Introduction
In order for the nurse to assure the patient of their safety during a lumbar puncture, they must effectively communicate the process and potential risks to them. First, the puncture is crucial in diagnosing infections such as meningitis. Second, the nurse should outline the steps of the procedure and their purpose.
Discussion
The needle insertion occurs in the lower back, specifically between two vertebrae, and works to remove the cerebrospinal fluid. The fluid can indicate a variety of possible infections or conditions. It is essential that the nurse provides an honest description of possible risks and side effects. They can include a post-puncture headache, back pain or discomfort, bleeding, or brainstem herniation (MayoClinic, 2022). A herniation is the most dangerous of the potential risks and can occur due to the presence of tumors. However, the patient must be assured that magnetic resonance imaging (MRI) or computerized tomography (CT) scans will be conducted before the puncture.
There are a number of factors that must be observed in the case that a patient is experiencing a seizure. This includes muscle tone, whether the patient fell, and if they fell backward or forwards. It is vital to note whether the patient has lost awareness and whether they are dazed or confused (Goldstein et al., 2021). The nurse must also note their breathing pattern and difficulties breathing such as noisinesses or labored inhales or exhales. Other visual components include changes in facial color, paleness, flushness, open or closed eyes during the seizure, and the direction of the eyes.
Conclusion
Motions must also be recorded and can include movements such as twitching, and jerking, and rhythm or symmetry must be noted if present. Automatisms, automatic behaviors, such as wandering, unusual movements or postures, picking up items, or fiddling are also vital to note.
References
Goldstein, J., Kwon, C.S., Harmon, M., Buchhalter, J., Kukla, A., McCallum, S., Raman, L., Herman, S. T., Fureman, B., & Jette, N. (2021). Seizure documentation in people living with epilepsy. Epilepsy & Behavior, 125. Web.
MayoClinic. (2022). Lumbar puncture (spinal tap). MayoClinic. Web.