【solved】How to write a procedure note

What is procedure note?

The largest section of the OP report is the procedure note. This is where the physician documents the specifics of what he or she did. The physician should clearly outline all procedures performed and provide details, including: Patient position.

How do you write a procedure note for a lumbar puncture?

The area was prepped and draped in the usual sterile fashion. Using landmarks, a 22 guage spinal needle was inserted in the L4-L5 innerspace. The stylet was removed and the opening pressure was measured at 18 cm of water. 4cc of clear fluid was collected and sent for routine studies.

Do you need to be NPO for lumbar puncture?

However, on the day of the procedure, do not eat for three hours before the procedure. You may have liquids and can take your usual medications unless previously advised to hold certain medications in preparation for the lumbar puncture.

What can CSF tell you?

Infections, such as meningitis and encephalitis—testing is used to determine if infection is caused by bacteria, viruses or, less commonly, by Mycobacterium tuberculosis, fungi or parasites, and to distinguish them from other conditions. CSF testing may also be used to detect infections of or near the spinal cord.

What is normal CSF cell count?

Normally, there are no RBCs in the cerebrospinal fluid, and there should be no more than five WBCs per cubic millimeter of CSF. If your fluid contains RBCs, this may indicate bleeding. It is also possible that you had a traumatic tap (blood leaked into the fluid sample during collection).

How do you perform a CSF exam?

An “opening” or initial pressure reading of the CSF is obtained. The doctor then collects a small amount of CSF in multiple sterile vials. A “closing” pressure is obtained, the needle is withdrawn, and a sterile dressing and pressure are applied to the puncture site.

What happens if CSF leak is not treated?

Untreated CSF leaks can lead to life-threatening meningitis, brain infections, or stroke. UT Southwestern specialists offer rapid, accurate diagnosis of this dangerous condition, world-class surgical services to correct it, and pre- and post-surgical care that optimizes each patient’s treatment and recovery.

What do you do if you suspect a CSF leak?

If a leak is suspected, referral to a specialist with expertise in this area is recommended. This may be a neurologist (particularly those with an interest in headaches), neurosurgeon or neuroradiologist. Many patients will undergo a CT brain early in their presentation that may be reported as normal.

How do you treat a CSF leak at home?

In many cases, a CSF leak will heal on its own accord following conservative treatment, including strict bed rest, increased fluid intake and caffeine. Conservative treatment and the tincture of time is not always enough, however.

Is CSF leak an emergency?

A CSF leak is a serious health issue. It involves this type of fluid escaping through a tear in the dura mater. The symptoms of a CSF leak include fluid drainage from the ears or nose and a headache that worsens when the head is upright.

When should you suspect a CSF leak?

The most common and classic symptom suggestive of a spinal CSF leak is a positional headache: a headache that is worse when upright and improved when positioned horizontally. It is not unusual for the headache to become less positional over time, or for the positional aspect to resolve entirely.

Can CSF heal itself?

Most cases heal by themselves with no lasting symptoms. If the CSF leak keeps coming back, high pressure of the CSF (hydrocephalus) might be the cause and should be treated.

How do you sleep with a CSF leak?

How do I care for myself while I have a CSF leak?

  1. Stay in bed with your head raised on pillows.
  2. Do not blow your nose.
  3. Avoid coughing.
  4. Avoid vomiting.
  5. Avoid straining when you have a bowel movement.

Can you have a CSF leak for years?

Spinal fluid leaks also can lead to serious complications, including seizures. Patients may have a CSF leak for years or decades before it is diagnosed.

What does CSF fluid look like?

Normal CSF is a clear, colorless fluid that contains small quantities of glucose (a sugar) and protein. CSF surrounds the outside of the brain and spinal cord and also fills the ventricles (spaces) of the brain and the central canal of the spinal cord.

What does a CSF headache feel like?

The classic symptom is a headache that becomes severe when the patient is upright and quickly disappears when the patient is lying flat. So, the headaches are typically absent first thing in the morning, and start or worsen shortly after getting out of bed.

How do you check for CSF leak?

To determine the exact location of the leak, a CT cisternogram would be performed. A CT cisternogram involves using a contrast injected into the spinal fluid through a spinal tap and then performing CT scans. This test identifies the exact location of the CSF leak and the pathway of the drainage into the nose.

What happens if too much CSF is drained?

It is possible that the puncture of the ventricle or the opening of the dura will result in an intracranial hemorrhage. It is possible that if too much CSF is removed from the ventricles, either during a drainage procedure or when the ventricle is first punctured, the ventricle may collapse and occlude the catheter.

How long is hospital stay for shunt surgery?

About the Shunt Operation

The actual surgical procedure to implant a shunt typically requires about an hour in the operating room. Afterward, you will be carefully observed for 24 hours. Your stay in the hospital will generally be for two to four days total.

What are symptoms of shunt failure?

Shunt Malfunction Signs

  • Headaches.
  • Vomiting.
  • Lethargy (sleepiness)
  • Irritability.
  • Swelling or redness along the shunt tract.
  • Decreased school performance.
  • Periods of confusion.
  • Seizures.

Why is too much cerebrospinal fluid bad?

Cerebrospinal fluid normally flows through the ventricles and bathes the brain and spinal column. But the pressure of too much cerebrospinal fluid associated with hydrocephalus can damage brain tissues and cause a range of impairments in brain function.

Is hydrocephalus a disability?

Shunts may drain too little CSF, in which case the symptoms of hydrocephalus get worse. A diagnosis of hydrocephalus is not enough to “automatically” qualify for Long-Term Disability (LTD) benefits under either the Social Security Disability (SSDI) program or under an employer-provided group disability plan (ERISA).

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