The nurse is caring for a patient scheduled for a lumbar puncture. Which actions should the nurse anticipate providing? (Select all that apply.)
a. Position the patient prone on the bed.
b. Check the puncture site for swelling or drainage.
c. Ensure that the patient has given informed consent to the procedure.
d. Keep the patient on bedrest with the head of the bed flat for 6 hours after the procedure.
e. Limit fluid intake.
f. Assess movement and sensation of lower extremities frequently for several hours after the procedure.
ANS: B, C, D, F
Ensure that informed consent has been obtained prior to the procedure. A. Assist the patient into a side-lying (not prone) position with his or her back as close to the edge of the bed nearest the practitioner as possible. After the lumbar puncture is completed, instruct the patient to remain on bedrest with the head of the bed flat for 6 to 8 hours, as ordered by the physician. E. Oral intake of fluids should be increased. Keeping the head flat decreases the likelihood of leakage of cerebrospinal fluid from the puncture site, which can result in a severe headache. Increasing fluid intake promotes replacement of the fluid that was removed. Check the puncture site for swelling or drainage of cerebrospinal fluid and report any leakage to the health care provider. Assess the movement and sensation to the lower extremities frequently for the first 4 hours after the procedure. Assess the patient for headache, and if necessary, obtain an order for analgesia.
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