Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [165], C).
2. 2.Show
   Patient should empty their bladder and bowels before the procedure.
   To ensure comfort (Doherty and Forbes [50], E; Pagana and Pagana [177], E).
3. 3.Show
   Assist patient into the required position on a firm surface. Either lying (Action figure 13.19):

   • one pillow under the patient's head
   • on side with knees drawn up to the abdomen and clasped by the hands
   • support patient to maintain this position.

   Or sitting:

   • patient straddles a straight‐backed chair so that their back is facing the doctor
   • patient folds arms on the back of the chair and rests head on them.
   To ensure maximum widening of the intervertebral spaces and thus easier access to the subarachnoid space (Lindsay et al. [126], E). To avoid sudden movement by the patient, which would produce trauma (Barker and Laia [10], E).

   Either sitting or lying may be used, depending on what the patient can tolerate. The sitting position allows more accurate identification of the spinous processes and thus the intervertebral spaces (Barker and Laia [10], E; Doherty and Forbes [50], E).
4. 4.Show
   Continue to support and observe the patient throughout the procedure, and explain the procedure.
   To facilitate psychological and physical wellbeing (Barker and Laia [10], E).

Procedure

1. 5.Show
   Wash hands with antibacterial detergent. Put on gloves and apron.
   To reduce the risk of contamination and cross‐infection (Fraise and Bradley [62], E).
2. 6.Show
   Assist doctor/practitioner as required; doctor/practitioner will proceed to put on a hat and mask, clean hands with antiseptic solution, and put on a sterile apron and gloves.
   To minimize the risk of cross‐contamination (Gemmell et al. [67], E).
3. 7.Show
   Clean the skin with the antiseptic cleaning agent.
   To ensure the removal of skin flora to minimize the risk of infection (Lindsay et al. [126], E).
4. 8.Show
   Identify the area to be punctured and infiltrate the skin and subcutaneous layers with local anaesthetic.
   To minimize discomfort from the procedure (Barker and Laia [10], E).
5. 9.Show
   Introduce a spinal puncture needle below the second lumbar vertebra and into the subarachnoid space.
   This is below the level of the spinal cord but still within the subarachnoid space (Lindsay et al. [126], E).
6. 10.Show
   Ensure that the subarachnoid space has been entered and attach the manometer to the spinal needle, if required.
   To obtain a cerebrospinal fluid (CSF) pressure reading (normal pressure is 10–15 cmH₂O). This can only be measured if the patient is in a lateral position (Doherty and Forbes [50], E; Lindsay et al. [126], E).
7. 11.Show
   Obtain the appropriate specimens of CSF (approx. 10 mL) for analysis. Cell count and gram stain can be performed using 1 mL of fluid.
   To establish a diagnosis (Pagana and Pagana [177], E). The first specimen, which may be blood‐stained due to needle trauma, should go into bottle 1. This will assist the laboratory to differentiate between blood due to procedure trauma and blood due to subarachnoid haemorrhage (Chernecky and Berger [32], E).
8. 12.Show
   Ensure the specimens are labelled appropriately (as 1, 2 and 3) and sent with the correct forms to the laboratory.
   To maintain accurate records and provide accurate information for laboratory analysis (NMC [165], C; Weston [255], E).
9. 13.Show
   If intrathecal medication is to be instilled, the drug and dose must be checked and administered safely according to national guidelines.
   To ensure the correct drug and dosage of drug are safely administered (Coward and Cooley [37], E; DH [45], C).
10. 14.Show
    Withdraw the spinal needle once specimens have been obtained, appropriate pressure measurements have been taken and intrathecal medication has been administered.
    To minimize the risks of the procedure (Barker and Laia [10], E).
11. 15.Show
    When the needle has been withdrawn, apply pressure over the lumbar puncture site using a sterile topical swab.
    To maintain asepsis and to stop blood and CSF flow (Doherty and Forbes [50], E).
12. 16.Show
    When all leakage from the puncture site has ceased, apply a plaster dressing.
    To prevent secondary infection (Barker and Laia [10], E).

Post‐procedure

1. 17.Show
   Make the patient comfortable. They should lie flat or the head should be tilted slightly downwards. Time to lie flat varies from hospital to hospital, but it is usually around 4 hours if there is no headache.
   To avoid headache and decrease the possibility of brainstem herniation (coning) due to a reduction in CSF pressure (Barker and Laia [10], E; Doherty and Forbes [50], E).
2. 18.Show
   Remove equipment and dispose of it as appropriate.
   To prevent the spread of infection and reduce the risk of needle stick injury (DH [48], C).
3. 19.Show
   Document the procedure in the patient's records.
   To ensure timely and accurate record keeping (NMC [165], C).
4. 20.Show
   Patient should be monitored for the next 24 hours with careful observation of the following:

   • leakage from the puncture site
   • headache
   • backache
   • neurological observations and vital signs.
   Clear fluid may be a cerebrospinal leak (Barker and Laia [10], E).

   Headache and backache are not unusual following lumbar puncture and may be due to loss of CSF. E

   Neurological observations and vital signs may indicate signs of change in intracranial pressure (Doherty and Forbes [50], E). For further information on see Chapter c14: Observations.