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Zorluk: OrtaReduction of Risk Potential

A nurse is evaluating a client who returned to the neurological unit 30 minutes ago following a lumbar puncture. Which of the following assessment findings or observations require immediate intervention by the nurse? (Select all that apply.)

  1. The client is sitting upright in a high-Fowler's position to eat a meal.Cevap
  2. The sterile gauze dressing over the insertion site is saturated with clear fluid.Cevap
  3. The client reports a new onset of bilateral lower extremity numbness and weakness.Cevap
  4. D
    The client is resting in a strict supine position without a pillow.
  5. E
    The client reports mild, localized soreness in the lower back.

Cevap

The findings that require immediate intervention are the client sitting in a high-Fowler's position, the dressing being saturated with clear fluid, and the client reporting new-onset lower extremity numbness and weakness.
Following a lumbar puncture, the nurse must monitor for physiological complications such as cerebrospinal fluid (CSF) leaks, spinal hematomas, and positional contraindications. Sitting upright shortly after the procedure increases the risk of a spinal headache due to CSF leakage and requires immediate intervention to return the client to a flat position. A dressing saturated with clear fluid actively indicates a CSF leak, requiring prompt provider notification. New-onset numbness and weakness are signs of spinal cord or nerve root compression (such as from a developing spinal hematoma) and constitute a medical emergency.

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1
Evaluate each finding to distinguish between expected post-procedural outcomes and signs of impending complications.
Identified that mild lower back soreness and lying flat are expected and safe.
A lumbar puncture involves needle insertion into the subarachnoid space, causing expected local soreness. Flat positioning is mandated to prevent cerebrospinal fluid (CSF) leakage.
2
Identify findings that indicate a risk for neurological compromise.
Clear fluid on the dressing indicates a CSF leak. Numbness and weakness suggest spinal nerve compression.
A CSF leak can lead to severe spinal headaches and infection. Nerve compression (e.g., from an expanding hematoma) requires urgent evaluation to prevent permanent nerve damage.
3
Assess the client's current positioning for procedural safety.
Sitting upright in a high-Fowler's position immediately after the procedure is identified as a safety risk.
Upright positioning increases pressure on the dural puncture site, which can actively induce a CSF leak and subsequent spinal headache.

Anahtar Kavram

Reduction of Risk Potential: Post-Lumbar Puncture Complications
Tahmini Süre:1m 15s
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Reduction of Risk Potential

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