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Epidural Assessment

Epidural Assessment. Rebecca M Humphreys, BSN, RN Unit Based Educator, 5 East St. Luke’s Health System, Boise. What is epidural analgesia?.

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Epidural Assessment

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  1. Epidural Assessment Rebecca M Humphreys, BSN, RN Unit Based Educator, 5 East St. Luke’s Health System, Boise

  2. What is epidural analgesia? The administration of opioids/anesthetics via a catheter in the epidural space for pain management. The epidural catheter is inserted by an anesthesiologist or primary physician.

  3. Terminology Intraspinal- into the spine, either epidural or intrathecal Epidural - the potential space above the dura mater Intrathecal- the subarachnoid space. The cerebrospinal fluid surrounds the spinal cord here. Spinal - same as intrathecal Subarachnoid = spinal = intrathecal

  4. Epidural Insertion

  5. Epidural Catheter Placement

  6. Assessment • Maintain IV access for a minimum of 4 hours following last epidural dose or discontinuation of the epidural catheter. • Keep Naloxone (Narcan) 0.4mg available until 4 hours following last dose.

  7. Assessment • Assess and document the following parameters: • Respiratory status: rate, depth and oxygen saturation upon initiation, then every 30 minutes x 2, then every 1 hour x12 hours, and then every 2 hours x12 hours, then every 4 hours. Assess in 4 hours and as needed after epidural discontinuation. • If a bolus is administered then assess every 30 minutes X 2 then return to previous assessment times. • Use a continuous pulse oximeter monitor for patients on a continuous infusion unless provider constantly at bedside. • May place patient on continuous pulse oximeter per nursing judgment.

  8. Assessment • Sedation scale upon initiation, then every 30 minutes x 2, then every 1 hour x 12 hours, then every 2 hours x 12 hours, then every 4 hours until epidural discontinued. If a bolus is administered then assess every 30 minutes X 2 then return to previous assessment times. • Pain scale, heart rate and BP upon initiation, then every 30 minutes x 2, then every 4 hours on non-obstetrical patients. • Motor and sensory function every 4 hours and prior to first ambulation and 4 hours after catheter discontinued. • Two (2) persons will assist patient out of bed the first time and thereafter until full motor function has returned. • Use caution when transferring /moving patient to assure catheter does not become dislodged.

  9. Assessment • Epidural assessment for hematoma every 4 hours until 12 hours after the catheter has been removed. Assess for: • severe back pain • leg weakness or numbness • incontinence of stool and/or urine • Catheter insertion site for displacement, leakage, kinking, redness, fluid or bleeding every 4 hours and prior to bolus administration • Bladder distention, frequency, and urgency. Evaluate ability to void within 4 to 6 hours of discontinuation of epidural catheter. • Nausea and vomiting especially related to movement. Document at least every 4 hours until epidural discontinued. • Itching. Document at least every 4 hours until epidural discontinued. Why?

  10. Cautions! • Do not give anticoagulants (other than low dose heparin) until 2 hours after the epidral catheter has been discontinued. • No other CNS depressants are to be given without the written order of the anesthesiologist, this includes medications like muscle relaxants.

  11. When to Call: • Notify anesthesiologist or physician managing epidural if: • Respiratory rate <8 or oxygen saturation < 90%. • Sedation scale = 3 (somnolent, difficult to arouse) • Signs/symptoms of epidural hematoma (severe back pain, leg weakness or numbness, incontinence of stool/urine) • Signs/symptoms of CNS toxicity from anesthetic agents (metallic taste, numbness of lips, tinnitus, or dizziness) • Pain relief is inadequate after measures are taken to treat break-through pain • Itching not relieved by ordered medication • Nausea and vomiting is not relieved by prescribed medications • Urinary retention occurs (laboring patients, follow routine care) • Motor and sensory function in lower extremities or trunk decreases (laboring patients, follow routine care) • The epidural catheter insertion site has abnormalities • Severe or sudden onset of headache (may occur up to 24 hours after catheter discontinued)

  12. Removal • Removal of Epidural Catheter: • Epidural catheters are discontinued on the order from a physician. Check with physician managing the epidural if patient has received anticoagulant. • Have patient roll head and shoulders caudally (knee to chest or fetal position). This helps to expose back, slightly separate vertebrae, and ease catheter removal. • Wash hands. • Don Gloves. • Grasp catheter close to skin and remove slowly, pulling steadily. • Observe for presence of metal or blue plastic tip. If not present, notify anesthesiologist or physician managing the catheter. • Cover insertion site with a band-aid. • Document procedure and assessment of insertion site.

  13. PRACTICE CHANGECONTINUOUS EPIDURAL • picture of me giving med • T-CONNECTOR WILL BE PLACED ON THE END OF “YELLOW EPIDURAL TUBING” INTO HUB OF EPIDURAL CATH • TO GIVE BOLUS WITH CONTINUOUS: • SCRUB T-CONNECTOR PORT FOR 2 MINUTES WITH BETADINE • DO NOT USE ALCOHOL • DAB WITH 2X2 IF WET • USING 25G 5/8” NEEDLE ON SYRINGE MEDICATION, INSERT NEEDLE INTO PORT • SLOWLY INJECT • REMOVE ACTIVE SAFETY NEEDLE • DISCARD IN SHARPS QUESTIONS? CONTACT: • KIM KRUTZ – krutzk@slhs.org • RAQUEL HANSEN - hansenr@slhs.org, 1-1505 6/2010

  14. Bolus Dosing • BOLUS DOSING (Not for the pregnant/laboring patient) • Administer a bolus dose for breakthrough pain while receiving continuous infusions using the T-connector. • Use preservative-free medication and preservative free normal saline • Preservative-free vials are to be discarded after a single use • Draw up opioid dose: • Add the preservative free normal saline, if necessary • Assess insertion site for: • Excessive drainage • Catheter integrity • Signs and symptoms infection, redness, pain, or swelling. • Cleanse T-connector injection cap: • Scrub with povidone-iodine prep-pad. • NEVER USE ALCOHOL WITH EPIDURAL CATHETERS. • Allow to dry for 2 minutes. • Wipe with sterile 2x2 after 2-minute dry time has elapsed. • Attach empty syringe and check for placement of line by gently aspirating for blood or CSF. • Insert an empty 3-ml syringe with 25-gauge, 5/8-inch needle through the dry, prepped injection cap and aspirate. Little (< 0.5ml) or no fluid should return from the epidural space. • If no fluid aspirated, remove the needle and syringe from the epidural catheter cap. • If bloody fluid or clear fluid > 0.5 ml aspirated, STOP. Do not re-inject the aspirate. Withdraw the needle and notify the anesthesiologist, CRNA or physician managing the catheter. • Attach syringe with medication and administer slowly. You should feel some resistance as you inject; however, if you are unable to inject the medication, call the physician. • Resume infusion. • Document medication given.

  15. What if you see this?

  16. Case Study: Mrs. Green - 12 hours post hip replacement It’s 2 AM, Mrs. Green had Morphine 2 mg epidural at 1 AM. She appears to be sleeping. Her respiratory rate is 10/min. She does not wake up when you call her name.

  17. What would you do? • Stimulate • Turn off continuous infusion • Check O2 saturation • Call RT • Start oxygen • Give Narcan 0.4 IVP

  18. Case Study Mr. Jones 65 year old man with colon resection. Bolus of Morphine given by anesthesia 5 MG. Continuous epidural with Morphine at 0.5 mg/hr 8 hours post op- Rates pain as 8 What would you assess? What do you think Mr. Jones needs to have his pain relieved? Do you need to call the doctor?

  19. Mr. Jones • Assess pain • Assess Abdomen • Vital signs • Medicate for breakthrough pain (fentanyl) –sterile technique • Consider increasing continuous morphine • Call MD if order is needed or pain may be caused by a complication. • Nonpharmacologic pain measures

  20. Questions? ?

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