ࡱ> 24/01q`  CbjbjqPqP ::96```txxxx<dt8>$$$$$kkk.8080808080808$:hU=T8`NI"kNNT8$$%i8J J J N8$`$.8J N.8J J 2H`R6$ *xj 4"780884= 4=DR6=`R6Xk"J kkkT8T8: kkk8NNNNtttxtttxttt  Lesson plan Subject : Medical Surgical Nursing and Paediatrics Topic : Lumbar Puncture in Adult and children Submitted to: Submitted By: Mrs. Serin Shaji Thomas Geethu R 3rd year Bsc Nursing Subject : Medical Surgical Nursing and Paediatrics Unit : Topic : Lumbar Puncture in adult and children Level of student : 3rd year Bsc Nursing Date : Time : Place : lecture Room (3rd year Bsc Nursing Room) Method of Teaching : Lecture and discussion Instructional aids : Black board & chalk , OHP, chart Name of the student : Geethu R Name of supervisor : Mrs. Serin shaji Thomas Previous knowledge of student : Student have basic knowledge about lumbar puncture General objectives: At the end of the students will gain in deep knowledge about lumbar puncture. Specific objectives: At the end of the class student should be able to, define lumbar puncture purpose of lumbar puncture indication and contraindication procedure of lumbar puncture complication of lumbar puncture general instructions preparation of the article after care of lumbar puncture TIME OBJECTIVE CONDENTS AV AIDS TEACHER/ LEARNER ACTIVITIESEVALUATION 3 min 3 min 5 min 3 min 3 min 6 min 8 min 5 min 5 min 10 min 5 min 5 min 5 min 2 minIntroduce the topic Explain the definition Explain the purpose Explain the indication Explain the contra indication Explain about complications Describe the site of lumbar puncture Explain the position used in lumbar puncture List down the articles of lumbar puncture Describe about the procedure Explain about the general instructions Explain about preparation of patient Explain about the after care of patient Conclude the topicIntroduction: Lumbar puncture introduce the insertion of a sterile needle into the subarachnoid space of the spinal canal, Usually between the third and fourth lumbar vertebrae. This procedure is used to detect increased intracranial pressure on the presence of blood in cerebrospinal fluid, to obtain CSF specimens for laboratory analysis, and to inject dyes or gases for contrast in radiologic studies. Its also used to administer drugs or anesthetics and to relieve ICP by removing CSF. Definition: A lumbar puncture is the insertion of a needle into the spine, in such a manner that the needle enters the lumbar arachnoid space of the spinal canal and below the level of the cerebrospinal fluid can be withdrawn or a substance can be therapeutically or diagnostically injected. Purpose: To administer spinal anaesthesia before surgery in the lower half of the body. To administer medication into the spinal canal as in the case of meningitis To remove fluid contained in the subarachnoid space therapy reduce the intracranial presence, if it is dangerously high To remove a sample of CSF for laboratory examinations in disease To measure the pressure of CSF and to determine whether the lumbar subarachnoid space is in communication with the ventricle of brain To remove CSF and to replace it with air, oxygen or radiopaque substances for diagnostic x-rays in order to local tumors or other brain disorders. Indication: To rule out suspected meningitis or encephalitis To screen a fever of unknown origin in immunocompromised patient and in neonates under 8 weeks To identify suspected subarachnoid hemorahage with regular CT scan To diagnose certain neuralogic disorders, such as multiple sclerosis, guiltain barre syndrome or lertiary syphilis. Contraindication: Absolute: Cellulites or evidence of infection over proposed injection site Known supratintoual mass or lesion Relative: Coagulopathy or blood dyscrasia Complication: Injury to the spinal cord and spinal nerves Infection introduced in to the spinal cavity which may give rise to meningitis Leakage of CSF through the puncture site and lowering the intra-cranial pressure and may cause post puncture headache Damage to the inter vertebral discs Local pain, oedema and haematoma at the puncture site Temperature elevation Rapid reduction in the intracranial pressure caused by the removal of CSF can cause herniation of the brain structures in to the foramen magnum. This in turn cause pressure on the vital centres in the medulla causing respiratory failure and sudden death. Pain radialing to the thighs due to trauma of the spinal nerves. Site of lumbar puncture and positioning of the patient: Since the spinal cord ends at the level of the first lubar vertebra and the subarachnoid space extends up to the second sacral vertibrea any site between these two points may be used for the puncture of the spine. In children: In small children and infants, the site is still lower because the spinal cord extend up to the third lumbar vertebrae. These site are safe to prevent injury to the spinal cord. In adults: In adults the site of the lumbar puncture of the lumbar puncture is usually between the second and third or fourth and fifth lumbar vertebrae. Position: Patient is placed in a sidelying position at the edge of the table or bed. The patients body should be in foetal attitude (c shaped) with full flexion of the space. The back should be vertical to the bed and with no lateral flexion of the spine. The patient is asked draw both knees up towards the chim. The head and neck are flexed and brought towards the chest in order to maintain this position, the patient may keep both his hands between the knees . In this position the intervertebral space are widened and the needle can be easily is not able to maintain this position, the nurse helps him. The nurse stand infront of the patient and keeps one hand behind the knees and the other hand behind the ends and trees to bring the patient into the desired position. Preparation of articles: A sterile tray containing L. P needles -2 sizes with their stiletto Sponge holding forceps Syringes (5ml) with needle to give local anaesthesia Small bowl to take cleaning lotion Specimen bottles Cotton balls, gauze pieces and cotton pads Gloves, gown and masks Dressing towels or slit Three way adapter, manometer and tubing to measure the pressure of the CSF An un-sterile tray containing: Machintosh and towel Kidney tray and paper bag Spirit, rodine trbenzoin Lignocine 2 present Sterle normal saline to fill in the manometer Adhesic plastic and scissors Procedure: A patient is positioned correctly. The skin is prepared as for a surgical procedure. Under local anaesthesia, the needs is inserted between the second and third or between the third and fourth lumbar vertebrae. The position can be delumined by drawing a vertical line from the top of the iliac crest to the spine. This crosses the spine. This cross the spine at the 4th lumbar spine or L2-L3 inter space. One interspace cranially at L3-L4 is selected when the needle has entered the subarachnoid space, the stiletto is removed and the 3 way adaptive with the manometer filled with normal saline is attached. The pressure is noted . Normally the CSF oscillates in the manometer readily responding to coughing, deep oreathing etc. The patient is asked to relax as much as possible to get a stabilized pressure. Normally it is 6 to 13mm of Hg or 80 to 180mm of H2O. About 2 to 3ml of CSF is allowed to drip into each of 3 sterle test lubes and thin the needle is withdrawn. The puncture wound is scaled. General instructions: Since any infection introduce in to the spinal cavity would be fetal for the patient. Strict aseptive techniques are to be followed. The doctor scrubs the hands thoroughly, put on gown, gloves etc to maintain asepses. All articles used for the lumbar puncture should be avoid The patient should be placed in a position that will widen the intervertibral space . Usually sidelying with the knees drawn to the chin or a sitting position with the head and neck flexed is maintained during the procedure Unco-operative patients and children are to the restrain during the procedure Patient should to placed near the edge of the bed or table for the onvenece of the doctor. The patient back should be at right angles to the bed. The LP needles should be sharp, small in size and not curved If the nurse has to hold the manometer tube for recording the pressure she should hold it above the point where the doctors hand need to come in contact with it, since her hands are not sterile. After the lumbar puncture the patient should be flat on the bed The CSF collected should be sent to the laboratory with out any delay if it is allowed to stand . Changes will take place in the fluid and we will get only The amount of CSF withdrawn is equal to the volume of fluid to be introduced or is sufficient for the laboratory investigation planned. Drugs to be injected must be warmed to body temperature and it should be injected very slowly At the end of the procedure the puncture site is scaled to present leakage of fluid from the spinal cavity and infection entering into the spinal cavity Patients vital signs should be checked. Preparation of the patient: Explain the procedure to the patient to relieve his anxiety and fear Warm the patient that any movement during the procedure may cause injury to the spinal cord and its nerves. Check the B P pulse and respirations before sending the patient to the operation room and record the finding s on the nurses record for the future reference. Prepare the skin for surgical procedure. Shave and clan the area theroughly with soap and water. Again the skin is disinfected with spirit and iodine just before doing the spinal puncture Put on clean and loose garments Arrange the articles that are necessary for lumbar at the bed side table. Remove the unnecessary articles form the bed side. Fan told the top bedding well below the hips and cover the should with a bath blanket. Expose only the site of the spinal puncture. Fold back the upper garments above the worst above the worst line and the lower garments well below the hip exposing the site Protect the bed with mackintosh and towel The nurse should stand near the patient through out the procedure observing has general condition and helping him to maintain the desired position. After care of the patient: As soon as the needle is withdrawn seal the puncture site to prevent leakage of CSF Place the patient comfortably on the bed is a supine position. He should be asked to lie down flat on bed for 12 to 24 hours. If the patient develops post puncture headache, the following precaution are taken Dacken the room Give plenty of oral fluids to re-establish the CSF level Administer analgesics Raise the foot end of the bed The patient should be watched constantly for several hours, after LP . Any changes in the patients general condition should be reported immediately. Watch for patients colour, pulse, respiration, blood pressure and other signs of complications such as nausea, vomiting headache etc. Record the procedure on the patients chart with date and time. Record the amount and character of the fluid withdrawn the pressure of the CSF measured, patient tolerance to the procedure, any changes in the patients general conditions, any intervward reactions such as nausea , vomiting , headache etc developed in the post procedure period the specimens of CSF collected should be sent to the laboratory without any delay with proper labels and a requisition form If there are no complications observed the patient may be allowed to be upright after 8 to 12 hours. Conclusion: Students are able to tell about the definition, purpose, indication, procedure, general instructions, preparation of the patient and after care of the patient.Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Black board & chalk Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion Lecture & discussion What is lumbar puncture? What are the purpose of lumbar puncture? What are the indications of lumbar puncture? What are the contra indications ? List down the complications? What are the sites of lumbar puncture? Which are the position used in care of the lumbar puncture? What are the articles used for lumbar puncture? Explain about the lumbar puncture? Explain the care of a patient after lumbar puncture? Chalk board summary  Reference: Teachers references: Sr. Nancy PRINCIPLES AND PRACTICE OF NURSING, Volume-II N R brothers publication, indore page no :305-314. Michael A Carter, PROCEDURES FOR NURSE PRACTITIONERS,Spring House publications , page no: 167-171. 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