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Zorluk: OrtaBasic Care and Comfort

A nurse is receiving a client who has just returned to the clinical unit after undergoing a diagnostic lumbar puncture. The client reports the onset of a mild headache. Which of the following positioning interventions should the nurse implement?

  1. Keep the client in a supine position with the head of the bed flat.Cevap
  2. B
    Elevate the head of the bed to 45 degrees to help relieve the headache.
  3. C
    Position the client in a lateral recumbent posture with knees drawn to the chest.
  4. D
    Assist the client into a high-Fowler's position to facilitate oral hydration.

Cevap

Keep the client in a supine position with the head of the bed flat.
After a lumbar puncture, the client is at risk for developing a post-dural puncture headache (spinal headache) due to the leakage of cerebrospinal fluid (CSF) from the puncture site. Keeping the client in a flat, supine position minimizes hydrostatic pressure and CSF leakage, which helps prevent or alleviate the headache.

Adım Adım Çözüm

1
Analyze the client's procedure and current symptom.
The client had a lumbar puncture and is now experiencing a mild headache.
Identifying the procedure and symptoms is essential to determine the appropriate post-procedure care.
2
Recall the pathophysiology of a post-lumbar puncture headache.
A headache following this procedure is typically caused by the continuous leakage of cerebrospinal fluid (CSF) through the dural puncture site.
Understanding the cause of the complication guides the nursing intervention.
3
Determine the optimal positioning to manage this complication.
A flat, supine position minimizes hydrostatic pressure on the dural tear and reduces CSF leakage.
Keeping the spine horizontal prevents gravity from exacerbating the fluid loss, thereby helping to relieve or prevent the headache.

Anahtar Kavram

Post-Lumbar Puncture Positioning and Comfort
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Konular

Basic Care and Comfort

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