NIMHANS Nursing Officer - 2019
Edition 3
Medium
A person diagnosed with SDH and having continuous vomiting. What is the most probable contraindication for LP for this client?
Appeared in: NIMHANS Nursing Officer - 2019
Explanation
- A subdural hematoma (SDH) is a space-occupying lesion that increases the volume within the fixed cranial vault, leading to increased intracranial pressure (ICP).
- Continuous vomiting is a key clinical manifestation of elevated ICP, resulting from pressure on the brainstem's vomiting center.
- Performing a lumbar puncture (LP) in the presence of increased ICP is absolutely contraindicated.
- The sudden removal of cerebrospinal fluid (CSF) from the lumbar space creates a pressure gradient that can cause downward displacement and herniation of the brainstem, which is a fatal complication.
Why Other Options Were Wrong
- Option A: Decreased ICP is the opposite of the condition expected with an SDH and is not a contraindication for an LP.
- Option C: A mild fever is often an indication to perform an LP to rule out central nervous system infections like meningitis, not a reason to avoid it.
- Option D: Nausea is a symptom, not a primary contraindication. It is often associated with increased ICP, but the underlying pressure elevation is the true contraindication.
Related Visual
Clinical Relevance
- Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Contraindications for Lumbar Puncture as background academic context rather than a clinical decision trigger.
- A nurse's primary role is patient safety. Recognizing the signs of increased ICP (headache, vomiting, altered level of consciousness, pupillary changes) is a critical assessment skill.
- If a nurse assesses a patient with a head injury who is vomiting, they must immediately suspect increased ICP and alert the physician. They should question any order for a lumbar puncture in this scenario until imaging (like a CT scan) has ruled out a significant mass effect.
- What if? If the patient had a fever and headache but NO history of trauma, no SDH, and no vomiting, an LP would be a primary diagnostic tool to investigate for meningitis. The absence of signs of increased ICP makes the procedure safe.
How to Approach the Question
- First, identify the key elements of the clinical scenario: The patient has a known diagnosis (SDH) and a significant symptom (continuous vomiting).
- Connect the diagnosis and symptom to an underlying pathophysiology. An SDH is a mass, and vomiting is a classic sign of increased intracranial pressure (ICP).
- Consider the procedure in question: Lumbar Puncture (LP). Recall the purpose and risks of an LP.
- Evaluate how the patient's condition (increased ICP) interacts with the risks of the procedure (LP). The primary risk of LP in the setting of increased ICP is brain herniation.
- Analyze the options. 'Increased ICP' directly identifies the critical pathophysiological state that makes the LP dangerous. The other options are either irrelevant (decreased ICP), an indication (mild fever), or a symptom of the underlying problem (nausea).
Concept Tested & Keywords
- Concept Tested: Contraindications for Lumbar Puncture
- Stem keywords: Subdural Hematoma (SDH), continuous vomiting, Lumbar Puncture (LP), contraindication
- Lead-in keywords: most probable
- Clinical cues: Diagnosis of SDH suggests a space-occupying lesion.
- Clinical cues: Continuous vomiting is a classic sign of increased ICP.
Question ID
QB56vX9U2mxB0J5L_DCeMj
Reference Book
E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 29-31, 37-39, 33-35
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