Question

A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.

1. Monitor the client's ability to void.
2. Maintain the client in a flat position.
3. Restrict fluid intake for a period of 2 hours.
4. Monitor the client's ability to move the extremities.
5. Inspect the puncture site for swelling, redness, and drainage.
6. Maintain the client on a nothing-by-mouth (NPO) status for 24 hours.

Answer 1

Post lumbar puncture care includes monitoring the client's ability to urinate and move their extremities, positioning the client flat, and inspecting the puncture site for signs of infection. Fluid intake restrictions and NPO status are not typical interventions unless specifically indicated by the healthcare provider.

Step-by-step explanation:

Following a lumbar puncture, the plan of care for a client should include certain interventions for safety and to monitor for complications. A few key interventions that should be included are:

• Monitor the client's ability to void, as urinary retention can be a side effect of the procedure.
• Maintain the client in a flat position, usually for several hours post-procedure, to reduce the risk of cerebrospinal fluid (CSF) leak and headache.
• Monitor the client's ability to move the extremities to identify any changes or neurological deficits following the procedure.
• Inspect the puncture site for swelling, redness, and drainage to detect any signs of infection or hematoma.

Interventions that are typically not necessary include restricting fluid intake and maintaining NPO status (nothing by mouth) unless there are specific contraindications or procedural reasons as advised by the healthcare provider.