Lumbar Puncture (Lumbar tap)
Dr. Rosalinda A. Abuy
Learning Objectives
At the end of the discussion the students will be able to:
1. Define the procedure.
2. State the purposes of the procedure
3. Enumerate the nursing considerations before, during, and after the
procedure.
4. Assist in the physician/ anesthesiologist in the execution of procedure.
5. Recognize the side effects of the procedure.
6. Apply nursing process in the care of clients and family.
Lumbar Puncture (Lumbar tap)
it is an introduction of needle into spinal subarachnoid space usually at L3 – L4, L4 – L5, L5
– S1, intervertebral space, to assess cerebrospinal fluid (CSF).
- Lumbar puncture should be performed only after a neurological examination but should
never delay potentially life-saving interventions, such as the administration of antibiotics
and steroids to patients with suspected bacterial meningitis.
- It should not be painful, but may have a headache and some back pain for a few days.
A lumbar puncture may be used to:
take a sample of fluid from your spinal cord (cerebrospinal fluid)
or measure the fluid's pressure – to help diagnose a condition
inject medications – such as painkillers, antibiotics or
chemotherapy
inject a spinal anaesthetic (epidural) – to numb the lower part of
your body before an operation
remove some fluid to reduce pressure in the skull or spine
Duration of procedure:
A lumbar puncture takes around 30 to 45 minutes, but needed to stay lying
down at the hospital for at least another hour while the nurses monitor the client.
Patient can go home the same day if he/ she feel well enough.
Contraindication
Increased intracranial pressure due to a brain tumor. Cerebral or cerebellar
herniation with severe neurological deterioration may occur after the withdrawal
of CSF fluid.
Skin infection near the puncture site. The presence of skin infection near the site
of the lumbar puncture increases the risk of contamination of infected material
into the CSF.
Severe degenerative vertebral joint disease. There will be difficulty in passing
the needle through the degenerated arthritic interspinal space.
Severe coagulopathy. Due to the significant risk of epidural hematoma formation.
Nursing considerations:
Before and During the procedure:
Encourage client to void before the procedure. To promote comfort.
Assist client to assume “fetal position” (lateral recumbent position with back
arched, head and knees flexed on chest) to widen intervertebral spaces.
Local anesthesia is used to numb lumbar area.
Label the collected specimen accurately and accordingly.
Queckenstedt’d test may be performed to test for subarachnoid obstruction. The
jugular veins are compressed for 10 seconds, first on one side, and then on the
other side; note for any change in pressure of spinal fluid.
Nursing Responsibilities Before the Procedure
Lumbar puncture is ordered or prescribed by the physician.
This is a sterile invasive procedure, we need to secure consent from the parents or guardian.
Prior to the procedure the patient is referred by the attending physician to ophthalmologist
for funduscopy procedure.
fundoscopy
• Also known as ophthalmoscopy or funduscopy
• Is a procedure in which the back portion of the eye is examined. This part of the eye,
known as the fundus, includes the blood vessels that feed the eye, the retina, the optic
disk, and the choroid.
• Fundoscopic examination is a visualization of the retina using an ophthalmoscope,
a completely non-invasive procedure that is performed by ophthalmologists on the eye.
Nursing Responsibility for Lumbar Puncture Before the procedure
The following are the nursing interventions prior to a lumbar puncture:
1. 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.
2. Obtain informed consent. Make sure the patient has signed a consent form if required by the
institution.
3. Reinforce diet. Advise the patient that fasting is not required.
4. Promote comfort. Instruct the patient to empty the bladder and bowel before the procedure.
5. Establish a baseline assessment data. Do vital signs monitoring and neurologic assessment of the
legs by assessing the patient’s movement, strength, and sensation.
6. 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.
7. Instruct to remain still. Explain that he or she must lie very still throughout the procedure. Any
unnecessary movement may cause traumatic injury.
POSITION ON PROCEDURE:
Newborn – seated upright with the head forward
Older Infant or child – place on one side on the examining table, the head is flexed
forward, the knees are flexed on the abdomen and the back is arched as possible.
This position opens the space between the lumbar vertebrae, facilitating needle insertion.
EMLA or lidocaine cream can be applied to the puncture site 1 hour before the
procedure to reduce pain.
The child may receive conscious sedation for the procedure.
Duration of procedure:
A lumbar puncture takes around 30 to 45 minutes, but needed to stay lying down at the
hospital for at least another hour while the nurses monitor the client.
Equipment
The lumbar puncture kit contains:
Sterile gloves
Sterile drapes and procedure tray
Sterile gauze pads
Aseptic solution: povidone-iodine solution (Betadine)
Local anesthetic: Lidocaine 1% solution
25G needle
10ml syringe (1)
Spinal needle with stylet (size 22G or 25G)
CSF tube (2 to 4)
Stopcock
Manometer tubing
The step-by-step procedure for a lumbar puncture
(spinal tap) is as follows:
Position the patient to fetal position.The patient is positioned on his side at the edge of the bed
with his knees drawn up to his abdomen and chin tucked against his chest (fetal position) or sitting
while leaning over a bedside table. When the patient is positioned supine, pillows are provided to
support the spine on a horizontal plane.
Sterelize site of insertion. The skin is site is prepared and draped, and a local anesthetic is
injected.
Insert the spinal needle. The spinal needle is inserted in the midline between the spinous
processes of the vertebrae (usually between the third fourth or the fourth and fifth lumbar
vertebrae).
Remove the stylet from the needle.The stylet is removed from the needle. CSF will drip out of
the needle if it’s properly positioned. A stopcock and manometer are attached to the needle to
measure the initial (opening) CSF pressure.
Collect specimen. Specimens are collected and placed in the appropriate containers.
Remove the needle. The needle is removed, and a small sterile dressing is applied.
After procedure:
lie flat in bed for 6- 8 hours (may turn to sides). To prevent spinal headache
encourage fluids if not contraindicated.
Headache may develop due to CSF leakage; treated with bedrest, analgesics and
ice to head.
Observe for change in neurological status.
Side effects of a lumbar puncture
A lumbar puncture is generally a safe procedure and serious side effects are uncommon.
The most common side effects are:
headaches, which can last for up to a week –pain reliever can be given
swelling and lower back pain where the needle was inserted – this should get better on its
own after a few days and is normally nothing to worry about
headaches
feeling or being sick
have a very high temperature or feel hot and shivery
it's painful to look at bright lights
the swelling on back lasts for more than a few days or keeps getting worse
there are blood or clear fluid leaking back
Nursing Responsibilities After the procedure
The nurse should note of the following nursing interventions post-lumbar puncture:
1. 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.
2. Place the patient flat on bed. The patient remains flat on bed for 4 to 6 hours depending on the physician.
He or she may turn from side to side as long as the head is not elevated.
3. 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.
4. Monitor the puncture site for signs of CSF leakage and drainage of blood. Signs of CSF leakage
includes positional headaches, nausea and vomiting, neck stiffness, photophobia (sensitivity to light), sense of
imbalance, tinnitus (ringing in the ear), and phonophobia (sensitivity to sound).
5. 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.
6. Label and number the specimen tube correctly. Ensure all samples are properly labeled and sent to the
laboratory immediately for further evaluations.
7. Administer analgesia as ordered. Headaches after the procedure can last for a few hours or days and is
usually treated with analgesics.
Normal Results
Pressure: 70 to 180 mm H20.
Appearance: CSF is normally clear and colorless.
CSF total protein: 15-45 mg/dL
Gamma globulin: 3 to 12% of the total protein
CSF glucose: 50 to 80 mg/dl
CSF cell count: Normal CSF contains no red blood cells (RBCs), the
white blood cell (WBC) count is 0-5 WBCs per microliter (all
mononuclear)
CSF Chloride: 118 to 130 mEq/L
Gram stain: No microorganism (bacteria, fungi, or virus) is present.
Abnormal Results
These are the abnormal findings that can be found in CSF analysis:
Pressure:
Increased intracranial pressure (ICP) occurs as a result of a tumor, hemorrhage, or trauma-
induced edema.
Decreased intracranial pressure (ICP) may reveal a spinal subarachnoid obstruction.
Appearance:
Cloudy appearance indicating infection.
Yellow to reddish appearance indicating spinal cord obstruction or intracranial
hemorrhage.
Brown to orange appearance indicating increased protein levels or RBC breakdown.
CSF Protein:
Increased protein indicating tumor, trauma, diabetes mellitus, or blood in cerebrospinal
fluid (CSF).
Decreased protein indicating rapid CSF production.
Gamma globulin:
Increased gamma globulin indicating a demyelinating disease such as multiple sclerosis,
neurosyphilis, or Guillan-Barré Syndrome.
CSF Glucose:
Increased glucose indicating high blood sugar (hyperglycemia).
Decreased glucose indicating low blood sugar (hypoglycemia), bacterial or fungal infection,
tuberculosis, or meningitis.
CSF cell count:
Increased white blood cells in the CSF suggesting meningitis, tumor, abscess, acute
infection, stroke, or demyelinating disease.
Red blood cells in the CSF indicating bleeding into the spinal fluid or the result of a
traumatic lumbar puncture.
CSF Chloride:
Decreased chloride indicating infected meninges.
Gram stain:
Gram-positive or Gram-negative organism indicating bacterial meningitis.
Complications
Post-lumbar puncture headache. The most common complications of LP that
occurs due to the leakage of CSF from the puncture site or into the tissues around it.
The pain is aggravated while sitting, standing, or coughing and resolves after lying
down.
Back pain. A pain or discomfort in the lower back may happen as a result of
trauma to the local soft tissue.
Pain or numbness. A feeling of tingling sensation and numbness in the lower back
and legs is felt temporarily.
Bleeding. Bleeding is usually noted in the area of the punctured site, or in some
rare cases into the subarachnoid, subdural or epidural space.
Brainstem herniation: The increased pressure caused by the removal of CSF
during LP will cause sudden shifting of brain tissue that can lead to the compression
or herniation of the brainstem.
References
Lumbar puncture. (2018). Retrieved from
https://www.nhs.uk/conditions/lumbar-puncture/
Chernecky, C., & Berger, B. (2013).
Laboratory tests and diagnostic procedures. St. Louis, Mo.: Elsevier/Saunders.
Sempere, A. P., Berenguer-Ruiz, L., Lezcano-Rodas, M., Mira-Berenguer, F., &
Waez, M. (n.d.). [Lumbar puncture: Its indications, contraindications,
complications and technique]. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/17918111
Wright BL, e. (2018). Cerebrospinal fluid and lumbar puncture: a practical
review. – PubMed – NCBI. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/22278331
