HEAD AND NECK SERVICES

NEUROSCIENCE’S UNIT

LUMBAR PUNCTURE PROCEDURE

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Sheffield Teaching Hospitals

NHS Trust Title: Lumber Puncture Investigation

Unique Identifier

Scope: Neuroscience Dept.

Issue date – 2nd draft July 2003

Replaces – New Policy

Author/Originator Cath Waterhouse

Authorised by – Dr. G. Venables July 2003

Review Date – July 2004

Contents page no. Introduction 3

Purpose and scope of the policy 3

Policy statement 4

Definition and terminology 4

Indications for the procedure 5

Contra-Indications 5

Anatomy and physiology 6

Physiology of Cerebral Spinal Fluid 7

Spinal diagram (lateral view) 8

Principles of practice 9

Potential problems and complications of lumber puncture 12

Assessment of practice 14

Appendix 18

References 23

Introduction

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This protocol has been written by a small group of multi professional staff within the Neuroscience’s unit to provide a standard necessary to provide the basis of high quality patient care. Purpose This policy is to be adhered to sequentially; none of the stages are to be omitted. This policy for nurses undertaking a lumbar puncture is a multi disciplinary approach resulting in the safe and successful removal and measurement of cerebral spinal fluid (CSF) made on the basis of an individual patient assessment. Scope The policy aims to provide a standard procedure to enable the safe appropriate removal of a CSF sample following a lumbar puncture. It applies to medical staff and experienced nursing staff with a minimum of five years working in the specialty.

1. It is the responsibility of the medical staff to prescribe the investigation, document the reason to undertake the procedure and the samples required.

2. The nurse undertaking the lumbar puncture must be satisfied they are

competent to perform the procedure.

3. The approach must recognise registered nurses entering the Trust with differing levels of competency

4. Whilst undergoing the training to achieve competence: - (a) Patient must be consented to undergo the procedure by the

learning nurse (b) The Clinical Director, Director of Nursing and Matron are

responsible for agreeing with the individual trained nurse, following appropriate training, that they are competent to undertake the procedure.

5. If at any time the nurse feels that she cannot perform the procedure,

medical staff must take on responsibility to perform the investigation.

6. A consistent approach to competency practice is required

7. Competency must be used to its fullest extent, i.e. across directorate boundaries

8. The approach must recognise the managers responsibilities to maintaining standards

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9. If six months elapses without the skill being undertaken, the individual

is advised to refresh themselves Policy Statement All patients requiring a lumber puncture for either therapeutic or diagnostic purposes within the Sheffield Teaching Hospitals are to be treated according to this policy. Definition and Terminology. Lumbar Puncture - “Lumbar puncture involves withdrawing cerebrospinal fluid by the insertion of a hollow needle with a stylet into the lumbar subarachnoid space”. (Hickey 1997) Cerebral Spinal Fluid – Clear, lymph-like fluid that fills the entire subarachnoid space and surrounds and protects the brain. Lumbar puncture stylet – Sterile hollow, double lumen needle in varying lengths and gauges. Manometer – Clear glass or plastic tube use to measure pressure in the cerebro spinal fluid. Competent healthcare practitioner - describes the practice of a skilled and knowedgable doer. The practitioner is required to be able to apply critical thinking and be capable of doing or selecting the best choice in particular situations. (Cooper et al 2000).

INDICATIONS.

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Purpose of performing a Lumber Puncture on the Neurosciences Programmed Investigation Unit: -

1. In order to withdraw an adequate amount of CSF for appropriate laboratory examination.

2. In order to measure the circulating pressure of CSF

3. In order to remove a small amount of CSF for: -

(a) Treatment of Benign Intracranial Hypertension (b) Diagnosis of normal pressure hydrocephalus

CONTRA-INDICATIONS

1. Patient without neuro-imaging, unless documented by the Consultant that it is safe to undertake the procedure without a CT scan or MRI.

2. If there are any other signs, evidence or suspicion of increased intracranial

pressure caused by a space occupying lesion. 3. Patient’s under-going anti-coagulation therapy.

4. Patient’s who are likely to have a structural lesion pressing on the spinal

cord. 5. If the nurse undertaking the procedure has assessed the patient and

remains unsure about proceeding with the investigation. This might be due to: -

• High clinical activity in the unit • Lack of confidence in performing the procedure safely • Patient may be exhibiting non-compliant behaviour or perceived

lack of confidence in the nurse practitioner • The procedure may have been particularly difficult in that patient on

a previous occasion.

ANATOMY AND PHYSIOLOGY

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The spinal cord lies within the spinal column, beginning at the foramen magnum and terminating about the Level of the first Lumbar vertebra (fig 1). Like the brain, the spinal cord is enclosed and protected by the meninges, that is, the dura mater, arachnoid mater and pia mater. The dura and arachnoid mater are separated by a potential space known as the subdural space, which contains the CSF. Below the first Lumbar vertebra, the Subarachnoid space contains the CSF, the filum terminale and the cauda equina, (Weldon 1998). To avoid any damage to the spinal cord, it is imperative that the Lumbar Puncture is performed below the first Lumbar vertebra where the cord terminates (fig 2). The cord serves as the main pathway for the ascending and descending fibre tracts that connect the peripheral and spinal nerves with the brain. The peripheral nerves are attached to the spinal cord by 31 pairs of spinal nerves.

Figure 1. Saggital section through lumbosacral spine. The most common site for lumbar puncture is between L3 and L4 and between L4 and L5 as the spinal cord terminates at L1. Cerebrospinal Fluid (CSF)

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CSF is formed primarily by filtration and secretion from networks of capillaries called choroids plexuses, located in the ventricles of the brain. Eventually, absorption takes place through the arachnoid villi, which are finger-like projections of the arachnoid mater that push into the dural venous sinuses. CSF is clear, colourless and slightly alkaline with a specific gravity of 1005 (Draper 1989). In an adult, approximately 500ml of CSF are produced and reabsorbed each day (Welton 1998), with 120-150ml present at one time. CSF constituents include: -

1. Water 2. Mineral salts 3. Glucose 4. Protein (20-30mg) per 100ml (keel et al 1983) 5. Urea and creatinine

The functions of CSF include: -

1. Pulsatile displacement into the spinal canal to enable arterial blood to enter the brain in a pulsatile manner

2. To act as a shock absorber 3. To carry nutrients to the brain 4. To remove metabolites from the brain 5. To support and protect the brain and spinal cord 6. To keep the brain and spinal cord moist (Bickey 1997)

LABORATORY DETERMINATIONS: The following tests are routinely obtained on CSF’S, appearance, protein, glucose, serology, cell count, and if indicated, bacterial and fungal cultures.

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Figure 2. Lateral view of the spinal column and vertebrae.

1. Cervical vertebrae (C1-7)

2. Thoracic vertebrae (T1-

12)

3. Lumbar vertebrae (L1-5)

4. Sacrum (5 pieces)

5. Coccyx (3-4 pieces)

6. Atlas

7. Axis

8. Vertebrae prominens

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PROCEDURE

Equipment required

1. Antiseptic skin-cleansing agents e.g. chlorhexidine 2. Selection of needles and syringes 3. Local anaesthetic, e.g. lidocaine 1% 4. Sterile gloves, apron, eye protection 5. Sterile dressing pack 6. Lumbar Puncture needles of assorted sizes 7. Disposable manometer 8. Three sterile specimen bottles. (These should be labelled 1,2 and 3.

The first specimen, which may be bloodstained due to needle trauma, should go into the first bottle. This will assist the laboratory to differentiate between blood due to procedure trauma and that due to Subarachnoid haemorrhage).

9. Plaster dressing or plastic dressing spray.

Procedure

Rationale

Check medical notes 1. CT scan normal 2. Or imaging not necessary 3. Check anti-coagulation i.e. warfarin

(a) To ensure patient does not have raised intracranial pressure (b) Avoid bleeding

Explain and discuss the procedure and check that: - 1. Consent form has been signed. 2. the Ct or MRI has been seen and checked

by the patient’s doctor.

Ensure patient gives valid informed consent.

Assist patient into position. 1. Wash hands thoroughly and apply apron and eye protection. 2. Place the patient in the left lateral position. the lumbosacral region should be as close to the edge of the bed as possible. 3. Ask the patient to curl up to the maximum extent possible and to clasp his hands around the knees and hug them as close to the chest as possible. 4. The neck should be flexed forward and the patient’s back should be perpendicular to the ground.

To ensure maximum widening of the intervertebral spaces and thus easier access

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Procedure

Rationale

Infection control Wash hands thoroughly and apply sterile gloves. Prepare the lumbosacral region by swabbing in a spiral from the L4-5 interspace outwards until an area of aprox 20cm in diameter has been covered using the chlorhexidine 70% or betadine solution. Ensure that all trace of iodine is removed with alcohol prior to performing the L.P

Using aseptic technique throughout the whole procedure. Refer to Infection Control STH Trust Policy The introduction of iodine into the Subarachnoid space can produce irritative arachnoiditis.

Analgesia A lumber puncture can be performed at any of the lumber interspaces although the L2/3 or below. Using a syringe and size 20 gauge needle (orange). Inject the lignocaine under the subcutaneous layer to raise a wheal.

This is below the level of the spinal cord but still within the subarachnoid space. To minimize discomfort Allow the analgesia to take effect. 3-5mins (check with the point of a needle against the skin surface).

Procedure Change needle size to 18 gauge (blue); proceed as if performing the procedure into the lumber interspace. Draw back the syringe to ensure that the needle is not contaminated with blood or CSF. Slowly inject about 2ml of analgesia at that interspace. Introduce the spinal needle in the exact midline between the 2nd and 3rd lumbar vertebrae and into Subarachnoid space. The needle should be parallel to the ground at all times. Insertion is continued until a slight pop is felt. Withdraw the stylet to ensure it is in the Subarachnoid space – allow only one drop of CSF to escape, otherwise an erroneously low pressure recording will result. If the needle strikes bone it should be withdrawn to just below the skin, then reinserted.

Most errors are made by aiming the needle too far caudally, by being off the midline or if the needle is not precisely parallel to the ground.

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Procedure

Rationale

Following three failed attempts, the practitioner should discontinue the procedure and refer to the patient’s doctor.

To minimise the patient’s discomfort and anxiety.

Measuring the pressure The manometer is attached to the hub of the needle with a three-way stopcock in the appropriate position. When cerebral-spinal fluid is seen, attach the manometer to the spinal needle. Record the pressure.

Normal pressure is 11-16 cm H2o

Obtain the appropriate specimens of cerebral-spinal fluid (see notes for amounts required)

To establish diagnosis.

Closing pressures should be measured before withdrawal of the needle. After withdrawal, the needle puncture point should be briefly massaged with a sterile piece of gauze and a plaster applied

To maintain sepsis and stop fluid leak To prevent infection

The patient can rest for as long as they wish or alternatively the patient can get straight up.

Research shows that bed rest is not necessary and will not influence whether a patient complains of a post lumbar puncture headache.

Remove and dispose of sharps as appropriate.

Refer to STH Trust Policy as removal of sharps and waste.

Document the procedure:

(a) Complexity of procedure (b) Amount of local anaesthetic used (c) Opening pressure (d) Closing pressure (e) Colour of CSF

Provide accurate record of procedure.

Ensure that specimens are labelled appropriately and sent with correct forms.

To ensure correct patient results.

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Procedure

Rationale

Special procedures for suspected Normal hydrocephalus: Ensure patient understands purpose of procedure. Before undertaking lumbar puncture undertake 10 metre timed walk, mini mental test and any other assessment detailed by referring consultant. Undertake LP, removing 20-30ml CSF. Wait 30-60 minutes Repeat timed walk, mini mental test and any other assessment Document the procedure in the notes.

Symptoms of Normal Pressure hydrocephalus include apraxia and decline in cognitive function. Aim of the procedure is to determine if patients neurological status improves temporarily after removal of 20-30ml of CSF.

POTENTIAL PROBLEMS

PROBLEM

CAUSE

ACTION

Pain down one leg during the procedure.

The spinal needle may have touched a dorsal nerve root.

a. Reposition the needle. b. Reassure the patient

Headache may develop up to 24 hrs following procedure.

Removal of cerebrospinal fluid.

a) Reassure patient b) Relieve by lying flat c) Encourage increased fluid intake d) Take analgesia e) If severe and increasing inform G.P

Backache

a) Insertion of needle b) Position required to procedure

a) Reassure patient b) Lie flat c) Take analgesia

Leakage

a) Leakage of cerebro- spinal fluid.

a) No further action required b) Report immediately if associated with other symptoms

Deterioration in neurological status

Presence of space occupying lesion in the brain not appreciated

Summon medical assistance immediately.

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ASSESSMENT

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MANAGEMENT OF PATIENTS UNDERGOING A LUMBAR PUNCTURE.

Performing a Lumbar Puncture

Aim: To understand the procedure of Lumbar Puncture. Range: Qualified Nurses ASSESSMENT SPECIFICATION: The Employee is required to meet all the performance indicators at least once to indicate completion. This may be achieved through a number of any of the following methods of assessment, however, the observation of real work. Followed by questioning to check underpinning knowledge is preferable in the first instance. Assessment method key Index D/O: direct observation Q&A: Question and answer T: Testimony of others. S: Simulation Evidence of performance Assessment Method of

assessment Date

completed

1. Accurately identify rationale for the procedure.

3. Can explain related anatomy and physiology.

4. Can describe patient’s condition and relevant history

4. Provide the appropriate information related to the procedure to the patient and discuss the term ‘informed consent’.

5. Ensure that the patient has completed the consent form and is happy for the practitioner to perform the procedure.

6. Checks that the patient has a recent MRI or CT scan to exclude space occupying lesion.

7. Can discuss the nurses role regarding accountability and legal issues

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Evidence of performance Assessment Method of assessment

Date completed

8. Can explain what is meant by the term “Scope of Professional Practice”.

9. Complete the patient assessment form and demonstrate knowledge of the contra-indications to performing the procedure.

10. Position the patient correctly on the bed, ensuring that the patient is protected from potential risk of falling or injury.

11. Ensure that Universal Precautions are adhered to.

12. Demonstrate an understanding of the potential risk to the practitioner and ensure adequate safeguards are in place.

13. Demonstrate appropriate preparation and cleaning of the site.

14. Discuss the potential complications resulting from inadequate skin preparation.

15. Can explain selection of correct equipment and prepares trolley and equipment as per local policy

16. Understands the rationale for not undertaking the procedure

17. Can discuss potential complications of the procedure

18. Is able to identify correct route of entry.

19. Demonstrates safe administration of local anaesthetic.

20. Demonstrates the safe insertion of the lumbar puncture needle.

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Evidence of performance Assessment Method of assessment

Date completed

21. Demonstrates the correct measurement of the CSF pressure and can discuss the normal values and significance of altered pressures.

22. Obtains the necessary CSF samples and labels the bottles appropriately.

23. Demonstrates the safe removal of the lumbar puncture needle and manages the puncture wound appropriately.

24. Disposes of equipment appropriately are according to local policy.

25. Can perform post-procedure observations and record as appropriate.

26. Accurately records the procedure in the patient’s records.

Methods of attainment of competence. • Observation of procedure carried out by medical staff • Observation of procedure carried out by Nurse observed by senior

medical staff • Observation of procedure by junior medical staff • Independent performance with medical staff nearby • Independent performance

The timescale will be dependent on the attainment of confidence and competency.

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APPENDICES

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Appendix 1

COMPETENCE WITHIN THE PRACTISE OF A LUMBAR PUNCTURE

Historically, nursing practise has always been a combination of theoretical knowledge and experience. The knowledge embedded in clinical expertise and practise is central to the advancement of nursing practise and the development of nursing science. As nurses have continued to examine the nature of nursing within personal portfolios, through examples of good practise and reflective practise, the competencies defining skilled nursing practise founded by Benner (1984) and later, re-examined by authors such as Fearon (1998), are continually reclassified.

The introduction of the Scope of Professional Practise (UKCC 1992) again raised the issue of competence within clinical nursing practise putting an end to the extended role as it was previously known by allowing nurses to develop their skills, examine their own competence to practise and determine the extend to which these competencies continue to be achieved and maintained at a satisfactory level. For nurses familiar with the mandatory requirements to maintain professional knowledge and competence (PREP UKCC 1995) a clinical competency framework seemed a viable concept to assist the process and provide a framework to support changes within their practise.

Since then, there have been numerous references within later UKCC documents and more recently within the Making A Difference: A strategy for Nursing Document (DOH 1999:) and the new NMC Code of Professional Conduct (NMC 2002). Discussion of competence is not a new phenomenon. All nursing curricula of the 1990’s describe competencies and learning outcomes for students. The NVQ system provided a standard set of competencies nationwide, whilst all nurses and midwives wanting admission to part or parts of the register needed to achieve the statutory requirements of the Nurses, Midwives and Health Visitors Acts of 1979 and 1992. Rules therein specify competencies of which the practitioner must demonstrate achievement. True competency – based learning situations require performance criteria and the fair assessment of evidence (indication of performance) of learning through a range of practical tasks and recollection of theoretical concepts which underpin the practise. Attainment of competencies via a structured framework allows for both experienced and less experienced practitioners to develop safe, effective practise within a supportive, reflective environment.

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Since nursing and midwifery is a mixture of practical skill and theoretical knowledge, competencies should identify the skills, knowledge aptitude and attitude needed to perform as particular skill, task or activity in any clinical setting. Competencies therefore need to be realistic, achievable and reflective of current activity and yet allow for action planning for skills, which may require refinement. They need allow for acknowledgement of prior learning, experiences and expertise, whilst providing a framework to ensure that upon completion, practitioners all possess the agreed level of competence.

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Appendix 2 DISCUSSION / ACTION PLAN

Please use this part of the document to record meetings relating to the proposed achievement of elements of the clinical competencies. Date:

Assessor:

Elements Discussed:

Planned method of attainment of skills and assessments

Target date: If the action plan has not been achieved please state as to the reason why: Date:

Assessor:

Elements Discussed:

Planned method of attainment of skills and assessments

Target date: If the action plan has not been achieved please state as to the reason why: Date:

Assessor:

Elements Discussed:

Planned method of attainment of skills and assessments

Target date: If the action plan has not been achieved please state as to the reason why: Signature of Assessor: Signature of Learner:

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Appendix 3 COMPETENCY TO PRACTICE DECLARATION

The professional position In order to bring into proper focus the professional responsibility and consequent accountability of individual practitioners, it is the council’s principles rather than certificates that for which should form the basis for adjustments to the scope of practice. (UKCC, 1992). Implications for employers This change has consequences for managers of clinical practice and professional leaders of nursing, midwifery and health visiting, who must ensure that local policies and procedures based upon the principles set out in this paper an in the councils Code of professional Conduct. Any local arrangements must ensure that registered nurses midwives and health visitors are assisted to undertake, and are enabled to fulfil any suitable adjustments to their scope if practice (UKCC, 1992). These requirements are met by: • A position paper on the scope of professional practice for nurses,

midwives and Health Visitors • A signed Competency Statement detailing preparation nurses have

received to practice • A standard education package for specific areas for practice

development The Trust requires the nurse to: • Read the position paper notes above • Satisfy themselves that preparation they have received matches the

Neurology standard • Undertake the education package if the y are undertaking a new skill or

role. • Refresh their competency to practice by reading updated policies and

procedures as they are issued • Recognise when their competency requires a refresher due to the lack of

opportunity to use the skill • Read nursing matters that will highlight significant changes in practice.

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Appendix 4 COMPETENCY TO PRACTICE DECLARATION

I confirm that I am competent to practice ……………………………..(specify skill/task) and understand that I am responsible and accountable for my own practice. I have: • Undertaken supervised practice (new skill) or demonstrated competent

practice (transferred skill). • Read the accountability documents and policies and procedures

identified in the package • Completed the education package (or a similar preparation)

I understand that I am responsible and accountable for keeping my practice up-to-date, that I am advised to read policies and procedures annually as they are reviewed and seek to update my practice as necessary. Authorised by ………………… Clinical Director

Signed …………………….. Date ………………………… Print Name …………………

Director of Nursing

Signed ……………………… Date ……………………….. Print Name …………………

Matron

Signed ……………………… Date ……………………….. Print Name …………………

Signed ………………………… Date …………………………….. Print Name ……………………

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References

Department of Health (2000). The NHS Plan: A plan for investment, a plan for reform: Department of Health: London Department of Health (1999). Making a Difference: Strengthening the nursing, midwifery and health visiting contribution to health and health core. Department of Health. London. Hickey, J. (1997). The Clinical Practice of Neurology and Neurosurgical nursing 4th ed. J.B Lippincott. Philodelphia. NMC (202). Code of Professional Practice, London: United Kingdom Central Council for Nursing, Midwifery and Health Visiting. UKCC (1995) PREP, London United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Weldon, K. (1988). Anatomy and Physiology of the Nervous system.pp 1-28, in Neuro-oncology for nurses – Whurr, London.

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