The nurse is caring for a patient who had a lumbar puncture (LP) 1 hour ago. The patient is drowsy and his pupils are dilated. After notifying the healthcare provider, what should the nurse do?
a. Maintain airway and monitor vital signs.
b. Reduce total fluid intake.
c. Lie the patient flat.
d. Maintain pressure on the LP site.
A
A patient undergoing an LP can develop an excessive loss of CSF, which causes reduced LOC, dilated pupils, and increased BP. The nurse should notify the healthcare provider, monitor vital signs, and prepare to transfer the patient to the ICU. The patient should not be flat because that would compromise the airway. Pressure on the site will not stop the leak, and the patient should have not fluids restricted.
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