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Zorluk: ZorBasic Care and Comfort

Two hours following a diagnostic lumbar puncture, a client reports intense hunger and requests the lunch tray that was just delivered. The provider has prescribed strict flat bed rest for six hours. Which action is the most appropriate for the nurse to take?

  1. A
    Elevate the head of the bed to 30 degrees for 20 minutes while the client consumes the meal.
  2. B
    Assist the client with eating while they remain strictly in a flat, supine position.
  3. Log-roll the client into a lateral position while maintaining a flat spinal alignment to assist with the meal.Cevap
  4. D
    Instruct the unlicensed assistive personnel (UAP) to feed the client and monitor for signs of aspiration.

Cevap

Log-roll the client into a lateral position while maintaining a flat spinal alignment to assist with the meal.
After a lumbar puncture, clients must remain flat (zero-degree elevation) for several hours to prevent cerebrospinal fluid (CSF) from leaking at the puncture site, which can cause a severe post-dural puncture headache. However, eating while flat and supine poses a critical aspiration risk. The safest nursing intervention is to log-roll the client into a lateral (side-lying) position. This maintains the required flat spinal alignment to protect the dural puncture site while utilizing gravity to clear the airway and facilitate safer swallowing, thus addressing both safety constraints simultaneously.

Adım Adım Çözüm

1
Analyze the client's current procedural restrictions based on the recent intervention.
The client had a lumbar puncture and is prescribed strict flat bed rest to prevent a cerebrospinal fluid (CSF) leak.
Hydrostatic pressure on the dural puncture site increases when the head is elevated above the spine, which can cause a severe spinal headache.
2
Evaluate the competing physiological need and its associated risks.
The client is hungry and needs to eat, which introduces a severe aspiration risk if oral intake occurs while lying flat in a supine position.
Swallowing against gravity in a supine position impairs airway protection.
3
Synthesize a nursing intervention that safely addresses both the procedural constraint and the physiological need.
Positioning the client in a lateral (side-lying) position without head elevation maintains the required flat spinal alignment while facilitating safer swallowing.
The lateral position keeps the dural puncture site protected at zero degrees of elevation while using gravity to keep the airway clear of pooled food or liquids.

Anahtar Kavram

Post-Lumbar Puncture Positioning and Aspiration Precautions
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Konular

Basic Care and Comfort

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