Steps

Rationale/Points of Emphasis

1 Perform hand hygiene.

Reduces transmission of microorganisms.

2 Set up equipment using aseptic technique.

Maintains sterile integrity of environment, promotes efficient time management, and provides an organized approach to the procedure.

3 Airborne and/or contact isolation precautions may be needed. Don gown, gloves, and mask as needed if the procedure is being performed on a child with a potential infection.

Meningococcal meningitis is highly contagious and is an airborne contaminant. Unprotected staff exposed to this organism by the child will have to undergo prophylactic treatment measures.

4 Verify child’s identity and transport child to treatment room (unless procedure is to be done at the bedside). If using an anesthetic cream, apply to site prior to transporting child to treatment room; ensuring the agent has been applied for the period of time recommended by manufacturer. If using a needleless injectable anesthetic agent, apply after patient is in treatment room, just prior to the start of the procedure.

Helps ensure correct patient, correct procedure. Painful procedures should not be performed at the child’s bedside unless absolutely necessary because of the child’s critical condition. The child’s hospital room should remain a safe haven where intrusive procedures are not completed. Applying anesthetic agent, the site will be desensitized by the time procedure is performed.

5 Position child on the treatment table in one of the following ways:

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  Knee-chest position (Figure 59-1): With back rounded and parallel to side of treatment table, place child on side with lumbar area exposed. Hold small infant in position by placing one hand over his or her neck and the other hand over the buttocks. Bend the child’s back to the desired position.

Best position for infant. Maximizes separation of the vertebral bodies. The L3-L4 interspace is the preferred site for a lumbar puncture, but the L2-L3 and L4-L5 interspaces can also be used.

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  Recumbent position (Figure 59-2): Hold older infant or child in position by placing one hand behind child’s neck or one arm around neck and grasping child’s legs behind the knees. Place the other arm around child’s buttocks and grasp his or her hands. Put pressure on neck and legs to bend child’s body as necessary.

Best position for older infant or young child to maximize separation of vertebral bodies.

Modification of the positions may be necessary if the child is intubated or has fractures.

Figure 59-1 Knee-chest position.

Figure 59-2 Recumbent position.

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  Sitting position (Figure 59-3): Support the child in position by having the child sit at edge of the table with shoulders and head bent forward. Elbows should be placed on the knees and the back arched.

This may be a comfortable position for the older child who is able to cooperate without restraint. An assistant must hold infants placed in the sitting position.

KidKare A pillow or large stuffed animal can be placed in front of the chest with the child instructed to grasp it.

Figure 59-3 Sitting position.

6a When the child is in position, the sterile drapes are placed over the back to expose the puncture area only.

Aseptic technique is used to decrease exposure to microorganisms during this invasive procedure.

6b The child is instructed to stay as still as possible while the assistant continues to hold the child securely in position. The assistant or family member present in the room initiates distraction measures.

Research supports that parental presence decreases child fear and anxiety and that parents can use a variety of comforting and distracting strategies to support their child during the painful procedure.

7 Identify the patient using two unique identifiers and a “universal procedure or time-out” is completed before start of procedure. The healthcare provider performing the procedure identifies the puncture area and scrubs the area with povidone-iodine. Tell the child he or she will feel a cold sensation on the back during the cleansing.

Implements Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery and follows The Joint Commission (2015) National Patient Safety Goals to improve the accuracy of patient identification; eliminates wrong site, wrong patient, wrong procedure surgery. Decreases microorganisms at site. Telling the child what sensations he or she will feel may help him or her cope.

As of 2008 all chlorhexidine-based topical skin antiseptics have the warning “do not use for lumbar puncture or in contact with the meninges,” thus povidone-iodine antiseptic solutions are recommended to cleanse the skin before lumbar puncture.

8 The healthcare provider performing the procedure instills lidocaine (xylocaine) intradermally around the area of the puncture site.

Provides local anesthesia to the site.

9a The healthcare provider performing the procedure inserts needle and stylet into the subarachnoid space. When the needle is in position, a free drip of cerebrospinal fluid (CSF) is established, and spinal pressure may be assessed using the spinal pressure manometer. The manometer is attached to the spinal needle by means of a three-way stopcock.

When CSF fluid fills the manometer, CSF pressure can be monitored. Normal pressure in the relaxed patient is 50-80 mm in children (Table 59-1 ). Each heartbeat creates a fluctuation of 2-5 mm and each respiration a fluctuation of 4-10 mm. Increased CSF pressure may be present with meningitis and other neurologic conditions that cause increased intracranial pressure.

9b When the measurement is completed, the stopcock is turned to allow the CSF fluid to be collected in three to five sterile specimen tubes. CSF color and turbidity are noted at this time.

Normal CSF fluid is clear. Red fluid can indicate intracranial hemorrhage or a traumatic tap. Cloudy turbid fluid indicates infection. Yellow fluid indicates hyperbilirubinemia or hemolyzed red blood cells.

caREminder

Number the collection tubes in the order in which they were filled.

9c Before removing the needle, the healthcare provider performing the procedure may choose to use the manometer to measure closing CSF pressure.

Assists in appropriate collection of results.

10 Throughout the procedure, the assistant monitors for complications such as:

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  Abnormal breathing due to positioning

  
  
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  Decreased responsiveness

  
  
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  Tachycardia or bradycardia

  
  
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  Sluggish or unequal pupil reaction

  
  
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  Complaints of severe pain

Brainstem herniation is a potential complication. Children with increased intracranial pressure are at greatest risk. Other complications include penetration of a nerve and breakage of the needle (in an uncooperative moving child).

11 Spinal needle is withdrawn, the child’s back is wiped clean of wet fluids, and an adhesive bandage is placed over the puncture site.

Protects the puncture site.

12 Dispose of equipment and waste in appropriate receptacle. Perform hand hygiene.

Standard precautions. Reduces transmission of microorganisms.

13 Return child to his or her own bed, making the child comfortable lying flat in the bed. The child should remain lying flat for at least 1 hour after the procedure.

Despite a lower incidence than is seen in the adult population, postdural puncture headaches do occur in children. The headaches usually start within 48 hours after the procedure and resolve within 5-7 days without therapy. Lying flat and providing the child with good hydration can minimize the risk for headaches.

14 Continue to monitor the child for the complications noted in step 10.

Postprocedural complications may become evident and need to be treated.

15 Ensure that specimens are correctly labeled and sent to the laboratory immediately.

Prompt distribution of the specimens will assist in early diagnosis of the child’s condition.