A lumbar puncture involves inserting a sterile needle into the subarachnoid space to collect cerebrospinal fluid for diagnostic purposes, such as detecting infections or other CNS conditions. The procedure requires careful technique, patient positioning, and specific equipment, with considerations for contraindications and complications. Nursing implications include patient education, monitoring for adverse reactions, and ensuring post-procedure care to minimize complications.

1. LUMBAR PUNCTURE
PREPARED BY :-Prof. Blessy Thomas, MSc Nursing
Vice Principal, FNCON, SPN

2. LUMBAR PUNCTURE

3. MEANING
• It is the insertion of a sterile needle into the
subarachnoid space of the spinal canal,usually
between the third and fourth vertebra, to reach the
cerebrospinal fluid.This test requires sterile technique
and careful patient positioning.

4. DIAGNOSTIC USES FOR
LUMBAR PUNCTURE
• To determine the pressure of the cerebrospinal fluid
• To detect increased intracranial pressure
• To detect presence of blood in the cerebrospinal
fluid which indicates cerebral hemorrhage
• To obtain cerebral spinal fluid specimens for
laboratory analysis.

5. INDICATIONS
• Suspicion of meningitis
• Suspicion of subarachnoid hemorrhage
• Suspicion of central nervous system disease such as
Guillain Barre syndrome

6. CONTRAINDICATIONS
• Increased intracranial pressure
• Coagulopathy
• Brain abscess
Indications for brain CT scan prior to lumbar puncture include
the following
• Patients who are older than 60 yrs
• Patients who are immunocompromised
• Patients with known CNS lesions

7. CONTD……………
• Patients whohave had a seizure within 1 week of
presentation
• Patient with abnormal level of consciousness
• Patient with papilledema seen on physical
examination with elevated ICP.

8. EQUIPMENT
• Spinal or lumbar puncture tray
• Sterile gloves
• Antiseptic solution with skin swabs
• Sterile drape
• Lidocaine 1% without epinephrine
• Syringe 3ml
• Needles 20 and 25 gauge
• Three way stopcock
• Manometer
• Four plastic test tubes, numbered 1-4 with caps
• Sterile dressing
• Optional syringe 10ml

10. POSITIONING
• Position the patient in the lateral recumbent position
with hips, knees and chin flexed toward the chest in
order to open the interlaminar spaces. A pillow can be
used to support the head
• The sitting position may be a helpful alternative
position especially in obese patient. In order to open the
interlaminar spaces, the patient should lean forward and
be supported by a Mayo stand with a pillow on it, by a
hunching over the back of stool, or by another person

14. PROCEDURE
• Explain the procedure ,benefits, risk, complications,
and alternative options to the patient or the patients
representative and obtain a signed informed consent
• Wearing nonsterile gloves, locate the L3-L4
interspace by palpating the right and left posterior
superior iliac crest and moving the fingers medially
towards the spine.

15. Contd……….
• Palpate the interspace L3-L4 as well as one above L2-
L3 and one below L4-L5 to find the widest space
• Open the spinal tray, change to sterile gloves, and
prepare the equipment. Open the numbered plastic
tubes and place them upright, assemble the stopcock
on the manometer and draw the lidocaine into the
10ml syringe.

16. Contd…………..
• Use the skin swabs and antiseptic solution to clean the
skin in a circular motion starting at the L3-L4 interspace
and moving outward to include at least I interspace above
and below. just before applying the skin swabs, warn the
patients that the solution is very cold, since this can be
unnerving to the patient.
• Place a sterile drape below the patient and fenestrated
drapes on the patient. most spinal trays contain fenestrated
drapes with an adhesive tape that keeps the drape in place.

17. Contd…………….
• Use the 10ml syringe to administer local anesthesia.
Raise a skin wheal using the 25 gauge needle and
then switch to the longer 20 gauge needle to
anesthetize the deeper tissue. Insert the needle all the
way to the hub, aspirate to confirm that the needle is
not in a blood vessel, and inject a small amount as
the needle is with drawn a few centimeters continue
this process above, below and to the sides very
slightly.

19. Contd…………
• This process anesthetizes the entire immediate area so
that, if redirection of the spinal needle is necessary,
the area will be anesthetized. For this reason a 10ml
syringe may be more beneficial than the usual 3ml
syringe supplied with the standards lumbar puncture
kit. The 20 ga needle can also be used as a guide for
the general direction in which to aim the spinal needle
can be confirmed if the 20 ga needle encounters bone
I one direction but not in another.

20. Contd…………….
• Stabilize the needle(20 or 22 ga) with the index fingers
and advance it through the skin wheal using the thumbs.
• To measure the opening pressure, the patient must be in
the lateral recumbent position. after fluid returns from
the needle. Attach the manometer through the stopcock
and note the height of the fluid column .the patients legs
should be straightened when measuring open pressure
or a falsely elevated pressure will be obtained.

22. Contd……………
• Collect at least 10 drops of CSF in each of the 4
plastic tubes.
• Replace the stylet and remove the needle.Clean off
the skin .Apply a sterile dressing and place the patient
in the supine position

25. IMPORTANT
CONSIDERATION
• If the patient is dehydrated a falsely negative dry tap
may be obtained as a result of very low csf volume
and pressure.If this is suspected,attempt to rehydrate
the patient prior to the procedure.
• If the procedure is performed in the sitting position
and an opening pressureis required,replace the stylet
and have an assistant help the patient into the left
lateral recumbent position.

26. Contd…………….
• If the CSF flow is too slow, ask the patient to cough or
bear down as in the valsalva maneuver ,or ask an
assistant to intermittently press on the patients
abdomen to increase the flow.
• Never delay intravenous antibiotics for a lumbar
puncture or prelumbar puncture CT scan
• The smaller the needle used for the lumbar puncture ,
the lower the risk of the patient developing a post
lumbar puncture headache.

27. COMPLICATIONS
• Post spinal puncture headache.
• Infection
• Hemorrhage
• Postdural puncture cerebral herniation

28. THEORY APPLICATION
• Lydia Hall’s CORE-CARE-CURE model is
selected for this procedure .
• CORE-Refers to the person.
• CARE-Refers to the body, the intimate bodily care.
• CURE-It refers to the disease.

29. MODIFIED CORE-CARE-CURE
MODEL
CORE CARE
CURE
Those who
undergone for
lumbar
puncture and
have pain.
Comfort position,
device,divertional
therapy, medications
Reduction in pain

30. NURSING IMPLICATIONS
• Review the patients clinical record to determine the
reason for the patients scheduled lumbar puncture
procedure and what the patient has been told about the
procedure
• Assemble the necessary equipments
• Approach and identify the patient
• Interview the patient to determine his or her knowledge
of the purpose of the lumbar puncture procedure

31. Contd……………..
• As indicated ,explain to the patient the specific
purpose of the lumbar puncture procedure.
• Explain the procedure to the patient.
• Send the CSF specimen to the laboratory
immediately.
• Instruct the patient to lie flat for several hours to
reduce chance of headache.

32. Contd………………
• Monitor the patient carefully following the
procedure. Adverse reaction like
headache,vertigo,syncope,nausea,tinnitus,respiratory
distress, change in vital signs, meningitis and fever
should be reported to the professional nurse.
• Give the patient increased fluids at least 24 hours
after the procedure

33. Contd………………
• Inform the patient that the physician will report the
result of the lumbar puncture as soon as they are
available
• Ensure the comfort and safety of the patient
• Remove equipments from bed side and dispose
properly
• Record the procedure in the patients chart.

39. THANK YOU