Lumbar Puncture Template

ICU LUMBAR PUNCTURE PROCEDURE NOTE

  • OPERATOR:
  • INDICATION:
  • PROCEDURE:  Lumbar Puncture
    • Informed consent was obtained from the patient’s family ____________
    • Patient was put in full spinal flexion/lateral decubitus (neck in flexion and knees to abdomen/chest)
    • Spinous processes land-marked for Tuffier’s line (PSIS across laterally) – location of L4
    • Cap/mask + sterile gown/gloves donned by operator
    • Lower back prepared with chlorhexidine and draped in standard sterile fashion
    • Local anesthetic instilled into back (Lidocaine 1% w/o epinephrine –  ___ cc)
    • 22-Gauge (8.9cm) Tuohy (bevel) needle utilized:
      • 1st attempt: operator started in L4 – midline – able to get CSF (inferior/downward – aimed needle cephalad towards head to get in between spinous processes)
      • CSF collected (3-4 cc drops per tube – color: clear)
      • Opening pressure: performed/not performed
      • Overall body habitus good – patient thin

SPECIMENS:

  • Tube #1: Cell count + differential, flow cytometry/cytology
  • Tube #2: Protein/Glucose
  • Tube #3: Gram stain/C&S/viruses
  • Tube #4: Oligoclonal banding

COMPLICATIONS:   None

IMPRESSION/PLAN:   Successful lumbar puncture

– Copy & paste the above report into the Powerchart Advanced Clinic Procedure Note

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Lumbar Puncture Record