for any signs of discomfort, skin
irritation, or difficulty breathing, and adjust the
binder as needed.
o Monitoring: Regularly monitor vital signs,
particularly respiratory rate and depth, to ensure the
binder is not impeding breathing. Observe for any
signs of complications such as increased pain,
swelling, or changes in skin color or temperature.
AFTER:
o Reassessment: After application, reassess the
patient's abdomen and overall condition to ensure
the binder is providing the intended support and
comfort. Evaluate any changes in pain level,
mobility, or respiratory status.
o Patient Comfort: Address any discomfort or
concerns the patient may have related to wearing
the abdominal binder. Provide appropriate pain
management and assist with repositioning or
adjustment of the binder as needed for optimal
comfort.
o Education and Follow-up: Provide thorough
discharge instructions, including how long to wear
the binder, when to remove it for activities such as
bathing, and signs of complications to watch for.
Schedule follow-up appointments as needed to
monitor the patient's progress and adjust the
treatment plan accordingly.
EVALUATION
Scultetus and straight abdominal binder keeps dressing
in place and supports the abdomen.
 RLE116GEP

STRAIGHT ABDOMINAL BINDER PROCEDURE

1. Explain the procedure
2. Prepare the needed equipment (specify what type of binder is needed).
3. Able to give the purpose(s) of placing abdominal binder
To promote proper support to the abdominal area
4. Wash hands and wear gloves, if necessary (if with drainage)
5. Provide Privacy
6. Loosen top sheet at foot part
7. Position patient in supine position with head slightly elevated and knees slightly flexed
8. Instruct and help the client roll away from the nurse toward the raised side rails while supporting abdominal incision
and dressing firmly with the hands. Place the fan folded binder under the patient’s lower back, in the same manner
as applying a sheet for an occupied bed
9. Instruct or assist the client to roll over folded ends
10. Unfold and stretch ends out smoothly on the far side of the bed
11. Instruct client to roll back into supine position
Facilitates chest expansion and adequate wound support when binder is closed
12. Adjust binder so that client is centered over the binder using symphysis pubis and costal margins as lower and
upper landmarks
Centers support from binder over abdominal structures, which reduces incidence of decreased lung expansion
13. Close binder. Pull one end of the binder over the center of the client's abdomen. While maintaining tension on that
end of the binder, pull the opposite end of the binder over center and secure Velcro closure tabs, metal fasteners,
or horizontally placed safety pins
14. Assess the client's comfort level Adjust binder as necessary

SCULTETUS BINDER PROCEDURE

1. Prepare the needed equipment. Secure the kind of binder needed and the number of pins necessary or tapes.
2. Explain the procedure to the client. Teach skill to clients or significant others.
3. Wash hands and wear gloves (if likely to contact wound drainage).
4. Provide privacy
5. Apply binder
6. Position client in supine position with head slightly elevated and knees flexed
Minimizes muscular tension on abdominal organs
7. Fan-fold the far side of the binder toward the midline of the binder
Reduces time client remains in an uncomfortable position
8. Instruct and help the client to roll away from the nurse toward the raised side rail while firmly supporting
abdominal incisions and dressing with hands
9. Able to rationalize why the patient's knees are slightly flexed
Minimizes muscular tension on abdominal organs
10. (Take note of the client’s case)
For obstetrical or OB Surgical clients: - Start overlapping the tails from the top moving toward the bottom.
For Non- OB Surgical clients: - Start overlapping the tails from bottom moving toward the top.
11. Able to identify the difference in applying binder of an obstetric patient from non- OB surgical patients.
12. Secure the top or bottom pair of tails with a horizontally placed pin for each end.
13. Remove gloves (if there are any). Arrange beddings. Make the patient comfortable.
14. Observe site for skin integrity, circulation, and characteristics of wound (periodically remove binder and surgical
dressing to assess wound characteristics.)
15. Assess comfort level of the client, using analog scale of 0 to 10 and noting any OBJECTIVES signs and symptoms.
16. Assess client’s ability to ventilate properly
17. Identify client’s needs for assistance with activities such as hair combing, dressing and ambulating.

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ASSISTING IN LUMBAR PUNCTURE
• The insertion of a large needle through the
intervertebral space in the lumbar region of the spine
to enter the spinal canal, subarachnoid space below
the level of termination of the spinal cord between
L3-L4 or L4-L5 region for the purpose of studying
cerebrospinal fluid.
• Other names of Lumbar Puncture: Spinal Tap, CSF
Examination, Spinal Puncture
SPINAL CORD
• It begins at the level of the foramen magnum and
extends downward through the vertebral column to
the level of the disk between the first and second
lumbar vertebrae.
• Covered and protected by three meninges or
membranes, which are downward extensions of
those that cover the brain.
DURA MATER (HARD MOTHER)
• Outermost membrane, and it is composed of dense
connective tissue.
• This tough sheath extends downward to the level of
the second sacral segment where it ends as a blind
sac.
ARACHNOID MEMBRANE
• is a thin, transparent sheath, which lies immediately
under the dura mater and follows it to the end of the
dura sac.
SUBARACHNOID SPACE
• A relatively roomy area between the arachnoid and
pia mater. It is filled with spinal fluid or cerebrospinal
fluid (CSF) since it is also found in the cranial
subarachnoid space.
PIA MATER (GENTLE MOTHER)
• Innermost layer of the meninges that is very closely
applied to the spinal cord.
CEREBROSPINAL FLUID
• CSF that is withdrawn is evaluated for color, blood,
cells, bacteria, malignant cells, glucose, protein,
chloride, lactic dehydrogenase, lactic acid and
glutamine.
• It is generally used to diagnose or rule out such things
as: primary or metastatic brain or spinal cord
neoplasm, cerebral hemorrhage, meningitis,
encephalitis, degenerative brain disease,
autoimmune diseases of the CNS, demyelinating
disorders (such as MS), neurosyphilis.
OBJECTIVES
→ Ensure the patient is comfortable and well- informed
about the procedure.
→ Maintain a sterile environment to minimize the risk of
infection
→ Assist the healthcare provider in positioning the
patient correctly for the lumbar puncture
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→ Identify the anatomical structures, indications, and
contraindications of lumbar puncture.
→ Describe the equipment, personnel, preparation,
and technique in regards to lumbar puncture.
→ Review the potential complications and clinical
significance of lumbar puncture.
→ Outline interprofessional team strategies for
improving care coordination and communication to
advance lumbar puncture and improve outcomes.
ASSESSMENT
1. Assess vital signs and other pertinent health status
before, during, and after the procedure.
2. Assess the patient's ability to maintain the position
necessary for the procedure.
3. Assess the patient's knowledge of the procedure to
be performed.
4. Review pertinent laboratory tests prior to procedure.
5. Evaluate the signs and symptoms that may indicate a
potential problem if the test is performed.
6. Ensure that cerebrospinal fluid (CS) specimens are
correctly labeled and send them immediately to the
laboratory with the completed requisition form.
7. Assess the puncture site for leakage of cerebrospinal
fluid (CSF).
INDICATIONS
Cerebrospinal Fluid Analysis:
o To obtain cerebrospinal fluid (CSF) for analysis,
which can aid in diagnosing various neurological
conditions, such as infections (meningitis,
encephalitis), bleeding, and certain inflammatory
disorders.
Infection Diagnosis:
o To identify the presence of infectious agents in the
CSF, helping diagnose bacterial, viral, or fungal
infections affecting the central nervous system.
Evaluation of Intracranial Pressure:
o To measure intracranial pressure directly,
particularly in cases of suspected elevated pressure
due to conditions like hydrocephalus or tumors.
Neurological Disorders:
o To assist in diagnosing neurological disorders,
including multiple sclerosis or certain types of
neuropathies.
Subarachnoid Hemorrhage:
o In cases of suspected subarachnoid hemorrhage,
the lumbar puncture can detect the presence of
blood in the CSF, aiding in the diagnosis of conditions
like ruptured aneurysms.
Guillain-Barré Syndrome Diagnosis:
o To help diagnose Guillain-Barré syndrome, a disorder
affecting the peripheral nervous system.
Therapeutic Interventions:
o To administer medications directly into the CSF,
such as antibiotics for central nervous system
infections or chemotherapy for certain types of
cancer.
 RLE116GEP
Evaluating Demyelinating Diseases:
o To assist in the evaluation of demyelinating diseases,
such as neuromyelitis optica or transverse myelitis.
Alzheimer's Disease Research:
o In some research settings, lumbar punctures are
used to collect CSF for biomarker analysis, aiding in
the study of conditions like Alzheimer's disease.
EQUIPMENT
o Lumbar puncture tray, Spinal needle gauge 22-23,
Alocoprep, 5cc syringe, OS (6 pieces) sponges 4x4,
Xylocaine 2% nebule, Disposable needle gauge 23-
24, Eye sheet, Empty sterile pan G bottle (3 pieces)
specimen containers, Withdrawal needle gauge 19,
Flashlight, Adhesive tape, Sterile gloves, Kidney
Basin, Manometer, Three-way stopcock, Pressing
tray with betadine, Small dressing to put over the
puncture site, Mask
PROCEDURE (CHECK EVAL TOOL)
NURSING CONSIDERATIONS
BEFORE THE PROCEDURE
o Explain the procedure to the patient. Explain to the
patient the purpose of lumbar puncture, how and
where it’s done, and who will perform the procedure.
o Obtain informed consent. Make sure the patient has
signed a consent form if required by the institution.
o Reinforce diet. Advise the patient that fasting is not
required.
o Promote comfort. Instruct the patient to empty the
bladder and bowel before the procedure.
o Establish baseline assessment data. Do vital signs
monitoring and neurologic assessment of the legs by
assessing the patient’s movement, strength, and
sensation.
o Place the client in a lateral decubitus position. Assist
the client to assume a lateral decubitus (fetal)
position, near the side of the bed with the neck, hips,
and knees drawn up to the chest. An alternative
position is to have the patient sit on the edge of the
bed while leaning over a bedside table.
o Instruct to remain still. Explain that he or she must lie
very still throughout the procedure. Any unnecessary
movement may cause traumatic injury.
DURING THE PROCEDURE
o Help patient stay in a fetal position.
o Instruct patient to breathe normally.
o Observe patients skin color, respiration, and pulse.
Continually support and reassure patient during the
lumbar puncture.
o Do not let the patient move during the procedure.
AFTER THE PROCEDURE
o Apply brief pressure to the puncture site. Pressure
will be applied to avoid bleeding, and the site is
covered by a small occlusive dressing or band-aid.
o Place the patient flat on the bed. The patient
remains flat on the bed for 4 to 6 hours depending on
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the physician. He or she may turn from side to side
as long as the head is not elevated.
o Monitor vital signs, neurologic status, and intake
and output. Take vital signs, measure intake, and
output, and assess neurologic status at least every
4 hours for 24 hours to allow further evaluation of
the patient’s condition.
o Monitor the puncture site for signs of CSF leakage
and drainage of blood. Signs of CSF leakage include
positional headaches, nausea and vomiting, neck
stiffness, photophobia (sensitivity to light), sense of
imbalance, tinnitus (ringing in the ear), and
phonophobia (sensitivity to sound).
o Encourage increased fluid intake. An increased
amount of fluid intake (up to 3,000 ml in 24 hours)
will replace CSF removed during the lumbar
puncture.
o Label and number the specimen tube correctly.
Ensure all samples are properly labeled and sent to
the laboratory immediately for further evaluation.
o Administer analgesia as ordered. Headaches after
the procedure can last for a few hours or days and
are usually treated with analgesics.
EVALUATION
1. Patient is prepared psychologically and physically for
the procedure.
2. Diagnostic tests performed with minimal discomfort.
3. Vital signs remain within normal range.
4. Specimen sent to the laboratory in appropriate
container and in a timely manner.
SIR ELMER NOTES
o PRE-OP DBE: To reduce anxiety
o POST-OP DBE: For pain; To relax muscles
LUMBAR TAP also known as:
→ Spinal Tap
→ CSF Exam
→ Spinal Puncture
LAB TESTS FOR LUMBAR TAP:
→ PCR Test (Cell count)
→ Cytology (Study of Cells)
→ Gram Stain Culture & Sensitivity (GSCS)
→ Specimen collected is placed in 3 separate bottles
3-5 cc per bottle
L4-L5 = common site for lumbar tap (less complications)
QUECKENSTEDT’S TEST (sometimes done to cancer px)
o To check blockage in jugular vein
o Complication: SPINAL STENOSIS
→ S/S: lower back pain, numbness
or tingling in lower extremities
→ If with S/S = NO LUMBAR TAP
(also if with high/increased ICP)
o Increase fluid intake to 3000 ml