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NEUROSCIENCE’S UNIT
LUMBAR PUNCTURE
PROCEDURE
1
Sheffield Teaching Hospitals
NHS Trust
Introduction 3
Purpose and scope of the policy 3
Policy statement 4
Definition and terminology 4
Indications for the procedure 5
Contra-Indications 5
Anatomy and physiology 6
Physiology of Cerebral Spinal Fluid 7
Spinal diagram (lateral view) 8
Principles of practice 9
Potential problems and complications of lumber puncture 12
Assessment of practice 14
Appendix 18
References 23
Introduction
2
This protocol has been written by a small group of multi professional staff
within the Neuroscience’s unit to provide a standard necessary to provide the
basis of high quality patient care.
Purpose
Scope
3. The approach must recognise registered nurses entering the Trust with
differing levels of competency
3
9. If six months elapses without the skill being undertaken, the individual
is advised to refresh themselves
Policy Statement
Cerebral Spinal Fluid – Clear, lymph-like fluid that fills the entire subarachnoid
space and surrounds and protects the brain.
INDICATIONS.
4
Purpose of performing a Lumber Puncture on the Neurosciences
Programmed Investigation Unit: -
CONTRA-INDICATIONS
4. Patient’s who are likely to have a structural lesion pressing on the spinal
cord.
5. If the nurse undertaking the procedure has assessed the patient and
remains unsure about proceeding with the investigation. This might be due
to: -
5
The spinal cord lies within the spinal column, beginning at the foramen
magnum and terminating about the Level of the first Lumbar vertebra (fig 1).
Like the brain, the spinal cord is enclosed and protected by the meninges, that
is, the dura mater, arachnoid mater and pia mater. The dura and arachnoid
mater are separated by a potential space known as the subdural space, which
contains the CSF. Below the first Lumbar vertebra, the Subarachnoid space
contains the CSF, the filum terminale and the cauda equina, (Weldon 1998).
To avoid any damage to the spinal cord, it is imperative that the Lumbar
Puncture is performed below the first Lumbar vertebra where the cord
terminates (fig 2). The cord serves as the main pathway for the ascending
and descending fibre tracts that connect the peripheral and spinal nerves with
the brain. The peripheral nerves are attached to the spinal cord by 31 pairs of
spinal nerves.
6
CSF is formed primarily by filtration and secretion from networks of capillaries
called choroids plexuses, located in the ventricles of the brain. Eventually,
absorption takes place through the arachnoid villi, which are finger-like
projections of the arachnoid mater that push into the dural venous sinuses.
CSF is clear, colourless and slightly alkaline with a specific gravity of 1005
(Draper 1989). In an adult, approximately 500ml of CSF are produced and
reabsorbed each day (Welton 1998), with 120-150ml present at one time.
CSF constituents include: -
1. Water
2. Mineral salts
3. Glucose
4. Protein (20-30mg) per 100ml (keel et al 1983)
5. Urea and creatinine
LABORATORY DETERMINATIONS:
7
Figure 2. Lateral view of the spinal column and vertebrae.
8
PROCEDURE
Equipment required
Procedure Rationale
Check medical notes
1. CT scan normal (a) To ensure patient does not have
2. Or imaging not necessary raised intracranial pressure
3. Check anti-coagulation i.e. warfarin (b) Avoid bleeding
9
Procedure Rationale
Infection control
Wash hands thoroughly and apply sterile Using aseptic technique throughout
gloves. the whole procedure. Refer to
Infection Control STH Trust Policy
Prepare the lumbosacral region by swabbing in
a spiral from the L4-5 interspace outwards until
an area of aprox 20cm in diameter has been
covered using the chlorhexidine 70% or
betadine solution. The introduction of iodine into the
Subarachnoid space can produce
Ensure that all trace of iodine is removed with irritative arachnoiditis.
alcohol prior to performing the L.P
Analgesia
This is below the level of the spinal
A lumber puncture can be performed at any of cord but still within the subarachnoid
the lumber interspaces although the L2/3 or space.
below.
To minimize discomfort
Using a syringe and size 20 gauge needle
(orange). Inject the lignocaine under the Allow the analgesia to take effect. 3-
subcutaneous layer to raise a wheal. 5mins (check with the point of a
needle against the skin surface).
Procedure
10
Procedure Rationale
Following three failed attempts, the practitioner To minimise the patient’s discomfort
should discontinue the procedure and refer to and anxiety.
the patient’s doctor.
Closing pressures should be measured before To maintain sepsis and stop fluid leak
withdrawal of the needle. After withdrawal, the
needle puncture point should be briefly To prevent infection
massaged with a sterile piece of gauze and a
plaster applied
The patient can rest for as long as they wish or Research shows that bed rest is not
alternatively the patient can get straight up. necessary and will not influence
whether a patient complains of a post
lumbar puncture headache.
Remove and dispose of sharps as appropriate. Refer to STH Trust Policy as removal
of sharps and waste.
11
Procedure Rationale
Special procedures for suspected Normal Symptoms of Normal Pressure
hydrocephalus: hydrocephalus include apraxia and
decline in cognitive function.
Ensure patient understands purpose of
procedure. Before undertaking lumbar Aim of the procedure is to determine if
puncture undertake 10 metre timed walk, mini patients neurological status improves
mental test and any other assessment detailed temporarily after removal of 20-30ml
by referring consultant. of CSF.
POTENTIAL PROBLEMS
12
ASSESSMENT
13
MANAGEMENT OF PATIENTS UNDERGOING A LUMBAR PUNCTURE.
ASSESSMENT SPECIFICATION:
The Employee is required to meet all the performance indicators at least once
to indicate completion. This may be achieved through a number of any of the
following methods of assessment, however, the observation of real work.
Followed by questioning to check underpinning knowledge is preferable in the
first instance.
14
Evidence of performance Assessment Method of Date
assessment completed
15
Evidence of performance Assessment Method of Date
assessment completed
16
APPENDICES
17
Appendix 1
Since then, there have been numerous references within later UKCC
documents and more recently within the Making A Difference: A strategy for
Nursing Document (DOH 1999:) and the new NMC Code of Professional
Conduct (NMC 2002).
18
Since nursing and midwifery is a mixture of practical skill and theoretical
knowledge, competencies should identify the skills, knowledge aptitude and
attitude needed to perform as particular skill, task or activity in any clinical
setting.
19
Appendix 2
DISCUSSION / ACTION PLAN
Please use this part of the document to record meetings relating to the
proposed achievement of elements of the clinical competencies.
Date: Assessor:
Elements Discussed:
Date: Assessor:
Elements Discussed:
Date: Assessor:
Elements Discussed:
20
Appendix 3
COMPETENCY TO PRACTICE DECLARATION
21
Appendix 4
COMPETENCY TO PRACTICE DECLARATION
I have:
Authorised by …………………
Clinical Director
Director of Nursing
Matron
22
References
Department of Health (2000). The NHS Plan: A plan for investment, a plan for
reform: Department of Health: London
UKCC (1995) PREP, London United Kingdom Central Council for Nursing,
Midwifery and Health Visiting.
23