Patient Care Procedures During Lymphatic System and CNS Investigations

INTRODUCTION

PART A: INVESTIGATIONS OF THE LYMPHATIC SYSTEM

1. Lymphangiography
2. Lymph Node Biopsy
3. Bone Marrow Examination (Biopsy / Aspiration)
4. Blood tests (CBC, ESR, serum proteins)

1. Lymphangiography

Nursing Responsibilities:

• Explain the procedure to the patient to reduce anxiety and obtain informed consent.
• Check for allergy to iodine/contrast dye (hypersensitivity testing).
• Shave and clean the dorsum of both feet (site of dye injection).
• Keep the patient NPO (nothing by mouth) for 4–6 hours prior.
• Record baseline vital signs (BP, pulse, respiratory rate, temperature).
• Ensure IV line is established.

• Assist the patient to maintain the required position (supine).
• Monitor for allergic reactions to contrast dye (urticaria, dyspnea, hypotension).
• Provide reassurance; monitor vital signs continuously.

• Monitor for delayed allergic reactions.
• Observe injection sites for bleeding, swelling, or infection.
• Inform the patient that urine and stool may appear blue-green for 48 hours (effect of dye).
• Skin may show blue discoloration at feet — reassure the patient it is temporary.
• Bedrest for several hours; elevate legs to reduce swelling.
• Document findings and report abnormalities to the physician.

2. Lymph Node Biopsy

Nursing Responsibilities:

• Obtain informed consent; explain purpose and procedure.
• Baseline vital signs; record any bleeding tendency.
• NPO if general anesthesia is planned.
• Prepare surgical site (shave and clean).

• Assist surgeon with sterile technique.
• Monitor patient's condition and provide emotional support.

• Monitor surgical site for hematoma, bleeding, or infection.
• Apply pressure dressing; check dressing for excessive bleeding.
• Administer analgesics as prescribed.
• Send specimen to the laboratory immediately in appropriate container.
• Document and monitor for complications.

3. Bone Marrow Aspiration/Biopsy

• Explain the procedure; obtain consent.
• Assess patient for clotting disorders; check platelet count.
• Position patient (prone for posterior iliac crest; lateral for anterior iliac crest).
• Clean and drape the site.

• Support and reassure the patient (procedure is painful).
• Assist with sterile supplies.

• Apply firm pressure and sterile dressing to prevent hematoma.
• Monitor for excessive bleeding and pain.
• Observe for signs of infection.
• Send sample to lab promptly.

PART B: INVESTIGATIONS OF THE CNS (Central Nervous System)

1. Lumbar Puncture (LP) / Spinal Tap — CSF analysis
2. Electroencephalogram (EEG)
3. Myelography
4. CT Scan / MRI of the Brain

1. Lumbar Puncture (Spinal Tap)

Nursing Responsibilities:

• Explain the procedure clearly; obtain written informed consent.
• Ask the patient to empty the bladder before the procedure.
• Record baseline vital signs and neurological status.
• Position the patient in lateral decubitus (fetal) position — knees drawn to chest, chin tucked — to widen intervertebral spaces.
• Prepare LP tray with sterile equipment (spinal needle, manometer, specimen tubes).
• Educate patient: they must remain still throughout; they may feel pressure.

• Assist the patient to maintain the correct position throughout.
• Monitor for sudden change in breathing, pain radiation, or numbness.
• Label and number CSF specimen tubes (1, 2, 3) in order of collection.
• Measure and record opening pressure using a manometer.

• Keep patient flat (supine) for 4–6 hours to prevent post-lumbar puncture headache (spinal headache due to CSF leakage).
• Encourage oral fluids to replace CSF lost.
• Monitor for complications: headache, back pain, bleeding, infection, neurological changes.
• Assess sensation and movement in lower limbs.
• Apply small sterile dressing to puncture site.
• Send CSF samples to lab immediately.
• Document procedure, CSF appearance (clear/cloudy/bloody), pressure, and patient response.

2. Electroencephalogram (EEG)

Nursing Responsibilities:

• Wash and dry the patient's hair thoroughly (no oil or spray — affects electrode contact).
• Do NOT withhold anticonvulsant medications unless specifically ordered by the physician.
• If a sleep EEG is ordered, keep the patient sleep-deprived the night before (as instructed).
• Remove all metal hairpins and jewelry.
• Explain the procedure: painless, non-invasive, takes 45–60 minutes.
• Record last seizure date and medications.

• Ask patient to remain still and relaxed.
• Hyperventilation or photostimulation may be used to provoke activity — explain this beforehand.

• Remove electrode paste from scalp; assist with hair washing if needed.
• Resume normal medications if withheld.
• Document findings and patient tolerance.

3. Myelography

Nursing Responsibilities:

• NPO for 4–8 hours before the procedure.
• Check for contrast dye allergy (iodine sensitivity).
• Obtain informed consent; explain that dye will be injected into the spine.
• Baseline vital signs and neurological assessment.
• Ask the patient to void.

• Assist with patient positioning (prone or lateral).
• Monitor vital signs and neurological response.

• Depending on dye used:
  • Water-soluble dye (metrizamide): elevate head of bed 30–45° to prevent dye from irritating the brain.
  • Oil-based dye (Pantopaque): keep patient flat for several hours.
• Monitor for seizures (especially with metrizamide).
• Encourage oral fluids.
• Observe for headache, meningeal irritation, urinary retention.
• Monitor vital signs and neurological status every 30 minutes for 2 hours.

SUMMARY TABLE (for quick revision)

CONCLUSION

• Use bold headings and sub-headings (Before / During / After) — examiners reward structure.
• Write in points, not paragraphs — faster to write and easier to mark.
• Always include at least 3 investigations per system.
• A summary table at the end shows excellent understanding and earns extra credit.

Laying Up a Sterile Trolley — Detailed Procedure

DEFINITION

PURPOSE

• To prevent Healthcare-Associated Infections (HAIs) and cross-infection
• To maintain a sterile environment for procedures
• To provide all necessary equipment in an organized, accessible manner
• To protect the patient from wound contamination and sepsis

PRINCIPLES OF ASEPTIC TECHNIQUE (Must Know)

1. A sterile object becomes contaminated when touched by an unsterile object.
2. Only sterile items are placed on the sterile field.
3. Sterile persons/items contact only sterile areas.
4. Unsterile persons avoid the sterile field.
5. The edges of a sterile field are considered unsterile (1-inch border rule).
6. A wet/moist sterile field is considered contaminated (strike-through contamination).
7. Sterile field must always be kept in the nurse's view.
8. Sterile field should never be left unattended.

ARTICLES / EQUIPMENT REQUIRED

Upper Shelf (Sterile Items):

• Sterile dressing pack (gauze swabs, cotton balls, drape)
• Sterile gloves (correct size)
• Sterile bowl/gallipot (for antiseptic solution)
• Sterile forceps (2 pairs — one for handling dressings, one for wound)
• Sterile scissors
• Sterile syringe and needle (if required)
• Sterile wound dressing / bandage
• Sterile drape / sterile towel

Lower Shelf (Clean/Non-Sterile Items):

• Antiseptic solution (e.g., Betadine/Savlon/Normal saline) — in original container
• Adhesive tape / bandage
• Waterproof mackintosh / disposable pad
• Receiver/kidney tray (clean — for waste)
• Disposal bag / clinical waste bag
• Extra sterile packs (in original sealed packaging)
• Patient's case notes / treatment card

Personal Protective Equipment (PPE):

• Apron (plastic/disposable)
• Mask (if required)
• Non-sterile gloves (for initial preparation)

PREPARATION OF THE NURSE

1. Check the patient's treatment card — understand what procedure needs to be done and what equipment is needed.
2. Wash hands thoroughly using the 7-step WHO handwashing technique for a minimum of 40–60 seconds.
3. Put on apron and mask as appropriate.
4. Tie back hair; ensure no hanging jewelry.
5. Ensure your uniform/clothing is not trailing over the trolley.

PREPARATION OF THE ENVIRONMENT

1. Select a clean, quiet area — away from windows, fans, air vents, or heavy traffic (to reduce airborne contamination).
2. Close windows and doors to minimize air currents (which carry microorganisms).
3. If possible, clean the trolley with a disinfectant wipe (70% isopropyl alcohol) and allow it to dry completely before use.
4. Check the trolley is clean, dry, and structurally sound (no rust, no cracks).

STEP-BY-STEP PROCEDURE: LAYING UP THE STERILE TROLLEY

Step 1: Check Sterility of All Packs

• Inspect each sterile pack:
  • Expiry date — must not be past due.
  • Integrity of packaging — no tears, holes, dampness, or broken seals.
  • Chemical indicator/autoclave tape — color change confirms sterilization (e.g., diagonal lines turn dark).
• Discard any pack that fails these checks.

Step 2: Open the Sterile Drape / Sterile Towel onto the Upper Shelf

• Hold the outer (unsterile) edge of the drape pack.
• Open the outer packaging by peeling back the edges — do not reach over the sterile contents.
• Allow the sterile drape to fall onto the upper shelf without touching the sterile surface.
• Using the corners only (1-inch rule), unfold the sterile drape to cover the entire upper shelf — this creates the sterile field.
• Do not allow the drape to hang over the edge (edges are non-sterile).

Step 3: Add Sterile Items onto the Upper Shelf

• Method 1 — Flap-opening technique: Hold the outer pack in both hands, peel back all four flaps away from you, then tip or drop the sterile item onto the sterile field without touching the field.
• Method 2 — Forceps method: Use sterile transfer forceps to pick up and place items onto the field.

1. Sterile galley pot/bowl (for antiseptic)
2. Sterile gauze swabs and cotton balls
3. Sterile forceps (arrange neatly — handles toward the nurse's side)
4. Sterile syringe/needle if required
5. Sterile dressing / wound cover

Key rule: Once an item is placed on the sterile field, it must not be moved back or repositioned with bare hands.

Step 4: Pour Antiseptic Solution

• Pick up the antiseptic bottle with clean (non-sterile) hands.
• Pour a small amount first (first few ml) and discard into the waste tray — this flushes any contamination from the bottle mouth.
• Then carefully pour the required amount into the sterile galley pot on the upper shelf.
• Do not touch the galley pot rim with the bottle mouth.
• Cap the bottle and replace it on the lower shelf.

Step 5: Arrange the Lower Shelf

• Antiseptic solution bottle (after pouring)
• Adhesive tape / bandage roll
• Waterproof pad / mackintosh
• Kidney tray / waste receiver
• Disposal/clinical waste bag — open it and attach to the side of the trolley
• Patient's treatment card

Step 6: Cover the Sterile Field (if not proceeding immediately)

• If there is a delay between setting up and using the trolley:
  • Cover the sterile field with a second sterile drape to protect it.
  • Sterile field should not remain uncovered for more than 30 minutes (some authorities say 1 hour maximum).
• If a delay is unavoidable, it is better to re-set the trolley than risk contamination.

Step 7: Transport the Trolley to the Bedside

• Wash hands again before moving the trolley.
• Push from the lower shelf side — never lean over the upper shelf.
• Place the trolley beside the patient's bed at a comfortable working height.
• Ensure the upper shelf is level and stable.
• Arrange the trolley so the sterile field is within easy reach but away from the patient's immediate environment (bed linen, bedclothes, patient's hands).

Step 8: Prepare the Patient

• Explain the procedure to the patient.
• Provide privacy (draw curtains).
• Position the patient appropriately.
• Place waterproof mackintosh under the treatment area.

Step 9: Perform Hand Hygiene and Don Sterile Gloves

• Wash hands again using WHO 7-step technique.
• Open sterile glove pack onto sterile field.
• Don sterile gloves using the closed glove technique or open glove technique.
• Now you may handle items on the sterile field directly with gloved hands.

Step 10: Proceed with the Procedure

• Always work from the sterile field inward toward the patient.
• Keep sterile hands above waist level at all times.
• If contamination occurs at any point — stop, discard, and start fresh.

Step 11: Disposal and After-Care

• Remove gloves and discard into the clinical waste bag.
• Dispose of all sharps immediately into the sharps container at the bedside.
• Place all soiled dressings and materials into the clinical waste bag (yellow bag for clinical waste).
• Remove the trolley from bedside.
• Clean trolley with disinfectant wipe on both shelves.
• Wash hands thoroughly.
• Document the procedure — wound condition, dressing applied, any observations.
• Report abnormalities (signs of infection, wound breakdown) to the nurse in charge.

IMPORTANT POINTS / COMMON MISTAKES TO AVOID

SUMMARY

• Definition + Purpose (1 mark)
• Principles of aseptic technique (1 mark)
• Articles required (2 marks)
• Step-by-step procedure — the main body (5 marks)
• After-care and documentation (1 mark)