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Zorluk: OrtaBasic Care and Comfort

Following a diagnostic spinal tap, a client is transported back to the clinical unit. The client is alert and reports a dull ache near the lumbar insertion site. To promote client comfort and minimize the risk of procedural complications, which of the following actions should the nurse take?

  1. Ensure the client remains resting in a completely flat, horizontal position for the prescribed duration.Cevap
  2. B
    Raise the upper half of the bed to a semi-upright angle to facilitate cerebrospinal fluid circulation.
  3. C
    Encourage the client to maintain a lateral fetal position with knees drawn toward the chest.
  4. D
    Direct an unlicensed assistive personnel to routinely inspect the lumbar dressing for clear drainage.

Cevap

Ensure the client remains resting in a completely flat, horizontal position for the prescribed duration.
After a lumbar puncture, placing the client in a flat, supine posture is the standard evidence-based intervention. This position equalizes pressure in the central nervous system, drastically reducing the loss of cerebrospinal fluid through the puncture site and thereby preventing a post-dural puncture headache.

Adım Adım Çözüm

1
Identify the procedure the client just underwent and its common complications.
The client had a diagnostic spinal tap (lumbar puncture), which carries a high risk of a post-dural puncture headache due to cerebrospinal fluid leakage.
Understanding the procedural risks dictates the appropriate basic care and comfort interventions.
2
Determine the optimal positioning to prevent this complication.
A flat, supine posture is required to equalize pressure and allow the dural puncture site to seal.
Positioning is a primary independent nursing intervention to promote comfort and prevent post-procedure injury.
3
Evaluate the distractors against the correct nursing action and scope of practice.
Elevating the head or maintaining a fetal position is contraindicated post-procedure. Furthermore, assessing a dressing cannot be delegated.
Safe nursing practice requires selecting the most appropriate evidence-based intervention while adhering to delegation rules.

Anahtar Kavram

Post-Lumbar Puncture Positioning and Comfort
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