An invasive procedure with a diagnostic and/or therapeutic purpose

• puncture of natural body cavities (nasal cavity, chest cavity, abdominal cavity, spinal canal, joints, urinary bladder, Douglas space)
• piercing of organs (blood vessels, bones, lymph nodes, thyroid gland, liver, kidney, spleen)
• drainage of pathological forms (abscess, cyst, haematoma)

A puncture is often needed in order to perform

• body fluid collection – blood, urine, exudate, mucus, pus, joint fluid, cerebrospinal fluid, bone marrow
• tissue sampling (biopsy)

Puncture needles

Depending on the type of puncture, standard injection needles or special puncture needles are used. Puncture needles have different diameters and lengths. The puncture needles used to puncture tissues include an inner obturator that prevents the clogging of the needle after penetration into an organ. Special puncture needles called trocars allow instruments to be placed after removal of the obturator.

Overview of some punctures

Lumbar puncture
Insertion site	spinal canal between lumbar / loins / vertebrae L3-L4 or L4-L5
Diagnostic purpose	cerebrospinal fluid (CSF) collection for biochemical, microbiological, serological and cytological examination delivery of contrast dye control of CSF pressure
Therapeutic purpose	relief of CSF (in case of overproduction, circulatory disorder, obstruction of cavity pathways, hydrocephalus administration of therapeutic agents into the spinal canal delivery of anaesthetics in spinal anaesthesia
Position during procedure	lying on the side, with knees drawn to chest (embryo position) sitting on a bed or chair, leaning forward (cat's back position)
Patient and equipment preparation	inform the patient about the procedure gain signed informed consent prepare a sterile table with equipment for lumbar puncture sterile tubes for CSF samples Claude manometer (for CSF pressure measurement)
Handling after the procedure	horizontal position on the back—for 24 hours after using a traumatic needle, for 4 hours after using an atraumatic needle (with a rounded tip) increased fluid intake (for faster cerebrospinal fluid production and supplementation) monitoring vital signs and neurological symptoms (numbness and tingling of the legs, headache, nausea, vomiting, unconsciousness) monitoring the injection site (swelling, bleeding, leakage)

Sternal puncture
Insertion site	chest bone, at the level of the 2nd–3rd intercostal space, in the sternal manubrium in children
Diagnostic purpose	obtaining bone marrow for morphological, immunological and cytogenetic examination (for detection of abnormal development of blood elements, to diagnose anaemia, leukaemia, lymphoma …)
Therapeutic purpose	none
Position during examination	in a horizontal position on the back, resting on a firm surface
Patient and equipment preparation	inform the patient about the procedure gain signed informed consent a sterile table with equipment for sternal puncture biopsy slides and cover glass slides to smear the obtained aspirate
Handling after examination	rest on bed for 2 hours monitoring vital signs monitoring the injection site (swelling, bleeding, haematoma)

Trephine biopsy
Insertion site	wing of ilium of the hip bone
Diagnostic purpose	bone marrow aspiration for cytological and histological examination – in contrast to a sternal puncture, trephine biopsy allows for a histological examination (a punch biopsy of bone marrow for microscopical evaluation of the tissue structure, used to diagnose haematological diseases)
Therapeutic purpose	none
Position during examination	on the belly or on the side
Patient and equipment preparation	inform the patient about the procedure gain signed informed consent hemocoagulation examination – procedure with increased risk of bleeding sterile table with equipment for trephine biopsy Jamshidi needle (special puncture needle for bone marrow biopsy) fixation solution for the tissue sample
Handling after examination	rest on bed, on the side of the puncture site, compression bandage at the puncture site for 1–6 hours monitoring vital signs monitoring for pain (analgesics application) monitoring the insertion site (swelling, bleeding, haematoma)

Abdominal puncture
Insertion site	insertion site at the Monro point (a point at the right edge of the rectus abdominis muscle, between the umbilicus and the anterior superior spine of the ilium)
Diagnostic purpose	collection of exudate for biochemical, microbiological and cytological examinations
Therapeutic purpose	evacuation of the exudate / ascites from the abdominal cavity (ascites occurs in liver cirrhosis, heart failure, kidney and pancreas diseases, tumours in the abdominal cavity, inflammation and thrombosis in the abdominal cavity, lack of proteins) administration of therapeutic substances lavage in peritoneal dialysis
Position during examination	Fowler's position
Patient and equipment preparation	inform the patient about the procedure gain signed informed consent abdominal X-ray weigh the patient and measure the circumference of the belly a sterile table with abdominal puncture equipment sterile tubes for aspirated samples drainage set with graduated collecting container for evacuation of the exudate
Handling after examination	weighing the patient and measuring the circumference of the belly rest on bed in semi-sitting position for 2 hours monitoring vital signs monitoring for pain (analgesics application) monitoring the insertion site (swelling, bleeding, haematoma)

Pleural puncture (Thoracentesis)
Insertion site	when removing the fluid: in the 6th–8th intercostal space, in the posterior axillary line (below the level of the effusion) when removing air: in the 2nd–3rd intercostal space, in the mid clavicular line
Diagnostic purpose	collection of exudate for biochemical, microbiological and cytological examinations
Therapeutic purpose	evacuation of exudate or air into a closed drainage system (in order to restore negative chest pressure, to relieve overpressure, and/or allow a collapsed lung to expand) administration of medicinal substances
Position during examination	the position depends on the insertion site sitting on a chair, legs wide open, the patient leaning forward into the back of the chair sitting with the forearms supported sitting on a chair with the arm raised on the puncture side
Patient and equipment preparation	inform the patient about the procedure gain signed informed consent examine the breathing by auscultation and evaluation of respiratory phenomena examine by tapping and evaluate the sounds lungs and chest X-ray ultrasound of the lungs and chest a sterile table with equipment for thoracentesis sterile sample tubes closed drainage system for draining the exudate
Handling after examination	rest on bed in elevated position monitoring vital signs (with emphasis on the quality and character of breathing, occurrence of dyspnoea, coughing and expectoration) monitoring pain (analgesics application) monitoring the insertion site (swelling, bleeding, haematoma)

Renal puncture
Insertion site	depending on the position of the organ, insertion of the puncture needle aided by ultrasound
Diagnostic purpose	tissue sampling for histological examination
Therapeutic purpose	none
Position during examination	on the belly, with abdominal support
Patient and equipment preparation	inform the patient about the procedure gain signed informed consent check blood pressure compensation pause during administration of drugs to check for blood clotting provide biochemical examination of blood and urine provide hemocoagulation examination – procedure with increased risk of bleeding provide ultrasound examination of the kidneys admission to hospital fasting after midnight local anaesthesia, sedation a sterile table with puncture equipment fixation solution for obtained tissue samples
Handling after examination	rest on bed for 24 hours, in horizontal position, on the back compression bandage at the insertion site for 6 hours monitoring urine (blood in urine, bleeding into the kidney) sufficient hydration (bleeding prevention) monitoring vital signs monitoring pain (analgesics application) insertion site monitoring (swelling, bleeding, haematoma) ultrasound to check renal area 24 hours after examination no physical exercise or bathing in warm water for 14 days after the procedure

Hepatic puncture
Insertion site	depending on the position of the organ targeted liver biopsy – puncture aided by ultrasound (gaining a sample from a specific part of the liver, directly from the affected source) non-targeted liver biopsy – puncture not aided by ultrasound (aspiration of any part of the liver, in case of pathological changes affecting the whole liver)
Diagnostic purpose	tissue sampling for histological examination
Therapeutic purpose	none
Position during examination	horizontal position, on the back, with the right hand behind the head
Patient and equipment preparation	inform the patient about the procedure gain signed informed consent blood pressure compensation pause during administration of drugs to check for blood clotting provide haemocoagulation examination – procedure with increased risk of bleeding admission to one-day hospital stay (may also be done as an outpatient procedure) fasting after midnight local anaesthesia, sedation a sterile table with puncture equipment fixation solution for obtained tissue samples
Handling after examination	rest on bed for 24 hours lying on the right side compression bandage at the insertion site for 6 hours monitoring vital signs insertion site monitoring (swelling, bleeding, haematoma) checking the blood picture before discharge no physical exercise or bathing in warm water for 14 days after the procedure

Literature

• Krišková, A. a kol. Ošetrovateľské techniky – metodika sesterských činností. Martin, Slovakia: Osveta, 2006, pp. 539-555. ISBN 80-8063-202-2
• Pokorná, A. a Komínková, A. Ošetřovatelské postupy založené na důkazech 2. díl. Brno, Czech Republic: Masaryk University, 2014, pp. 146-158. ISBN 978-80-210-7415-6