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Epidural Assessment

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EPIDURAL ASSESSMENT Rebecca M Humphreys, BSN, RN Unit Based Educator, 5 East St. Luke s Health System, Boise * Ask group what should you do? Stimulate. – PowerPoint PPT presentation

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Title: Epidural Assessment


1
Epidural Assessment
  • Rebecca M Humphreys, BSN, RN
  • Unit Based Educator, 5 East
  • St. Lukes 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 lt8 or oxygen saturation lt 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
  • 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_at_slhs.org
  • RAQUEL HANSEN - hansenr_at_slhs.org, 1-1505
  • picture of me giving med

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 (lt 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 gt 0.5 ml
    aspirated, STOP. Do not re-inject the aspirate.
    Withdraw the needle and notify the
    anesthesiologist, CRNA or physician managing the
    catheter.

15
What if you see this?
16
Case Study Mrs. Green - 12 hours post hip
replacement
  • Its 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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