How to care after lumbar puncture

Lumbar puncture is a very important diagnosis and treatment technique commonly used in various clinical departments. With the continuous progress of medical science, lumbar puncture is also widely used in pediatrics, and effective nursing cooperation and intervention play an important role in the smooth progress of the examination, improving the success rate of puncture and alleviating the pain of children.

1 General care

1.1 Posture and body position

The ideal puncture position is to use the natural lateral recumbent position. The line connecting the patient's shoulders and the iliac crest is perpendicular to the operating table, the thighs are flexed toward the body, and the head and neck are flexed toward the chest, so that the spine can achieve the best flexion rate. The spinous processes are separated from each other. Assist the non-cooperator to fix the posture, especially to maintain a good posture when the needle is inserted, so as to improve the success rate of the puncture. During the operation, closely observe the complexion, consciousness, and breathing of the child. If there is any abnormality, report it to the doctor, stop the puncture, and deal with it accordingly.

1.2 Postoperative care

1.2.1 Supine position

Lie down with the pillow removed for 4 to 6 hours, depending on the condition of the child. For those who are accustomed to using pillows, place a thin pillow (3 cm to 5 cm thick) behind the head to relax the neck muscles. Also put a thin pillow to prevent back discomfort after puncture.

1.2.2 Disease observation

Dynamically monitor body temperature, pulse, respiration, blood pressure, consciousness, pupils, vomiting, headache, etc., and report any abnormalities to the doctor in time.

1.2.3 Psychological care

Psychological care should be done before the puncture, and it is the key to eliminate the concerns of parents. Due to the influence of traditional concepts, parents have certain resistance to lumbar puncture, and they are afraid that the child will not be smart after lumbar puncture or leave the sequelae of lumbar puncture. Therefore, parents should do detailed explanation work to change their understanding and eliminate their concerns. , Influence the child to cooperate with the treatment with a positive attitude and language, and avoid giving the child bad hints and increasing their fear.

Do a good job of psychological counseling for children. Children's nervousness and fear of diagnosis and treatment are particularly prominent. Children receiving diagnosis and treatment should take targeted psychological care according to different ages. Explain clearly the purpose of the examination and the method of intraoperative cooperation to the older child, answer their questions patiently, give the child enough psychological support, explain it in affirmative language as much as possible, and praise the child for being a brave and obedient child. You can also try to let the child talk more, or give favorite toys to distract their attention. No matter before or after the puncture, the child should not be discussed or hinted about possible discomfort in order to reduce their fear. For children under the age of 3, because they cannot understand complex language, they should be more patient and talk to them kindly, so that they have a sense of closeness and dependence. During the puncture, the parents were accompanied by their side for psychological support, and the children were basically able to cooperate through the above measures.

2 Symptomatic care

2.1 Nursing intervention for headache after lumbar puncture

During the lumbar puncture procedure, if the puncture needle accidentally penetrates the dura mater and enters the subarachnoid space, it may cause the patient post-lumbar puncture headache (PLPHA). A considerable number of PLPHA patients suffer from headaches affecting their normal life and work, so this phenomenon has attracted widespread attention in the medical community. Xie Shuli and others took nursing interventions to prevent PLPHA with obvious effect. The main intervention measures are as follows: (1) Once the dura is penetrated, the epidural space is injected with warm (30 ℃) normal saline in the early stage, and the postoperative infusion is combined with analgesic drug treatment to relieve the headache. Place the patient in the "natural back position", that is, lying on the side, with the back in a natural comfortable position, with the hip and knee joints slightly bent, whichever can support the lateral position and facilitate puncture, instead of the excessively bent back position previously used, with To prevent the dura mater from being too tight and making the perforation larger, after dural puncture, withdraw the puncture needle by 0.5 cm until the outflow of cerebrospinal fluid stops completely, and inject 5 mL of warm normal saline into the epidural space to increase the pressure in the epidural space , reduce the leakage of cerebrospinal fluid. ②Strict aseptic operation and non-contact technology, based on the principle of prevention, strictly disinfect the puncture equipment and the patient's skin, and do not mix the local anesthetic liquid into the air or blood. Give active symptomatic treatment to patients who may have pseudomeningitis. Apply a small amount of sulfonamides. ③ Mild headache disappears after 2-3 days of bed rest. Acupuncture at Taiyang, Yintang, Hegu and other acupoints is used to relieve headache. ④ infusion to accelerate the formation of cerebrospinal fluid. If there is no obvious improvement, 10 mL-20 mL of warm normal saline or 5% dextrose saline should be injected into the epidural space at the puncture point to increase the pressure in the space and slow down the loss of cerebrospinal fluid.

2.2 Nursing care of low back pain after lumbar puncture

Some studies have shown that parents' bad suggestion is the main cause of low back pain in children, and children's nervousness and fear are an important factor in causing low back pain, and improper puncture posture damages ligaments and sarcolemma is another important reason. . Therefore, posture and body position during the entire lumbar puncture process, as well as psychological care before puncture, are important measures to reduce back pain after lumbar puncture. Before lumbar puncture, explain to parents or older children that lumbar puncture is one of the indispensable means of diagnosing diseases, and the diagnosis and treatment of diseases should not be delayed because of worries, and explain to them the generation process of cerebrospinal fluid, and 500 mL of cerebrospinal fluid is generated every day. , that is, about 20 mL of cerebrospinal fluid can be produced per hour, and 2 mL of cerebrospinal fluid can be produced in about 10 minutes, which will not affect normal physiological functions. The purpose is to explain that the damage of lumbar puncture to the body is not large, so as to eliminate the ideological concerns of parents and older children, so as to timely check the lumbar puncture, achieve early diagnosis, early treatment and early recovery. Explain the whole process of lumbar puncture, and demonstrate the position of lumbar puncture, so that the patient can be placed in the correct position, and parents can be allowed to accompany the lumbar puncture during the operation, so as to reduce the tension and strangeness of the child. After the puncture, the patient should be placed in the supine position, and whether to lie down on the pillow for 4 to 6 hours depends on the patient's condition. For those who are used to pillows, put a thin pillow (3 cm to 5 cm thick) behind their head when lying down to relax the neck muscles, and also put a thin pillow on the back. This is the main measure to prevent low back pain after puncture.

2.3 Nursing care of continuous drainage of lumbar puncture

2.3.1 Preoperative preparation

Prepare a 18-gauge epidural trocar, an epidural catheter, a self-made sterile drainage bag with a speed-regulating valve (ordinary liquid pick-up and sterile drainage bag can also be used instead), and a tee tube if intracranial pressure monitoring is required ,Monitor.

2.3.2 Intraoperative cooperation

If the patient has obvious symptoms of increased intracranial pressure, such as severe headache, frequent vomiting, etc., a rapid intravenous infusion of 20% mannitol can be performed half an hour before the puncture. For restless children, intramuscular sedatives such as luminal sodium can be injected half an hour before surgery. Assist the child to maintain the correct body position, usually choose the gap between waist 3 and waist 4 or between waist 4 and waist 5, and strictly disinfect the skin of the puncture area. After successful puncture, an epidural catheter was placed along the epidural cannula to the cephalic subarachnoid space, and a closed sterile drainage bag with a speed-regulating valve was connected at the end. The epidural catheter was secured to the back with sterile tape and a sterile cotton ball was applied to the eye of the needle.

2.3.3 Postoperative care and precautions

Adjust the dripping speed according to different needs, preferably no more than 20 drops per minute, too fast and excessive drainage may cause the risk of intracranial hematoma or brain herniation. The amount of cerebrospinal fluid drainage should be controlled according to the needs. The total amount of intraoperative drainage is 40 mL to 60 mL, and the daily drainage amount for preventive and therapeutic treatment is about 150 mL and 350 mL, respectively. For those who need blood cerebrospinal fluid replacement, normal saline can be injected through the three-way tube. The volume of normal saline should be less than the amount of cerebrospinal fluid released each time. Intrathecal antibiotics can also be injected through the three-way tube to treat intraventricular infection. Avoid twisting and breaking the catheter to prevent the drainage tube from being blocked. Because the catheter is thin and easy to be blocked by the broken tissue in the cerebrospinal fluid, it can be flushed with a small amount of normal saline. Pay attention to aseptic operation. Redness at the puncture needle eye can be disinfected with iodophor or ethanol cotton balls, and then replaced with sterile dry cotton balls. And daily monitoring of cerebrospinal fluid routine. Pay attention to the patient's position, and you can change the position between 15° and 30° of head height to avoid pressure ulcers.

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