RLE116GEP

GASTROINTESTINAL SYSTEM • Patients susceptible to accumulating respiratory

Preoperative problems.
DEEP BREATHING EXERCISES • Patients who have had abdominal or chest surgery
• Deep breathing and coughing exercises remove need to perform deep breathing at least 3-4 turns
secretions from the airways and facilitate daily. Each session should include a minimum of 5
respiratory function. deep breaths.
• Voluntary coughing exercises in conjunction with • Deep breathing should be performed every hour
deep breathing facilitate the movement and while awake.
expectoration of secretion in the respiratory tract. • Deep breathing may be performed every hour,
Frequent deep breathing automatically initiates especially by patients who are prone to pulmonary
the cough reflex. problems.

Types EQUIPMENT
DIAPHRAGMATIC INCENTIVE SPIROMETER
Technique: Place one hand on the abdomen, and the o A medical device used to help patients improve the
other on the chest. Inhale deeply through the nose, functioning of their lungs.
focusing on expanding the abdomen while keeping the o It consists of a clear plastic chamber connected to
chest relatively still. Hold air in your lungs for five counts. a tube with a mouthpiece or a facemask. Inside the
Exhale slowly, while the abdomen hand moves inward chamber, there's a piston or a ball that moves up as
and the chest hand remains still. the patient inhales.

Effect: Stimulates the diaphragm to descend, promoting Uses:

deeper inhalation and increased oxygen intake. It can o The primary purpose of an incentive spirometer is to
help improve lung capacity and efficiency. encourage deep breathing and to prevent lung
complications such as atelectasis (partial collapse
PURSED-LIP BREATHING of the lung) and pneumonia, especially after surgery
• Help maintain open airways by maintaining positive or prolonged bed rest.
pressure longer during exhalation.
When is it used?
Technique: Involves inhalation through the nose o Post-Surgery Recovery
followed by exhalation through pursed lips, as if blowing o Respiratory Conditions
out a candle. Exhalation is slower and more controlled o Physical Rehabilitation
compared to inhalation. o Prevention of Respiratory Complications

Effect: Creates back pressure in the airways, preventing NURSING CONSIDERATIONS

them from collapsing too quickly. This reduces the effort 1) Encourage the client to do deep-breathing and
required to breathe out and helps alleviate shortness of coughing exercises hourly, or at least every 2 hours,
breath, particularly in individuals with obstructive lung during waking hours for the first few days.
diseases like COPD. 2) Assist the client to a sitting position in bed or on the
side
OBJECTIVES 3) Educate patients on the device's importance and
→ To facilitate a wide exchange of gases proper technique. Evaluate patients' suitability for
→ To maximize the amount of oxygen available using incentive spirometry based on their condition
→ To lower heart rate and and blood pressure and capabilities
→ To decrease muscle tension 4) Assess the usage of the device and progress to track
→ Strengthen the immune system improvements and address any issues.
→ Activates the body's relaxation response 5) Be vigilant for adverse effects and prompt
→ Reduces stress hormones intervention are crucial to prevent complications.
→ To make client relaxed
EVALUATION
ASSESSMENT o Check for breath sounds after the procedure
1. Assess level of consciousness o Check if the patient is feeling any dizziness,
2. Evaluate vital signs lightheadedness or tingling sensations during and
3. Observe breathing pattern after the procedure.
4. Evaluate respiratory rate & pulse oximetry findings
5. Collect subjective data using interview questions

INDICATION
• Patients on bedrest or those who have undergone
any surgical procedure (e.g. abdominal or chest
surgery).
• Patients prone to pulmonary problems.
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DEEP BREATHING EXERCISE PROCEDURE

STEPS RATIONALE
Upright position allows increased diaphragmatic excursion
1. Assist client to fowlers or sitting position
secondary to downward shift of internal organs from gravity
2. Have client place hands palm down, with middle This position allows client to feel movement of diaphragm,
fingers touching, along lower border of rib cage indicating a deep breath.
3. Ask client to inhale slowly through the nose, feeling Inhaling through the nose allows air to be filtered, warmed,
middle fingers separate. Hold breath for 2 or 3 and humidified. Holding breath allows lungs to expand
seconds. fully.
Slow expulsion of air frequently initiates the coughing
4. Have client exhale slowly through mouth. Repeat
reflex, which facilitates expectoration of mucus and
three to five times
prevents hyperventilation.
Performing these exercises every two to three hours will
5. Instruct, reinforce, and supervise deep-breathing
facilitate pulmonary ventilation and promote airway
exercises every 2-3 hours postoperatively.
clearance without overtiring the client
Maintains legal record and communicates with the
6. Document procedure healthcare team.

COUGHING EXERCISE PROCEDURE

STEPS RATIONALE
Upright position allows increased diaphragmatic excursion
1. Assist client to fowlers or sitting position
secondary to downward shift of internal organs from gravity
2. If adventitious breath sounds or sputum is present, Several consecutive coughs are more effective than one
have client take a deep breath, hold for 3 seconds, single cough at moving mucus up and out of the respiratory
and cough deeply two or three times. Stand to the tract.
client's side to ensure the cough is not directed at
you. Client must cough deeply, not just clear the
throat.
3. If the client has an abdominal or chest incision that Coughing uses abdominal and accessory respiratory
will cause pain during coughing, instruct the client to muscles, which may have been cut during surgery.
hold a pillow firmly over the incision (splinting) when Splinting supports the incision and surrounding tissues and
coughing. reduces pain during coughing.
Performing these exercises every 2 to 3 hours will facilitate
4. Instruct, reinforce, and supervise deep-breathing and
pulmonary ventilation and promote airway clearance
coughing exercises every 2 to 3 hours postoperatively
without overtiring the client
Maintains legal record and communicates with the
5. Document procedure. healthcare team.

USING AN INCENTIVE SPIROMETER

1. Hold or place the spirometer in an upright position. A tilted flow-oriented device requires less effort to raise the
balls or disks; a volume-oriented device will not function correctly unless upright.
2. Exhale normally.
3. Seal the lips tightly around the mouthpiece.
4. Take in a slow, deep breath to elevate the balls or cylinder, and then hold the breath for 2 seconds initially,
increasing to 6 seconds (optimal), to keep the balls or cylinder elevated if possible.
5. Remove the mouthpiece and exhale normally.
6. Cough after the incentive effort. Deep ventilation may loosen secretions, and coughing can facilitate their removal.
7. Relax and take several normal breaths before using the spirometer again.
8. Repeat the procedure several times and then 4 or 5 times hourly. Practice increases inspiratory volume, maintains
alveolar ventilation, and prevents atelectasis (collapse of the air sacs).
9. Clean the mouthpiece with water and shake it dry.

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 RLE116GEP
WOUND CARE (DRESSING) EQUIPMENTS
• Wound dressings are materials applied to wounds to o Sterile forceps, Sterile Water, Pick up forceps, Kidney
promote healing, protect them from infection, and Basin, Sterile cotton balls, OS Micropore, Cidex
prevent further injury. Solution, Betadine, Hydrogen Peroxide, NSS Cotton
• They come in different forms and types; each with its applicator, Antibacterial ointment, Bandage scissors
purposes and benefits.
NURSING CONSIDERATIONS
2 TYPES OF SURGICAL WOUNDS o Assess the wound's size, appearance, and any
1. Incisional Wounds drainage.
• Are made by cutting through skin, muscle, and fat so o Choose the right dressing based on the wound's
that a body part can be repaired or removed. Small condition.
incisions are also created during laparoscopic and o Clean the wound using sterile techniques.
robotic surgery o Manage pain during and after wound care.
o Watch for signs of infection like redness or pus.
2. Excisional Wounds o Teach patients and caregivers how to care for the
• Are made for removal of cyst or other type of tissue wound.
o Check the wound regularly and adjust care as
2 TYPES OF DRESSING needed.
1. Primary Dressing o Ensure patient comfort during wound care
• Placed directly over the wound procedures.

2. Second Dressing EVALUATION

• Used to cover or hold a primary dressing in place 1) The client demonstrates progressive healing of
wound as evidenced by the ff:
KINDS OF DRESSING: o Wound edges closing together
Protective o Reduced swelling and redness of wound edges
→ Transparent Film, Silicone Dressing, Hydrogel o Reduction in amount and color of drainage
Dressing, Impregnated Gauze, Dry Gauze o Decreased wound pain
2) The client remains free of infection, with normal
Antibacterial temperature, WBC, absence of wound swelling,
odor, and purulent drainage, and no increase in pain.
→ Antibacterial Ointment, Iodosorb (cadexomer
3) The client practices self-care behaviors to promote
iodine), Silver Based Dressing
healing by the following:
o Washing hands appropriately
Absorbent
o Keeping hands away from the wound, wound
→ Foam Dressing, Alginate Dressing, Collagen
drainage, and dressing
Dressing, Hydrofiber
o Maintaining a well-balanced diet, as ordered
o The client verbalizes and demonstrates an
Debriding
understanding of wound and dressing care.
→ Hydrogel, Hydrocolloid

OBJECTIVES
→ To promote fast healing of the wound
→ To prevent debris/damaged cells
→ To prevent bacterial growth from mechanical injury
→ To absorb drainage or debride a wound or both

ASSESSMENT
1. Assess clients condition
2. Assess for signs of complication (hemorrhage,
infection, and dehiscence).
3. Assess wound appearance, drainage, swelling, odor,
dehiscence, and pain.
4. Gather data from patients about the level of comfort,
pain, and tenderness.

INDICATIONS
• Open wounds
• Infected wounds
• Removal of stitches, staples, or clips while
removing drains
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PROCEDURE
STEPS RATIONALE
1) Assemble all equipment. This saves time and energy.

2) Verify the physician's order. This clarifies type of dressing.

3) Wash your hands. This deters the spread of microorganisms.
4) Identify the patient.
5) Explain the procedure to the patient, including the To gain client cooperation and to reduce apprehension
importance of not touching the exposed wound.
6) Provide privacy. Assist the patient to the most This provides for comfort.
appropriate position for the dressing change
7) Provide a clean area in performing the procedure
8) Place kidney basin/cuffed plastic bag near your work Soiled dressings may be placed in disposal plastic bag
area; Provide adequate lighting without contaminating outside surfaces of bag
9) Loosen tape on dressing and remove by holding down Pressing down on skin provides counter traction against
the skin and pulling the tape gently but firmly toward the pulling motion. Tape is pulled toward the incision to
the wound and the direction of hair growth. Use prevent strain on the sutures or wound. Using
adhesive remover if necessary. If tape is soiled, don solvents/adhesive remover lessens discomfort especially
gloves. on hairy areas.
10) Don clean disposable gloves, and remove soiled Using clean gloves protects the nurse when handling
dressings carefully in a clean to less clean direction. contaminated dressings. Cautious removal of dressing is
Do not reach over wound. Check position of drains more comfortable for patient and ensures that drain is not
before removing dressing. If dressing is adhering to removed if one is present. Sterile saline provides for easier
skin surface, it may be moistened by pouring a small removal of dressing
amount of sterile saline onto it. Keep soiled side of
dressing away from client's views.
11) Assess amount, color, consistency, odor of drainage Wound healing process or infection should be documented
12) Inspect the wound and surrounding skin for
appearance of the drainage and approximation of the
wound edges.
13) Discard dressings in plastic disposal bag. Pull off Proper disposal of dressings prevents spread of
glove inside out and drop it in bag/waste receptacle microorganisms by contaminated dressings
14) Using aseptic technique, open sterile dressings and Supplies are within easy reach, and sterility is maintained
supplies on work area
15) Don sterile gloves or may use sterile forceps Using sterile gloves/forceps maintains surgical asepsis
16) Clean wound or surgical incision.
17) Clean from top to bottom or from center outward a) Cleaning is done from least to most contaminated area
18) Use one cotton ball/gauze square for each wipe, b) Previously cleaned area is not re-contaminated
discarding each ball/gauze by dropping into plastic c) Movement in this manner ensures cleaning from least
bag. Do not touch disposal bag. to most contaminated area.
19) Clean around drain, if present, moving from center d) Moisture provides medium for growth of
outward in a circular motion. Use one cotton microorganisms. Growth of microorganisms may be
ball/gauze for each circular motion retarded and healing process improved
20) Dry wound using gauze sponge or cotton ball and
same motion
21) Apply antiseptic ointment, if ordered, using cotton
applicator.
22) Apply the sterile dressing, using aseptic technique. If Drainage is absorbed and wound is protected.
with drain, place 2 pre-cut sterile gauze under or
around drain.
23) Remove gloves from inside out, and discard
24) Apply tape to secure dressings Tape is easier to apply after gloves have been removed
25) Assist client to a comfortable position , Return
equipment, Perform handwashing
26) Record dressing change and appearance of wound, Accurate documentation of procedure ensures continuity
and describe any drainage in the chart. Check of care and provides information for future assessments.
dressing and wound site every shift

by: 元美安
 RLE116GEP
SURGICAL DRAINAGE infection or development of granulation tissue. This
• Surgical drains are tubes placed near surgical can cause pain and trauma upon removal.
incisions in the post-operative patient, to remove o Pain should be assessed whilst the drain is in situ.
pus, blood, or other fluid, preventing it from Appropriate analgesia should be provided when
accumulating in the body. necessary. Please refer to the pain assessment and
• The type of drainage system inserted is based on management guideline for more information.
the needs of patient, type of surgery, type of
wound, amount of drainage expected and surgeon EQUIPMENTS
preference o Measuring Container, Gloves, Alcohol Prep

JACKSON-PRATT PROCEDURE
• A soft pliable tube with multiple perforations and a 1. Have all the supplies you need in front of you
bulb that can recreate low negative pressure 2. Explain the procedure to the client.
vacuum, designed so that body tissues are not To obtain trust and cooperation.
sucked into the tube, decreasing risk of bowel 3. Perform proper hand hygiene
perforation. 4. Milk the tubing before emptying the drainage bulb
Milking helps you move clots through your tubing and
OBJECTIVES keep drainage flowing.
→ To make sure drains do not clot or clog. 5. Pinch the tubing close to where it goes to your skin.
→ To maintain proper hygiene. 6. With your thumb and forefinger of your other hand,
pinch the tubing below your other fingers.
ASSESSMENT 7. Keeping your fingers pinched, slide them down the
INITIAL PHASE tubing. Keep doing this until any clots are out of the
o Surgical drains should be assessed 1-4 hourly tubing into the bulb.
throughout the shift. 8. Unplug the stopper
o Assess drain insertion site for signs of fluid or air 9. Turn the bulb upside down and gently squeeze it,
leakage, redness or irritation to the skin. pouring the contents into a measuring container.
o Document site conditions and notify the treating 10. With your thumb and forefinger of your other hand,
team if any concerns arise. pinch the tubing below your other fingers.
o Assess if the drain is maintaining suction. 11. Turn the bulb right side up and squeeze the bulb
o Assess securement type and document on line enough.
drains and airway (LDA). For air to come out.
o Assess patency of drain. Ensure drain is located 12. Keep squeezing the bulb until you plug in the stopper.
below the insertion site and free from kinks or knots. For the bulb to remain compressed.
o Document amount, output appearance, type of fluid 13. Secure the drain, not letting it dangle.
in drain bottle/receptacle and drain status on LDAs 14. Check the color and the amount of drainage in the
measuring container
ONGOING PHASE 15. Write both in the Jackson Pratt drainage record.
o Monitor for infection. 16. Note the measurements in the container are in
o Signs of infection include redness, tenderness at milliliters.
the drain site, warmth at the site, increased ooze, or 17. Empty the drainage down the toilet.
a change in collection fluid to purulent, or if the 18. Do aftercare of equipment. Wash hands.
patient is febrile.
o Drain patency and insertion site should be observed NURSING CONSIDERATIONS
at the beginning of your shift and before and after 1) Milking your tubing to help move clots.
moving a patient. A kinked, disconnected, dislodged 2) Emptying your drains 2 times a day. Do this once in
or blocked drain tube can lead to formation of the morning and once in the evening.
hematoma, increased pain and risk of infection. 3) Write down the amount of drainage on your Jackson-
o Drainage needs to be documented at a minimum 4 Pratt drainage log at the end of this resource. If you
hours and more frequently if output is high. This have more than 1 drain, measure and write down the
needs to be documented in flowsheets in the drainage of each one separately. Do not add them
sections “Output in previous hours” and “Chamber together.
reading” so an accurate fluid balance is maintained 4) Caring for your insertion site.
o Suction needs to be assessed throughout the shift. 5) Checking for problems.
Suction will no longer be maintained once the drain
becomes full. This drain will need to be emptied, EVALUATION
changed or suction reapplied. The drain will remain patent, the wound is not
o Discuss removal plans with the treating team. contaminated during care, no trauma is caused to the
Drains should be removed as soon as practicable, wound, and the client did not experience pain or
the longer a drain remains in situ, the higher risk of discomfort.

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ABDOMINAL BINDER watch for. Emphasize the importance of reporting
• Application of Abdominal binder is the application of any discomfort or changes in sensation promptly.
support or protection to the abdomen o Preparation: Ensure the appropriate size and type of
abdominal binder are selected based on the
TYPES patient's needs and condition. Prepare the
Straight Abdominal Binder necessary supplies, including any additional
• Is a rectangular piece of cotton or elasticized dressings or padding that may be required.
material that has a long extension on each side to
surround the abdomen. DURING:
o Application: Carefully apply the abdominal binder
Scultetus (many-tailed) Binder according to the manufacturer's instructions and
• Has many tails attached to the two longer sides to the healthcare provider's recommendations.
provide support to the abdomen and retain Ensure proper alignment and snugness without
dressings. excessive tightness that could compromise
circulation or breathing.
OBJECTIVES o Assessment: Continuously assess the patient's
→ To support large abdominal incisions that are comfort, breathing, and skin integrity while wearing
vulnerable to tension or stress as the client moves or the binder. Monitor for any signs of discomfort, skin
coughs. irritation, or difficulty breathing, and adjust the
→ To hold dressing in place. binder as needed.
→ To apply pressure. o Monitoring: Regularly monitor vital signs,
particularly respiratory rate and depth, to ensure the
ASSESSMENT binder is not impeding breathing. Observe for any
• Observe clients with need for support of the thorax or signs of complications such as increased pain,
abdomen. Observe the ability to breathe deeply and swelling, or changes in skin color or temperature.
cough effectively.
AFTER:
• Review medical records if a medical prescription for
o Reassessment: After application, reassess the
a particular binder is required and reasons for
patient's abdomen and overall condition to ensure
application.
the binder is providing the intended support and
• Inspect skin for actual or potential alteration in
comfort. Evaluate any changes in pain level,
integrity. Observe for irritation, abrasion, skin
mobility, or respiratory status.
surfaces that rub against each other or allergic
o Patient Comfort: Address any discomfort or
response to adhesive tape used to secure dressing.
concerns the patient may have related to wearing
• Inspect any surgical dressing.
the abdominal binder. Provide appropriate pain
• Assess the client's comfort level, use analog scale of management and assist with repositioning or
0 to 10 and noting any OBJECTIVE signs and adjustment of the binder as needed for optimal
symptoms. comfort.
• Gather necessary data regarding size of client and o Education and Follow-up: Provide thorough
appropriate binder. discharge instructions, including how long to wear
the binder, when to remove it for activities such as
INDICATIONS bathing, and signs of complications to watch for.
o Abdominal binders are often recommended for Schedule follow-up appointments as needed to
various conditions like post-surgery, hernias, or back monitor the patient's progress and adjust the
support. treatment plan accordingly.
o Indications for using one include providing support,
reducing pain, and promoting healing in the EVALUATION
abdominal region. Always follow your healthcare Scultetus and straight abdominal binder keeps dressing
provider's advice for proper usage. in place and supports the abdomen.

NURSING CONSIDERATIONS
BEFORE:
o Assessment: Conduct a thorough assessment of
the patient's abdomen, including any wounds,
surgical incisions, or hernias. Assess for any
contraindications to using an abdominal binder,
such as compromised circulation or respiratory
issues.
o Patient Education: Educate the patient about the
purpose of the abdominal binder, how to properly
wear and adjust it, and potential complications to
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STRAIGHT ABDOMINAL BINDER PROCEDURE

1. Explain the procedure
2. Prepare the needed equipment (specify what type of binder is needed).
3. Able to give the purpose(s) of placing abdominal binder
To promote proper support to the abdominal area
4. Wash hands and wear gloves, if necessary (if with drainage)
5. Provide Privacy
6. Loosen top sheet at foot part
7. Position patient in supine position with head slightly elevated and knees slightly flexed
8. Instruct and help the client roll away from the nurse toward the raised side rails while supporting abdominal incision
and dressing firmly with the hands. Place the fan folded binder under the patient’s lower back, in the same manner
as applying a sheet for an occupied bed
9. Instruct or assist the client to roll over folded ends
10. Unfold and stretch ends out smoothly on the far side of the bed
11. Instruct client to roll back into supine position
Facilitates chest expansion and adequate wound support when binder is closed
12. Adjust binder so that client is centered over the binder using symphysis pubis and costal margins as lower and
upper landmarks
Centers support from binder over abdominal structures, which reduces incidence of decreased lung expansion
13. Close binder. Pull one end of the binder over the center of the client's abdomen. While maintaining tension on that
end of the binder, pull the opposite end of the binder over center and secure Velcro closure tabs, metal fasteners,
or horizontally placed safety pins
14. Assess the client's comfort level Adjust binder as necessary

SCULTETUS BINDER PROCEDURE

1. Prepare the needed equipment. Secure the kind of binder needed and the number of pins necessary or tapes.
2. Explain the procedure to the client. Teach skill to clients or significant others.
3. Wash hands and wear gloves (if likely to contact wound drainage).
4. Provide privacy
5. Apply binder
6. Position client in supine position with head slightly elevated and knees flexed
Minimizes muscular tension on abdominal organs
7. Fan-fold the far side of the binder toward the midline of the binder
Reduces time client remains in an uncomfortable position
8. Instruct and help the client to roll away from the nurse toward the raised side rail while firmly supporting
abdominal incisions and dressing with hands
9. Able to rationalize why the patient's knees are slightly flexed
Minimizes muscular tension on abdominal organs
10. (Take note of the client’s case)
For obstetrical or OB Surgical clients: - Start overlapping the tails from the top moving toward the bottom.
For Non- OB Surgical clients: - Start overlapping the tails from bottom moving toward the top.
11. Able to identify the difference in applying binder of an obstetric patient from non- OB surgical patients.
12. Secure the top or bottom pair of tails with a horizontally placed pin for each end.
13. Remove gloves (if there are any). Arrange beddings. Make the patient comfortable.
14. Observe site for skin integrity, circulation, and characteristics of wound (periodically remove binder and surgical
dressing to assess wound characteristics.)
15. Assess comfort level of the client, using analog scale of 0 to 10 and noting any OBJECTIVES signs and symptoms.
16. Assess client’s ability to ventilate properly
17. Identify client’s needs for assistance with activities such as hair combing, dressing and ambulating.

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ASSISTING IN LUMBAR PUNCTURE → Identify the anatomical structures, indications, and
• The insertion of a large needle through the contraindications of lumbar puncture.
intervertebral space in the lumbar region of the spine → Describe the equipment, personnel, preparation,
to enter the spinal canal, subarachnoid space below and technique in regards to lumbar puncture.
the level of termination of the spinal cord between → Review the potential complications and clinical
L3-L4 or L4-L5 region for the purpose of studying significance of lumbar puncture.
cerebrospinal fluid. → Outline interprofessional team strategies for
• Other names of Lumbar Puncture: Spinal Tap, CSF improving care coordination and communication to
Examination, Spinal Puncture advance lumbar puncture and improve outcomes.

SPINAL CORD ASSESSMENT

• It begins at the level of the foramen magnum and 1. Assess vital signs and other pertinent health status
extends downward through the vertebral column to before, during, and after the procedure.
the level of the disk between the first and second 2. Assess the patient's ability to maintain the position
lumbar vertebrae. necessary for the procedure.
• Covered and protected by three meninges or 3. Assess the patient's knowledge of the procedure to
membranes, which are downward extensions of be performed.
those that cover the brain. 4. Review pertinent laboratory tests prior to procedure.
5. Evaluate the signs and symptoms that may indicate a
DURA MATER (HARD MOTHER) potential problem if the test is performed.
• Outermost membrane, and it is composed of dense 6. Ensure that cerebrospinal fluid (CS) specimens are
connective tissue. correctly labeled and send them immediately to the
• This tough sheath extends downward to the level of laboratory with the completed requisition form.
the second sacral segment where it ends as a blind 7. Assess the puncture site for leakage of cerebrospinal
sac. fluid (CSF).

ARACHNOID MEMBRANE INDICATIONS

• is a thin, transparent sheath, which lies immediately Cerebrospinal Fluid Analysis:
under the dura mater and follows it to the end of the o To obtain cerebrospinal fluid (CSF) for analysis,
dura sac. which can aid in diagnosing various neurological
conditions, such as infections (meningitis,
SUBARACHNOID SPACE encephalitis), bleeding, and certain inflammatory
• A relatively roomy area between the arachnoid and disorders.
pia mater. It is filled with spinal fluid or cerebrospinal Infection Diagnosis:
fluid (CSF) since it is also found in the cranial o To identify the presence of infectious agents in the
subarachnoid space. CSF, helping diagnose bacterial, viral, or fungal
infections affecting the central nervous system.
PIA MATER (GENTLE MOTHER) Evaluation of Intracranial Pressure:
• Innermost layer of the meninges that is very closely o To measure intracranial pressure directly,
applied to the spinal cord. particularly in cases of suspected elevated pressure
due to conditions like hydrocephalus or tumors.
CEREBROSPINAL FLUID Neurological Disorders:
• CSF that is withdrawn is evaluated for color, blood, o To assist in diagnosing neurological disorders,
cells, bacteria, malignant cells, glucose, protein, including multiple sclerosis or certain types of
chloride, lactic dehydrogenase, lactic acid and neuropathies.
glutamine. Subarachnoid Hemorrhage:
• It is generally used to diagnose or rule out such things o In cases of suspected subarachnoid hemorrhage,
as: primary or metastatic brain or spinal cord the lumbar puncture can detect the presence of
neoplasm, cerebral hemorrhage, meningitis, blood in the CSF, aiding in the diagnosis of conditions
encephalitis, degenerative brain disease, like ruptured aneurysms.
autoimmune diseases of the CNS, demyelinating Guillain-Barré Syndrome Diagnosis:
disorders (such as MS), neurosyphilis. o To help diagnose Guillain-Barré syndrome, a disorder
affecting the peripheral nervous system.
OBJECTIVES Therapeutic Interventions:
o To administer medications directly into the CSF,
→ Ensure the patient is comfortable and well- informed
such as antibiotics for central nervous system
about the procedure.
infections or chemotherapy for certain types of
→ Maintain a sterile environment to minimize the risk of
cancer.
infection
→ Assist the healthcare provider in positioning the
patient correctly for the lumbar puncture
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 RLE116GEP
the physician. He or she may turn from side to side
Evaluating Demyelinating Diseases: as long as the head is not elevated.
o To assist in the evaluation of demyelinating diseases, o Monitor vital signs, neurologic status, and intake
such as neuromyelitis optica or transverse myelitis. and output. Take vital signs, measure intake, and
Alzheimer's Disease Research: output, and assess neurologic status at least every
o In some research settings, lumbar punctures are 4 hours for 24 hours to allow further evaluation of
used to collect CSF for biomarker analysis, aiding in the patient’s condition.
the study of conditions like Alzheimer's disease. o Monitor the puncture site for signs of CSF leakage
and drainage of blood. Signs of CSF leakage include
EQUIPMENT positional headaches, nausea and vomiting, neck
o Lumbar puncture tray, Spinal needle gauge 22-23, stiffness, photophobia (sensitivity to light), sense of
Alocoprep, 5cc syringe, OS (6 pieces) sponges 4x4, imbalance, tinnitus (ringing in the ear), and
Xylocaine 2% nebule, Disposable needle gauge 23- phonophobia (sensitivity to sound).
24, Eye sheet, Empty sterile pan G bottle (3 pieces) o Encourage increased fluid intake. An increased
specimen containers, Withdrawal needle gauge 19, amount of fluid intake (up to 3,000 ml in 24 hours)
Flashlight, Adhesive tape, Sterile gloves, Kidney will replace CSF removed during the lumbar
Basin, Manometer, Three-way stopcock, Pressing puncture.
tray with betadine, Small dressing to put over the o Label and number the specimen tube correctly.
puncture site, Mask Ensure all samples are properly labeled and sent to
the laboratory immediately for further evaluation.
PROCEDURE (CHECK EVAL TOOL) o Administer analgesia as ordered. Headaches after
the procedure can last for a few hours or days and
NURSING CONSIDERATIONS are usually treated with analgesics.
BEFORE THE PROCEDURE
o Explain the procedure to the patient. Explain to the EVALUATION
patient the purpose of lumbar puncture, how and 1. Patient is prepared psychologically and physically for
where it’s done, and who will perform the procedure. the procedure.
o Obtain informed consent. Make sure the patient has 2. Diagnostic tests performed with minimal discomfort.
signed a consent form if required by the institution. 3. Vital signs remain within normal range.
o Reinforce diet. Advise the patient that fasting is not 4. Specimen sent to the laboratory in appropriate
required. container and in a timely manner.
o Promote comfort. Instruct the patient to empty the
bladder and bowel before the procedure. SIR ELMER NOTES
o Establish baseline assessment data. Do vital signs o PRE-OP DBE: To reduce anxiety
monitoring and neurologic assessment of the legs by o POST-OP DBE: For pain; To relax muscles
assessing the patient’s movement, strength, and
sensation. LUMBAR TAP also known as:
o Place the client in a lateral decubitus position. Assist → Spinal Tap
the client to assume a lateral decubitus (fetal) → CSF Exam
position, near the side of the bed with the neck, hips, → Spinal Puncture
and knees drawn up to the chest. An alternative
position is to have the patient sit on the edge of the LAB TESTS FOR LUMBAR TAP:
bed while leaning over a bedside table. → PCR Test (Cell count)
o Instruct to remain still. Explain that he or she must lie → Cytology (Study of Cells)
very still throughout the procedure. Any unnecessary → Gram Stain Culture & Sensitivity (GSCS)
movement may cause traumatic injury. → Specimen collected is placed in 3 separate bottles
3-5 cc per bottle
DURING THE PROCEDURE
o Help patient stay in a fetal position. L4-L5 = common site for lumbar tap (less complications)
o Instruct patient to breathe normally.
o Observe patients skin color, respiration, and pulse. QUECKENSTEDT’S TEST (sometimes done to cancer px)
Continually support and reassure patient during the o To check blockage in jugular vein
lumbar puncture. o Complication: SPINAL STENOSIS
o Do not let the patient move during the procedure.
→ S/S: lower back pain, numbness
or tingling in lower extremities
AFTER THE PROCEDURE
→ If with S/S = NO LUMBAR TAP
o Apply brief pressure to the puncture site. Pressure
(also if with high/increased ICP)
will be applied to avoid bleeding, and the site is
o Increase fluid intake to 3000 ml
covered by a small occlusive dressing or band-aid.
o Place the patient flat on the bed. The patient
remains flat on the bed for 4 to 6 hours depending on
by: 元美安