Lumbar Puncture

Kai Tiaki : the journal of the nurses of New Zealand, Volume XIII, Issue 4, 1 October 1920, Page 197

Lumbar Puncture

Herman Goodman

(By

8.5., M.D., New York, N.Y.)

• As was stated m the first article of the series, i i What a Nurse Should Kciow About Syphilis," Pournier recognised a relation between general paresis (general paralysis of the insane), tabes dorsalis (locomotor ataxis), and syphilis. It was left to later investigators, m the light of the great advances m bacteriology, seroiogy, and pathology of the 20th century, to prove these affections to be directly due to the syphilitic infection, and not parasyphilitic — that is, due to the toxins of an antecedent syphilis. In the effort to learn the character of the spinal fluid, and to give more direct contact between the affected nervous tissue and the therapeutic agent, usually salvarsanised serum I—lumbar1 — lumbar puncture has become a routine procedure m the practice of most syphiologists. When lumbar puncture, or spinal puncture as it may be called, is ordered, the nurse should make the following preparations : — 1. The patient is to be put to bed, wearing a nightshirt that is open, full length, m the back.

2. A bedside table and a low stool are to be placed beside the bed. 3. The bed should be so arranged as to have the best light on the back of the patient, who is to lie on his left side. 4. The lumbar puncture tray should be brought. The nurse should observe the most strict aseptic precautions. She should be able to vouch for everything, once the preparation of the lumbar puncture tray is entrusted to her. The tray should have : (a) Lumbar puncture needles having good points; the stylet should be easily withdrawn but a good fit. Needles showing any signs of rust should not be used. The needles after thorough cleansing are best sterilised by dry heat, each needle within a long, hard glass test tube plugged with cotton. If the hot air steriliser is not available, the spinal needles should be sterilised by boiling m distilled water. The water must be boiling for at least seven minutes. The needles are transferred to a sterile towel, using a sterile forceps.

(b) Two dry, sterile, labelled, and corked test tubes. (c) Solution of green soap. (d) Alcohol, .(e) Ether. (f) Sterile towels. (g) Sterile gauze wipes. (h) Sterile cotton. (i) Tincture of iodine. Although many operators perform lumbar puncture' without any anaesthetic, some doctors may require: (j) 2 c.c. hypodermic syringe and needle ; (k) Half per cent, cocaine solution. The patient lies on his left side, knees drawn up, head bent approximating the knees, and the hips slightly overlying the side of the bed. The patient's back must present a igood curve. The region of the lower back is exposed, and a wide area about the lumbar vertebrae is scrubbed with soap solution, followed by iodine-al-cohol, or alcohol-ether preparation, as the doctor directs. The nurse should always wipe away from the midline. Sterile towels are placed over the neighbouring parts. The nurse is occasionally asked to count drops per minute of spinal fluid flow, and should have her watch handy. She may be asked to hold the test tubes to catch the fluid. Ordinarily, about 5 c.c. is allowed to flow into the first tube, and 10 c.c. into the second. Tt is a breach m technic to have the test tube touch the needle, especialy if a treatment is to follow. After the needle is withdrawn, a pad of sterile gauze and a sterile towel are placed over the site, the patient turns over on his back, the pillows are removed, and most doctors will order the foot of the bed raised for six hours, and will leave a P.R.N. order for J-graih morphine. Headache is perhaps the only symptom following lumbar puncture. It may be severe, especially m persons m whom syphilitic involvement of the nervous system is not present, nor advanced m character. Lumbar puncture headache is more oft m absent m marked cases of cerebro-spinal syphilis. The patient should be urged to drink plenty of water, to stay flat, and to sleep

if possible. The diet should be restricted to tea and toast. Confinement to bed for 18 hours following the puncture should be enforced. The sample of spinal fluid should be labelled with the name of the patient, and other data for the information of the laboratory. All forms should be marked "spinal fluid." The cell count of the specimen should be done immediately following the withdrawal of the fluid. Ths doctor may do it at the bedside, or, if m an hospital, the specimens are immediately carried to the laboratory. The test for albuminous content is also performed on the freshly-withdrawn fluid. The Wassermann test is usually done m various dilutions. The Lange igold collodial test is also done. In most laboratories the second tube, containing more spinal fluid than the first, is reserved for these two delicate tests, the first tube, being probably contaminated each time fluid was withdrawn for cell count and globulin determination. By the results of such a complete analysis as just outlined, together with a complete physical and neurological examination, the diagnosis early of impending cerebro-spinal syphilis is facilitated, and the diagnosis m advanced cases is confirmed. Seldom will the nurse be entrusted r.ith the preparation of the salvarsanised serum, so the technic need not be given here, further than to mention that the blood from the patient is collected m a sterile, dry, 50 c.c. centrifuge tube provided with a sterile cork. For. the intraspinous treatment, the nurse should add to the lumbar puncture tray a small gravity tube, outlet at the bottom, with six inches of rubber tubing fitted with a male connection for the hilt of the lumbar puncture needle A3O c.c. glass barrel of a syringe does exceptionally well, with the rubber tube having a female connection to fit the syringe, and a male connection to fit the needle. Following treatment, the patient receives the routine described after ordinary lumbar puhcture, — ll American Journal of Nursing. M