Adult Lumbar Puncture (LP) Procedure for Diagnostic Testing

Adult Lumbar Puncture (LP) Procedure for Diagnostic Testing 

Indications 

For diagnosis of:  Subarachnoid hemorrhage, Meningitis, Neurological disorders, Cerebral lymphoma / metastatic disease 

Contra indications 

Bleeding disorders (e.g. PT > 1.3, Platelet count < 80,000), recent heparin, LMWH or other anticoagulant 

 Local sepsis such as cellulitis or abscess on back 

 Raised intracranial pressure 

 Note indications for CT scan prior to LP above 

 Previous back surgery (relative) 

 Prior history of back pain / pathology (relative) 

In certain conditions, a brain CT has to be done first before an LP is performed: 

 Immunocompromised patients 

  Recent history of head trauma 

  Impaired level of consciousness 

  Evidence of papilledema or focal neurological deficits

 If a lumbar puncture (LP) is delayed to conduct neuroimaging studies, empirical antibiotic therapy should begin after obtaining blood cultures. It is crucial to perform the LP, if there are no contraindications, and start antibiotics as soon as possible in a patient with suspected meningitis, as the outcome is dependent on the timeliness of the treatment initiation.

Supplies needed

 LP kit 

 Includes 23 g 9cm spinal needle 

 Mask, gown, gloves 

 Assistants- to hold the patient in position and to hand equipment to the operator

Consent 

Patient consent must be secured, and the procedure should be thoroughly explained to them. Major complications can involve post-dural puncture headaches, while significant back pain is rare.

 Operator (the person doing the LP)

Follow your hospital's GME policy for residents performing LP. In some city hospitals a resident has to complete 3 to 5 successful LPs with an attending doctor present. 

Patient position 

For right-handed practitioners, patients should be positioned on their left side, though a sitting position is also an option. In the sitting position, patients should sit at the edge of the bed or trolley with their legs hanging over the side. An assistant can help support the patient. Placing a pillow on the patient's lap can be beneficial, with the patient leaning forward over it.

Lumbar Puncture Procedure

The operator should wear a surgical mask, gown, and gloves after performing a surgical scrub. The patient's back should be prepared with Betadine or a similar antiseptic and allowed to dry.

Once the skin preparation is dry, the area should be covered using the plastic drape that comes with the kit, or alternatively, sterile sheets can be used to demarcate the prepared area.

The L3/4 interspace is identified using the intercristal line as a surface marker (the line at the level of the iliac crests). The spinal cord typically ends at the lower border of L1; lumbar punctures should be performed below this level.

A small amount of local anesthetic is injected into the skin and subcutaneous tissues. A 23-gauge spinal needle with a stylet is then inserted perpendicular to all planes at the L3/4 interspace and advanced into the subarachnoid space, which can be felt as a slight pop. 

The depth to the space is approximately 5 cm but can range from 3 cm to 9 cm in larger patients. If bone is encountered, withdraw the needle almost to the skin and try another approach, either more cephalad or caudad. Do not force the needle, as it can bend or fracture. Replace the stylet with each advancement of the needle. If there are three unsuccessful attempts, the operator should seek assistance. 

Remove the stylet and check for CSF flow. If CSF is present, use the manometer to measure opening pressure, considering the patient's position during interpretation. I possible, opening pressure should be measured. It is usually elevated in cases of bacterial or cryptococcal meningitis. 

Collect the initial CSF that emerges into the first tube and continue to collect CSF into pre-numbered tubes in the correct order. After collection, remove the needle and apply an appropriate dressing. Many emergency department texts recommend replacing the stylet before removing the needle. Ensure the needle is complete and intact after removal.

Cerebrospinal Fluid Collection Tubes

Tube one, which is potentially the most contaminated and blood-stained, is sent to biochemistry. Tube two is sent to cytology, and tube three, the least likely to be contaminated or blood-stained, is sent to microbiology. By keeping this in mind, it may be possible to collect additional CSF in certain tubes based on the clinical presentation. For example, in an adult with suspected meningitis:

 Always collect CSF into the tubes in the correct order (i.e. tube 1 first; tube 3 last). Some facilities require a 4rth tube to be collected which is used for comparison if result of any of the 3 other tubes need to be confirmed rather than sticking the patient again. 

You can watch the video here: Mastering the Lumbar Puncture: A Step-by-Step Guide

(Note: Always follow your facility's policy and procedure on lumbar puncture for diagnostic tests.)

Did you know that humans have a second heart?

 Did you know that humans have a second heart? 

The soleus muscle: The body's "second heart"

Did you know that the soleus muscle is often referred to as the "second heart"? 

It serves as an additional pump in the body, complementing the function of the heart. 

While the heart pumps blood outward to the extremities, deep muscles like the soleus aid in pumping blood back towards the heart. 

Positioned at the body's lowest gravitational point when standing upright, the soleus muscle is strategically located to work in harmony with the heart. This muscle, found in the calves, plays a crucial role in facilitating the return of venous blood to the heart from the periphery. 

It is also known as the skeletal-muscle pump, peripheral heart, or the sural (tricipital) pump.

Each time the calf muscle contracts, it triggers the opening of one-way valves within the leg veins, facilitating the upward movement of blood towards the heart. Conversely, when the calf muscle relaxes, these valves close to prevent the backward flow of blood into the legs. 

The dangers of prolonged sitting

Prolonged periods of sitting or standing can elevate pressure in the veins, potentially causing damage to the valves over time, resulting in increased blood pooling in the legs. 

This weakening of the calf muscle pump function can manifest in symptoms characteristic of chronic vein disease, including leg swelling, fatigue, and the development of varicose veins. 

A rare but serious complication of prolonged sitting, such as during a long flight, is the formation of blood clots.

How to keep the soleus pumping

Activate the "second heart" in one simple step: Just walk. Take walking breaks regularly throughout the day, ideally every hour or so, is key. You can get the calf muscle pumping by staying in motion. 

For those with desk jobs or who stand for long periods, prioritizing walking whenever possible is crucial. 

If circumstances prevent getting up, such as during a flight or while stuck at a desk, performing toe raises—flexing the foot up and down—can help replicate the motion of walking to some extent.

The “second heart” only starts pumping when your legs move so keep moving those legs and walk! 

Source: https://www.today.com/health/diet-fitness/what-is-the-second-heart-rcna117576

Metoprolol Mnemonics and Beta Blockers

Metoprolol Mnemonic and Other Betablockers

Metoprolol tartrate is short acting and usually given BID.  

Metoprolol succinate is long acting. and usually given once a day.

BETA BLOCKERS

These medications prevent norepinephrine and epinephrine from attaching to beta receptors on nerves. By inhibiting these neurotransmitters, they lower heart rate and blood pressure by dilating blood vessels.

Uses:

• Manage hypertension, heart failure, arrhythmias, and angina (not for immediate relief).
• Treat glaucoma (when used as eye drops).
• Prevent future heart attacks in patients who have had a heart attack.
• Prevent migraine headaches.

The generic names of beta blockers typically end in "lol." 

Beta blockers are also used to reduce brain activity, helping to alleviate palpitations during panic attacks, reduce essential tremors, and ease situational anxiety. They may also help reduce migraine headaches in some individuals.

Really Important to Know  

Warning! Patients should consult their physician before stopping their medication. Suddenly discontinuing beta blockers can lead to severe worsening of angina, heart attacks, or sudden death.

Examples

acebutolol (Sectral)

atenolol* (Tenormin)

betaxolol (Kerlone)

bisoprolol* (Zebeta)

carteolol (Cartrol)

carvedilol* (Coreg)

! esmolol (Brevibloc)

! labetalol (Trandate)

! metoprolol* (Lopressor, Toprol-XL)

nadolol (Corgard)

nebivolol* (Bystolic)

penbutolol (Levatol)

pindolol (Visken)

propranolol (Inderal)

sotalol (Betapace)

timolol (Timoptic)

One of the top 200 most commonly prescribed medications. 
! high alert drug

Beta blockers can be cardio selective or non-cardio selective. 

Cardio selective beta blockers act on Beta 1 receptors which are found in the heart.                

Beta 1=1 heart

Non cardio selective beta blockers act on Beta 2 receptors found in the lungs.                       

Beta 2=2 lungs

                                  

Nurses must check heart rate and blood pressure before and after administration of beta blockers. 

Beta blockers can mask the symptoms of hypoglycemia

Use with caution when giving betablockers to COPD and asthma patients because of the potential for causing bronchospasms and wheezing. 

Pradaxa (dabigatran etexilate mesylate) Capsules Storage Instructions From the FDA

Pradaxa (dabigatran etexilate mesylate) Capsules 

Storage Instructions From the FDA

Pradaxa capsules should only be dispensed and stored in their original bottle or blister package, and patients should follow specific handling requirements.

Facts about Pradaxa

• Pradaxa is an anticoagulant (blood thinner) known as a direct thrombin inhibitor, which prevents the formation of blood clots.
• It is used to help prevent strokes or serious blood clots in people with non-valvular atrial fibrillation (an irregular heartbeat), a condition that increases the risk of clot formation and stroke.
• Between October 2010 and January 2011, around 128,000 Pradaxa prescriptions were dispensed, with approximately 86,000 patients filling these prescriptions at outpatient retail pharmacies in the U.S.
• The Pradaxa label and Medication Guide provide information on special storage and handling requirements, but the FDA is concerned that these guidelines are not widely known or followed by Pradaxa users and pharmacies.

Many consumers use pill boxes or organizers to help them remember to take their medications. 

However, due to the risk of product degradation and potency loss Pradaxa should not be stored in any container other than its original manufacturer packaging. Keeping Pradaxa capsules in pillboxes can cause it to lose potency increasing the risk of stroke for the patients.

Pharmacists should also dispense Pradaxa capsules only in the original packaging to prevent moisture-related breakdown. Pradaxa bottles contain a 30-day supply with a desiccant (drying agent) in the cap to protect the capsules from moisture. Pradaxa capsules are also available in blister packages, which offer similar protection.

Source: FDA Drug Safety Communication: Special storage and handling requirements must be followed for Pradaxa (dabigatran etexilate mesylate) capsules | FDA

Anticoagulants in NCLEX and Warfarin Education for Patients

Anticoagulants 

 Examples

! heparin (generic)

! warfarin* (Coumadin)

Indirect factor Xa inhibitor

! fondaparinux (Arixtra)

LMWH

! dalteparin (Fragmin)

! enoxaparin (Lovenox)

! tinzaparin (Innohep)

Thrombin inhibitors

! argatroban (generic)

! bivalirudin (Angiomax)

! dabigatran* (Pradaxa)

! desirudin (Iprivask)

! lepirudin (rDNA)

*One of the top 200 most commonly prescribed medications. 
! high alert drug

These medications impede the synthesis of clotting factors, inhibit thrombin, or interfere with the formation of blood platelets.

Uses: They are utilized to prevent or manage blood clots associated with conditions such as stroke, heart attack, heart valve disease, coronary artery disease, heart failure, arrhythmia, atrial fibrillation, deep vein thrombosis, and pulmonary embolism.

Nice To Know: Foods high in vitamin K (such as leafy green vegetables) may diminish the effectiveness of anticoagulant drug therapy.

Good To Know: Clients should be asked about their use of herbal remedies as Ginseng and St. John's wort can decrease PT/INR, while Ginkgo biloba, garlic, chamomile, and licorice root can increase PT/INR.

Really Important To Know: The therapeutic range of effectiveness for most anticoagulants is typically 1.5-2 or 2.5 times the "normal" lab values. It's crucial to know the client's lab results before administering anticoagulants.

Warfarin Education for Patients

NCLEX Test Taking Tips

 

NCLEX Test Taking Tips

    Sometimes sheer hard work and mental preparation aren't sufficient when taking exams. The skill of answering exams or tests quickly is essential, especially when they're timed. Pressure often builds when time is running out, and even with thorough preparation, it can completely undermine your efforts. In this post, I have shared test-taking tips and strategies that are useful for any type of multiple-choice exam, including the NCLEX exams.

The Parts of a Question

the case (sometimes called scenario) – the description of the client and what is happening to him/her

the stem – the part of the question that asks the question the correct response

distracters – incorrect but feasible choices

Key Words

The most crucial skill for a test taker is the ability to carefully read the question and identify its key elements. Each question contains key words that pertain to the client, the problem, and specific details of the problem.

Client

Factors like age, sex, and marital status can be significant. When a child's age is mentioned, it is often crucial to the answer. Vital signs, preoperative teaching methods, and suitable toys or activities all differ based on age. Always take note of the client's age when it is provided. Additionally, consider who the client is in the question—whether it is the sick individual, a relative, or a staff member.

Problem/Behavior

The problem may be a disease, a symptom or a behavior.

Details of the Problem:

1. Is the question inquiring about nursing actions, client symptoms, or family reactions?

2. Does the question pertain to a specific aspect of nursing care such as assessment, planning, implementation, or evaluation?

3. Is the question focused on a particular symptom or behavior exhibited by the client?

4. Is there additional important information about the client or the problem that needs to be considered?

Priority Setting

"What action takes priority?"

"What should the nurse do first?"

"What is essential for the nurse to do?"

Physiological needs come first, followed by safety needs, then love and belonging, self-esteem, and self-actualization.

The first step in the nursing process is assessment. When a question asks for the initial nursing action, check if there is a relevant assessment answer. A nurse should only take action when there is sufficient data to do so. Call the physician only if no nursing action is required first. If the question asks for a nursing action, the correct response might be to assess.

When a question asks what is essential for the nurse to do, prioritize safety. Many test questions focus on safety.

Time Frame

Whenever a specific time frame is mentioned in a question, it is crucial to pay attention. Time-related terms might include early or late in relation to symptoms, preoperative or postoperative, care on the day of surgery, or later postoperative care.

Repeated Words

Words from the question often appear in the answer. Frequently, the same word or a synonym will be in both the question and the answer.

Opposites

When two answers are opposites, such as high blood pressure and low blood pressure, increasing the drip rate and stopping the IV, or turning on the right side and turning on the left side, the correct answer is usually one of the two.

Same Answer

If two or three answers express the same idea in different words, none of them can be correct. If the answers are too similar, then neither is correct.

Odd Answer Wins

The answer that stands out from the others is likely the correct one. It may be the longest, the shortest, or simply very different in content or style.

Umbrella Answer

One answer that encompasses the others is often the best choice. There may be more than one correct answer, but the best one includes all the others.

Test Item Check List

Use this handy list to check yourself every time you answer a test question.

Say to yourself, DID I CAREFULLY…

Read the stem?

Read all of the options?

Read the stem again?

Look for key words?

Eliminate obviously incorrect options?

Absolutes

Responses that include universal or absolute terms are likely to be incorrect. Few things in life or nursing are always right or wrong. Answers that are stated with absolute certainty should be approached with caution.

Deadly Words to Avoid

all

every

total

nothing

always

each

only

any

nobody

never

none

Dangerous Words to Avoid

main

chief

avoid

primarily

major

shall

inevitable

eliminate

rarely

impossible

too

Safe

usually

almost

frequently

probably

potentially

may

sometimes

partial

some

might

should

few

essentially

generally

occasionally

nearly

maybe

could

commonly

average

seldom

often

normally

.

Antidotes for Drugs and Toxins (NCLEX)

 

Toxin Antidotes

Toxin	Antidote / Treatment
Acetaminophen (Paracetamol)	N-acetylecysteine
Salicylates	Alkalinize urine, dialysis
Anticholinesterases, organophosphates	Atropine, Pralidoxime
Antimuscarinic, anticholinergic agents	Physostigmine salicylate
Beta blockers	Glucagon
Digitalis	Stop digitalis, normalize K; lidocaine, anti-dig FAB fragments ( Digitoxin) Digitalis Immune FAB
Iron (Ferrous Sulfate)	Deferoxamine
Lead	CaEDTA, dimercaprol, succimer, penicillamine
Arsenic, mercurym gold	Dimercaprol (BAL), succimer
Copper, arsenic, gold	Penicillamine
Cyanide	Nitride, Hydroxocobalamin
Methemoglobin	Methelyn blue
Carbon Monoxide	100% O2, hyperbaric O2
Methanol, ethylene glycol (antifreeze)	Ethanolm dialysism fomepizole
Opioids, Narcotic Analgesics: Demerol and Morphine Sulfate	Naloxone Hydrochloride (Narcan), Naltrexone
Benzodiazepines	Flumazenil (Romazicon)
Tricyclic antidepressants (Anafranil, Tofranil)	NaHCO3 (nonspecific)
Anticoagulant: Heparin	Protamine Sulfate
Anticoagulant: Warfarin	Vitamin K, fresh frozen plasma
Thrombolytics: t-PA, (Streptokinase, Urokinase)	Aminocaproic Acid ( Amicar)
Lithium Carbonate (Eskalith)	Sodium Bicarbonate
Calcium Channel Blocker (Verapamil)	Calcium
Magnesium Sulfate	Calcium Gluconate

Administering Tissue Plasminogen Activator (TPA) for Ischemic Stroke

 ADMINISTERING TISSUE PLASMINOGEN ACTIVATOR (TPA) FOR ISCHEMIC STROKE

Stroke is a clinical syndrome, believed to be of vascular origin, presents with sudden signs of localized or widespread brain dysfunction lasting more than 24 hours and may result in disability or in death. This can manifest as ischemic cerebral infarction (about 87% of cases) or as intracerebral hemorrhage (about 13%).

One of the treatments for ISCHEMIC STROKE is thrombolytic therapy. 

Candidates for thrombolytic therapy are given the appropriate therapy within the shortest time possible based on evidence-based guidelines such as the AHA. 

The window of opportunity for eligible patients to receive thrombolytic therapy for acute ischemic stroke is THREE to FOUR AND A HALF hours from a clearly defined time last known well or the onset of signs/symptoms

The door-to-needle time (time of bolus administration) should be within 60 minutes from hospital arrival.

IV rTPA Administration: 

0.9 mg/kg to a maximum of 90 mg

  First 10% of calculated dose given as intravenous bolus dose 

 Remaining 90% of calculated dose given in infusion over 1 hour 

o Verify that the Physician has reviewed the inclusion/exclusion criteria and discussed the plan with the patient and/or family if available. 

o Verify that administration will start within three hours of symptom onset or time last known well (Verbal Consent of pt./family). If administering after 3 hours, a written consent is needed. Follow your hospital's policy.

Equipment Needed:

o 1 vial of Alteplase (Activase) 50mg or 100 mg 

o One 10 ml syringe

o 50ml syringe and vented spike connector for the 50mg vial (does not come with kit)

o Two 19-gauge needles

o One blunt cannula

o Standard pump tubing

o Intravenous infusion pump

o 100 cc bag of 0.9% NS

o Alcohol wipes

o Two Medication labels

Administration Procedure:

o Verify the bolus dose and the infusion dose.

o Reconstitute the vial of t-PA with the supplied preservative-free water

o Direct stream of water into lypophilized cake

o Swirl but DO NOT SHAKE (slight foaming is common)

o Let stand several minutes to allow large bubbles to dissipate

o Final concentration is 1 mg/ml

o Fill out IV medication label with all required information (patient name, medication, dosage, time, date, RN signature) and affix label to Alteplase bottle. 

o Draw waste dose from bottle and verify waste amount by showing to the Stroke 

Neurologist/Physician and another nurse.

o Connect Activase bottle to IV pump tubing, carefully priming to avoid discarding any medication.

o Verify patency of IV site and tubing connections

o Verify that all blood work has been drawn and sent

o Attach noninvasive blood pressure cuff to other arm

o Set infusion pump rate for bolus dose to be given over 1 minute and infusion dose according to 

dosing sheet with a total infusion time of 1 hour.

o For manual bolus administration (as requested by the Physician/Neurologist), using a 10 ml syringe, withdraw the bolus dose directly from the Activase bottle (see dosing sheet for bolus dose based on patient weight*). 

o Fill out medication label with all required information (patient name, medication, dosage, time, date, RN signature). Hand the bolus dose syringe to the Stroke Neurologist/Physician.

o Ensure that the patient’s systolic is <180 and diastolic is <110 prior to and during infusion.

o Document infusion start time and name of Physician/Stroke Neurologist (as needed).

o When pump alarms "no flow above", there is still some medication left in the tubing which must be infused. Remove the IV tubing connector from the Activase bottle and attach it to a newly spiked 100 cc bag of 0.9% NS.

o Continue the infusion at the current setting to deliver the remainder of the original Activase volume over the remaining time. Continue the infusion until the preset volume is completed.

o Document end time of infusion. 

Monitoring

Once infusion begins monitor vital signs and neurologic status as follows:

 Every 15 min for 2 hours, then:

 Every 30 minutes for 6 hours, then:

 Every 60 minutes for 16 hours

*Notify physician immediately if SBP/DBP greater than 175/100

Precautions and Side Effects

 √Hemorrhage (GI, GU, catheter puncture site, intracranial, retroperitoneal, pericardial, 

gingival, epistaxis). NO blood works for 24 hours (except for emergent lab.).

 √New ischemic stroke

 √ Bruising

 √Anaphylaxis

 √Laryngeal edema

 √Rash, urticaria

o If the patient’s neurologic status declines during tPA infusion the following actions should be taken:

  Stop the infusion 

 Page the Stroke Neurologist 

 Draw and send PT/PTT, D-Dimer and fibrinogen 

 Prepare for emergent CT

NOTE: Always follow your hospital policy on TPA administration.

References: guidelines-for-mangaging-patients-with-ais-2019-update-to-2018-guidelines.pdf (stroke.org)

Acute Ischemic Stroke Resources | American Stroke Association