CHHS16/239

Canberra Hospital and Health ServicesClinical ProcedureLumbar Puncture – Nurse Assisting Guidelines – Adults OnlyContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Assisting Lumbar Puncture.....................................................................................2

Implementation........................................................................................................................ 5

Related Policies, Procedures, Guidelines,.................................................................................5

References................................................................................................................................ 5

Search Terms............................................................................................................................ 6

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Purpose

The purpose of this Clinical Procedure is to outline the roles and responsibilities when assisting with a lumbar puncture procedure.

A lumbar puncture is performed to collect and examine cerebrospinal fluid (CSF). CSF is collected by inserting a needle into the lumbar subarachnoid space and withdrawing the CSF. A lumbar puncture is performed for: Diagnostic purposes Administration of intrathecal medications Measuring CSF opening pressure with a manometer

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Alerts

If a lumbar puncture is performed for Creutzfeldt-Jakob Disease (CJD), single use drapes and equipment must be used. Refer to: Communicable Diseases Network Australia Creutzfeldt-Jakob Disease Guidelines 2013 located on the Policy Register.

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Scope

This document pertains to adult patients that require a lumbar puncture at Canberra Hospital.

This document applies to the following Canberra Hospital Health Services (CHHS) staff working within their scope of practice: Medical Officers Registered Nurses and Midwives Student Nurses and Midwives working under supervision

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Section 1 – Assisting Lumbar Puncture

Equipment Dressing towels x 2 Fenestrated drape and basic dressing pack Lumbar puncture set or, if preferred, a 22 gauge lumbar puncture needle, manometer,

specimen jars x 3 and glucose tube Spare lumbar puncture needles Gown & sterile gloves

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Personal protective equipment (PPE): gown, protective glasses / goggles or face shield Dressing e.g. occlusive dressing Local anaesthetic, lignocaine 1% ampoules x 2 Drawing up needle x 2 10 ml syringe x 2 Alcoholic chlorhexidine 2% skin preparation Patient identification labels Sedation and anti-emetic if required IV set-up kit if required Underpad to protect bed linen Sharps container Clinical waste bin Cytotoxic PPE and waste bin/sharps container if patient is receiving cytotoxic

medications or chemotherapy

Procedure1. Ensure relevant admission process is completed by Clerical, Medical Office and Nurse if

required2. Patient identification check and ID label secured, as per CHHS Patient Identification

policy3. Record baseline observations and neurological status4. Have the patient empty their bladder before the procedure is performed 5. Ensure privacy6. Have patient change into a hospital gown7. Ensure the medical officer explains the procedure to the patient, outlines possible post-

procedure symptoms, and obtains verbal consent.8. Insert IV cannula if required for sedation9. Perform hand hygiene10. Obtain a procedural trolley, clean all surfaces with detergent impregnated wipes11. Perform hand hygiene12. Prepare equipment on the aseptic field13. Position the patient in the left lateral position with flexed back close to the edge of the

bed, knees flexed, neck flexed, and arms under knees, or position as requested by the medical officer

14. Arrange patient’s lower limb clothing to expose lower lumbar area15. Administer sedation if ordered by the medical officer and document in the patient’s

medication chart. Patients pulse oximetry should be monitored and recorded if sedation is administered.

16. Assist the medical officer as required during the procedure17. Stand in front of the patient and reassure the patient during the procedure. Encourage

the patient to breathe normally and relax as much as possible to prevent excessive muscle tension. Rationale: Excessive muscle tension may result in a false reading of CSF pressure

18. Once the needle is in the subarachnoid space, assist the patient to relax and extend neck and legs, as directed by the medical officer. Otherwise, the patient must remain in the required position during the procedure

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19. The nurse may occasionally be requested to apply pressure over the jugular veins for the Queckenstedt test during the procedure. This test is used to determine whether or not the flow of CSF is blocked in the lumbar subarachnoid space. It is performed by measuring the CSF pressure and observing the change in pressure after manual compression of the jugular veins.

20. During the procedure continually observe patient's colour, respiration and level of consciousness. If multiple lumbar puncture attempts are required, it is advisable that patients’ blood pressure be monitored and recorded (e.g. 5 minutely or as directed by the medical officer). Note: During the procedure patients may experience backache (this can last several days) and shooting pain down the legs. It usually settles once the needle is removed

21. Ensure sterile dressing is secured over the puncture site 22. Ensure equipment is discarded appropriately 23. Perform hand hygiene24. Ensure pathology request form is completed by the medical officer with the patient’s full

name, date of birth and MRN. Ensure specimen labels are completed by the medical officer (as per Patient Identification procedure)and placed on the following specimens: CSF specimens x 3, glucose tube, along with any blood vials by the medical officer performing the procedure

25. Confirm patients’ identification by verbal confirmation with patient, patient’s identification band, the Pathology Request form, and labelled specimens

26. Assist the patient to a supine position with maximum one head pillow for the time prescribed by the medical officer

27. Observe the puncture site half hourly for a minimum of one hour (or as time specified by consultant) for CSF leakage, swelling or bleeding. Notify the medical officer if signs are evident

28. If patient required sedation, perform vital signs every 15 minutes for one hour post procedure

29. Administer analgesic and/or antiemetic as required30. Ensure documentation of the procedure is recorded in the patient's clinical record.

Completed nursing documentation as required 31. Provide post procedural patient education on potential side effects and management.

Headache: Regular Analgesic, lying down and increase fluid. Rationale: headache is caused by leakage of CSF from puncture site. Headaches can be exacerbated by being in an upright position and is relieved by lying down.

Nausea and Vomiting: Administer antiemetic.

Inform patient to seek medical advice if they experiences limb weakness or numbness, incontinence, draining of blood or persistence pain at insertion site, and persistence headaches.

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Implementation This procedure will be:

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Discussed at in-service education Distributed to staff via email Available on ACT Health Intranet Policies and Procedures

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Related Policies, Procedures, Guidelines,

Policies and Standard Operating Procedures Canberra Hospital and Health Services Standard Operating Procedure: Aseptic Non

Touch Technique, Document Number CHHS14/011 Canberra Hospital and Health Services Clinical Procedure: Healthcare Associated

Infections, Document Number CHHS15/072 Consent and Treatment Policy Canberra Hospital and Health Service: Patient Identification and Procedure Matching,

Document Number CHHS14/052 Canberra Hospital and Health Services Clinical Policy: Medication Handling, Document

Number CHHS15/086 Canberra Hospital and Health Service Procedure: Code Blue Response Procedure-

Adults, Paediatrics, Neonates, Document Number CHHS14/045

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References

1. Smith, S F., Duell D J., Martin B C., (2004) Clinical Nursing Skills-Basic to Advanced, 6th

Edition, Pearson Education, New Jersey, Chapter 21 Diagnostic Procedures, Fluid Analysis and Microscopic Studies, pages 689-690.

2. Australian Government Department of Health, 2013, Infection Control guidelines for the prevention of transmission of Infectious Diseases in the healthcare setting. Accessed 5/7/16; <http://www.health.gov.au/internet/main/publishing.nsf/content/icg-guidelines-index.htm>

3. John Hopkins Medicine, Health Library, Lumbar Puncture. Accessed on 4/7/16; <http://www.hopkinsmedicine.org/healthlibrary/test_procedures/neurological/lumbar_puncture_lp_92,p07666/>

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Search Terms

Lumbar Puncture, needle, CJD, Queckenstedt test, CSF pressure, and CSF leak.

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 8 August 2016

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Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register