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Zorluk: OrtaReduction of Risk Potential

An adult client is transferred to the neurology observation unit following a diagnostic lumbar puncture. Thirty minutes after arrival, the client complains of a severe, throbbing headache that intensifies noticeably whenever they attempt to sit upright. Vital signs reveal a blood pressure of 118/74118/74 mmHg, a heart rate of 7878 beats/min, and an oxygen saturation of 98%98\% on room air. Which intervention should the nurse prioritize to manage this post-procedure complication?

  1. A
    Elevate the head of the bed to a semi-Fowler's position and administer a prescribed oral analgesic.
  2. Maintain the client in a strictly flat, supine position and promote increased oral fluid intake.Cevap
  3. C
    Assist the client into a lateral decubitus position with the knees flexed tightly toward the chest.
  4. D
    Notify the healthcare provider immediately to prepare for an epidural blood patch procedure.

Cevap

The nurse should maintain the client in a strictly flat, supine position and promote increased oral fluid intake.
The client is experiencing a post-dural puncture headache, which classically worsens when the head is elevated due to the leakage of cerebrospinal fluid (CSF) from the puncture site. Maintaining a flat, supine position reduces tension on the meninges and minimizes further CSF leakage. Increasing fluid intake helps replenish CSF volume and decreases symptom severity.

Adım Adım Çözüm

1
Analyze the client's symptoms in the context of the recent procedure.
The client recently had a lumbar puncture and is now experiencing a headache that worsens upon sitting upright, which is the hallmark presentation of a post-dural puncture headache (spinal headache).
Identifying the specific post-procedure complication is necessary to guide the appropriate nursing intervention.
2
Determine the physiological cause of the complication.
A spinal headache is caused by the ongoing leakage of cerebrospinal fluid (CSF) from the dural puncture site, which decreases intracranial CSF volume and places downward traction on pain-sensitive meninges when the client is upright.
Understanding the etiology ensures the selected interventions will directly counteract the mechanism of injury.
3
Select the most appropriate conservative nursing intervention to mitigate the risk.
Keeping the client in a flat, supine position removes the gravitational pull on the meninges, and increasing fluid intake helps rebuild CSF volume.
Conservative, non-invasive nursing measures are the first-line treatment before escalating to invasive medical procedures.

Anahtar Kavram

Post-Lumbar Puncture Complication Management
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Konular

Reduction of Risk Potential

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