A nurse is providing care for a client who has just returned to the nursing unit following a lumbar puncture. Which of the following actions should the nurse take to reduce the risk of post-procedure complications?
- AElevate the head of the client's bed to at least 45 degrees immediately after the procedure.
- BDelegate the initial post-procedure assessment and vital sign measurements to an unlicensed assistive personnel (UAP).
- Maintain the client in a flat, supine position for the prescribed amount of time.Answer
- DInitiate airborne transmission-based precautions while awaiting the cerebrospinal fluid culture results.
Answer
The nurse should maintain the client in a flat, supine position for the prescribed amount of time.
Following a lumbar puncture, the primary goal is to prevent the leakage of cerebrospinal fluid (CSF) from the dural puncture site, which can lead to a severe spinal headache. Maintaining the client in a flat, supine position for a prescribed period (typically 1 to 4 hours, depending on facility policy and provider orders) minimizes hydrostatic pressure on the puncture site, allowing it to seal properly and reducing the risk of this complication.
Step-by-Step Solution
Key Concept
Post-Lumbar Puncture Care and Positioning