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Difficulty: MediumReduction of Risk Potential

A nurse in a neurology unit is developing a plan of care for a client who is scheduled for a lumbar puncture to rule out meningitis. To reduce the risk of procedural and post-procedural complications, which of the following actions should the nurse include? Select all that apply.

  1. Position the client in a lateral recumbent position with the knees drawn up to the abdomen during the procedure.Answer
  2. B
    Place the client in a high-Fowler's position immediately following the procedure to promote comfort.
  3. Verify the client's coagulation profile, including platelet count and prothrombin time, prior to the procedure.Answer
  4. D
    Delegate the initial post-procedure assessment of the client's lower extremity movement and sensation to the unlicensed assistive personnel (UAP).
  5. Ensure that the client remains in a flat, supine position for the prescribed duration after the needle is withdrawn.Answer
  6. F
    Assess for a widening pulse pressure and bradycardia as early physiological indicators of hypovolemic shock.

Answer

The correct interventions are positioning the client laterally with knees drawn up during the procedure, verifying the coagulation profile beforehand, and maintaining a flat, supine position afterward.
Risk reduction for a lumbar puncture requires verifying coagulation studies to prevent hemorrhage, utilizing the lateral recumbent position to safely open intervertebral spaces during insertion, and maintaining a flat, supine position post-procedure to prevent cerebrospinal fluid leakage and subsequent spinal headaches.

Step-by-Step Solution

1
Evaluate pre-procedure requirements for a lumbar puncture.
Coagulation studies must be verified to prevent bleeding complications like a spinal hematoma.
Invasive procedures carry a bleeding risk that must be mitigated prior to needle insertion.
2
Determine the optimal positioning during the procedure.
The lateral recumbent position with knees drawn up is necessary.
This position separates the vertebrae, providing safe and easier access to the subarachnoid space.
3
Identify correct post-procedure care to prevent complications.
The client must remain flat and supine for a prescribed duration.
Remaining flat minimizes cerebrospinal fluid leakage from the puncture site, preventing severe spinal headaches.
4
Rule out inappropriate or unsafe actions.
High-Fowler's position, delegating assessments to the UAP, and misinterpreting shock signs are rejected.
These actions directly compromise client safety and violate standards of nursing practice.

Key Concept

Lumbar Puncture Risk Reduction
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Topics

Reduction of Risk Potential

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