The practical nurse (PN) is assisting a healthcare provider with a lumbar puncture for an adult client on the medical-surgical unit. In what order should the PN perform the following actions to ensure client safety and reduce the risk of complications? Arrange the actions in the correct chronological sequence.
- 1Obtain the client's baseline vital signs and perform a focused neurological check.
- 2Assist the client into a side-lying position with the knees pulled toward the chest.
- 3Support the client and provide reminders to remain still during the needle insertion.
- 4Place a sterile dressing over the puncture site once the needle is withdrawn.
- 5Instruct the client to maintain a flat, supine position for the prescribed duration.
Answer
The correct sequence is: Obtain baseline vital signs, assist the client into a fetal position, support the client during insertion, apply a sterile dressing, and instruct the client to maintain a flat supine position.
Assisting with a lumbar puncture requires a strict chronological approach to reduce risk. First, baseline data must be collected to allow for accurate post-procedure monitoring. Next, the client is placed in the fetal position to optimally open the intervertebral spaces. During the procedure, the nurse's role is to ensure the client remains completely still to prevent injury. Following needle removal, the site must immediately be covered with a sterile dressing to prevent infection. Finally, placing the client in a flat, supine position reduces the risk of a spinal headache caused by cerebrospinal fluid leakage.
Step-by-Step Solution
Key Concept
Lumbar Puncture Risk Reduction