Lumbar puncture lp is a common invasive procedure in the acute medical setting but is not without its risks and complications, making best clinical practice and correct documentation important for patient safety. See to it that the patient does not move during procedure. It flows down from the ventricles into the area around the spinal cord. Lumbar puncture lp is a procedure to sample cerebrospinal fluid csf for evidence of bacterial, viral or fungal infection, biochemical analysis or markers of metabolic disorders. Improving the safety and efficiency of outpatient lumbar.
As the anesthesia wears off, you may feel some pain and discomfort from your procedure. Its a medical procedure that can involve collecting a sample of cerebrospinal fluid csf. Lumbar puncture is also commonly called a spinal tap. Ultrasound guided lumbar puncture procedure sonosite. Stanford lumbar puncture guidelines stanford lumbar puncture guidelines before you begin image prior to a lp. Standardized procedure neonatal lumbar puncture neonatal 6 4. Standardized procedure lumbar drain insertion adults, peds 3 c. The procedure was described to the patient in the presence of. The patient tolerated the procedure well, without any complaints.
A lumbar puncture lp is a procedure in which an aspiration needle is placed into the subarachnoid space of the spinal cord, usually via the fourth lumbar inter vertebral space, to collect cerebrospinal fluid csf for diagnostic purposes. It will include the number of procedures performed per year and any adverse outcomes. Lumbar puncture lp is a hematology procedure that can require repeated attempts. New focal neurological findings andor lesions, or imaging studies revealing significant mass effect. To determine the pressure within the cerebrospinal canal. Please eat and drink prior to your lumbar puncture, unless specifically told otherwise. Improving patient safety of acute care lumbar punctures. What do i need to know to bill for a lumbar puncture. After the procedure properly dispose of all sharps.
The amazing pdf diagnostic lumbar puncture throughout lumbar puncture procedure note template pics below, is section of lumbar puncture procedure note template article which is sorted within note template, lumbar puncture procedure note template and published at august 28, 2019. Procedure note procedure lumbar puncture anesthesia. Assuming the patient has no contraindications and the patient has given consent assuming it is not an emergency, the following information will describe the steps involved to complete a lumbar puncture for the purpose of measuring the opening pressure andor obtaining cerebrospinal fluid csf. Sah intubated icu sah not intubated icu status epilepticus. This involves placing a needle in the lower back to obtain fluid that bathes the brain and spinal cord this. The area where your procedure was performed may be sore or bruised. Even within the same institution, there are a variety of individual preferences among physicians with different perspectives based on a combination of literature familiarity, training, and personal experience. Informed consent should be supplied by the referring physician, but nuclear medicine nm should confirm that the patient knows we are to do the lumbar puncture lp and describe the imaging protocol. Sacral anatomical interspace landmark for lumbar puncture. Standardized procedure lumbar puncture intrathecal chemotherapy adult, peds 5 1.
The patient was placed in the lateral decubitus position in a semifetal position with help from the nursing staff. If an adverse outcome occurred, a copy of the procedure note will be submitted. Previous audit revealed poor levels of consistency in technique and documentation in the acute medical setting, highlighting it as an area for improvement. These should be opened and placed upright when one sets up the tray. Methods in this prospective, randomized, openlabel trial, there were 110 singleton pregnant patients with gestational. Lumbar puncture spinal tap discharge instructions what are my care instructions.
Secure specimen for diagnosis relieve intracranial pressure introduce drugs in therapy. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. Ventura family medicine lumbar puncture procedure note. Note the reason the procedure was unsuccessful, and document how much of the procedure was completed prior to termination. The area was cleansed and draped in usual sterile fashion. The procedure was completed without any complications. The bandaid is placed over the lumbar puncture site at the completion of the procedure to prevent mild bleeding from the skin puncture site. A clinical practice outcomes log is to be submitted with each renewal of credentials. An template that can be used to write a post procedure note following a lumbar puncture lp, spinal tap.
Identify interspaces and mark the puncture site at the l45 interspaces in a. Also, thank you to my two favorite websites for helping me write notes in the hospital. Ich intubated icu ich not intubated icu ischemic stroke without tpa or intervention. He was advised to report any persistent headache, low back pain, leg tingling, numbness or weakness. Using landmarks, a 22 guage spinal needle was inserted in the l4l5 innerspace. Procedure note procedure lumbar puncture indication meningitis anesthesia local 1% lidocaine w epi informed consent was obtained from the patients mother. A lumbar puncture is done to withdraw a cerebrospinal fluid csf specimen from the subarachnoid space. Lumbar puncture, also called a spinal tap, is the procedure doctors use to obtain a sample of cerebrospinal fluid the liquid that surrounds the brain and spinal cord for tests. Documentation of the pretreatment evaluation and any abnormal physical findings.
Procedure lumbar puncture indication insert here anesthesia local 1% lidocaine w. The stylet was removed and the opening pressure was. Lumbar puncture lp, also known as a spinal tap, is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid csf for diagnostic testing. Lumbar puncture 2 pants or bottoms and underwear can be kept on as long as the waist band can be lowered andor folded down. Pdf traumatic lumbar puncture at diagnosis adversely. More than 90% of cases of acute bacterial meningitis present with a csf white cell count of more than 100 cells per. Csf culture is the gold standard in the diagnosis of bacterial meningitis. Pdf diagnostic lumbar puncture throughout lumbar puncture. Standardized procedure lumbar puncture adult, peds 2 pulse pressure, papilledema, or significant decrease in the level of consciousness until imaging studies have ruled out mass effect. The patient was then placed in the lateral recumbent sitting position with knees drawn to the chest. What to expect preparation for the procedure maintain your regular eating schedule. Cerebrospinal fluid csf is formed in special areas of the brain called ventricles. The area was prepped and draped in the usual sterile fashion. Objective to determine whether the sacral anatomical interspace landmark sail technique is more accurate than the classic intercristal line icl technique in pregnant patients and to assess the percentage of clinical determinations above the third lumbar vertebra.
Identify anatomical landmarks before starting procedure. Testing of the csf might not be necessary if the spinal tap is done to inject a medicine such as baclofen. Lumbar puncture lp can confirm or exclude meningitis. There are many differences in fluoroscopyguided lumbar puncture fglp technique among radiologists. Standardized procedure lumbar puncture adult, peds 5. A lumbar puncture is sometimes called a spinal tap. You received local anesthesia during your lumbar puncture. The indications, contraindications, and procedure for performing a lumbar puncture in children are presented here. There are no dietary or fluid restrictions before the tests. Ultrasound guided lumbar puncture procedure sonosite ultrasound youtube. The main reason for a lumbar puncture is to help diagnose diseases of the central nervous system, including the brain and spine. A lumbar puncture will be carried out by a trained physician or specialist nurse. Lumbar puncture patient information jama jama network. Introduce air or opaque liquid before taking xray for diagnosis 2.
In immunocompromised patients, csf white cell counts are often low. Lumbar puncture lp with examination of cerebrospinal fluid csf is an important diagnostic tool for a variety of infectious and noninfectious neurologic cond it seems to us that you have your javascript disabled on your browser. To remove cerebrospinal fluid by gravity flow in order to. Description of procedure in detail after the patient was educated regarding the indications, procedural techniques, risk versus benefit and alternatives to the procedure, informed consent was obtained. If you are going to measure opening pressure, you must position patient in left lateral decubitus.
Examples of these conditions include meningitis and subarachnoid. The l34 interspace above this level may also be used. Thoracostomy chest tube swanganz catheter placement. Youll help the patient into position, support her during the procedure, and assess her for complications. Indications and procedure 1 lumbar puncture indications and procedure 2 ferne brain illness and injury course 3 4th mediterranean emergency medicine congress.
Most junior doctors learn common practical procedures, like lumbar puncture, on the job. A timeout was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. Patient was counseled about postlp headache and how to minimize it. Lumbar puncture in adults, the physiology and utility of examination of csf, and the diagnosis, prevention, and treatment of postspinal headache are discussed separately. Knowledge of the contraindications, the pertinent anatomy, and the methods to minimize the risk of. The patient tolerated the procedure well and there were no complications. Lumbar puncture, also called an lp or spinal tap, is a procedure where a needle is inserted in your back and into the spinal canal. One gathers the csf beginning with tube one and ending with tube four. Lumbar puncture has, for many years, been the responsibility of the internal medicine physician or the neurologist. The lumbar puncture lp may assist in the diagnosis of meningitis, encephalitis, metastatic.
Identify interspaces and mark the puncture site at the l45 interspaces in a perpendicular line from the iliac crest. As more patients have undergone spine surgery and with the current increase in body mass index of the general population, the radiologist has been consulted with increasing frequency to perform lumbar puncture with fluoroscopic guidance. Record the time out, indication for the procedure, procedure, type and size of needle used, ebl, the outcome, how the patient tolerated the procedure. Lumbar drain insertion adult peds medical staff affairs. Lumbar puncture lumbar puncture department of neurology faculty of medicine of unpad hasan sadikin hospital lumbar puncture. Especially note if a patient requested you stop the procedure, as this is a. Lumbar puncture is a commonly performed procedure in both inpatient and outpatient settings in elective and emergency circumstances, for diagnostic and occasionally therapeutic purposes. This is done to collect cerebrospinal fluid csf or treat certain medical conditions.
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