Care for the Patient Receiving Epidural Analgesia.
Local anesthetics used in epidural analgesia include lidocaine, mepivacaine, ropivacaine, and bupivacaine. These drugs have quick onset and a short duration of action; they work by preventing the conduction of nerve impulses and blocking the pain signal along spinal nerves. Fentanyl, hydromorphone, and morphine are the most commonly used opioids. They work by blocking the pain signal to the brain and have no effect on sympathetic, sensory, or motor nerve fibers (Cason, 2019; Polomano et al., 2017).
The medical-surgical nurse has a role in pre-procedure and post-procedure care, including the implementation of a plan of care for assessing, monitoring, and preventing complications. In preparation for epidural insertion, the nurse may witness the consent form, ensure a patent intravenous line is in place, and assist with positioning the patient for the epidural placement (Cason, 2019; Menez, 2016).
Post-procedure, the nurse should assess vital signs; catheter insertion site and dressing; the patient's pain intensity, including any breakthrough pain; and any signs of complications (Menez, 2016). These signs include hypotension, nausea, vomiting, urinary retention, and any motor or sensory block (Kennedy, 2016; Polomano et al., 2017). In addition, a thorough and frequent respiratory assessment during administration of epidural analgesia will reduce the patient's risk for respiratory depression. The nurse's assessment should include respiratory rate, depth of respiration, oxygenation by pulse oximetry, and level of consciousness (Cason, 2019; Kennedy, 2016). The nurse also should monitor the epidural catheter site dressing, ensuring it remains clean and intact (Cason, 2019).
When the patient's pain can be managed by oral analgesics, when the patient's pain is not managed adequately, or when the risk of complications outweighs the benefits, epidural analgesia should be discontinued (Cason, 2019). The nurse should work collaborative ly with the care team to develop the plan of care for optimal pain management (Polomano et al., 2017).
Mr. Smith, 56 years old and with no significant medical history, is admitted to the unit postoperatively for a total knee arthroplasty. An epidural catheter remains in place from surgery for administration of fentanyl with ropivacaine for pain management. His vital signs are stable and he states his pain intensity is acceptable at 2 (on 1-10 scale).
1. The nurse should know epidural analgesia is contraindicated if the patient has a:
a. urinary catheter in place.
b. high pain tolerance.
c. systemic infection.
d. thoracic incision.
2. Four hours postoperatively, Mr. Smith complains of nausea. The nurse should realize nausea may be a side effect of the opioid infusion and should know other side effects include:
a. urinary retention, only.
b. urinary retention and sedation, only.
c. urinary retention, sedation, and pruritus, only.
d. urinary retention, sedation, pruritus, and orthopnea.
3. Postoperatively, the nurse should know it is vital to assess Mr. Smith's:
a. capillary refill.
b. respiratory rate.
c. bowel sounds.
d. visual acuity.
4. Mr. Smith's epidural is scheduled to be discontinued tomorrow. The nurse thus should expect which of the following orders?
a. Hold enoxaparin (Lovenox[R]) dose for 24 hours before catheter removal.
b. Place the patient NPO for 8 hours before catheter removal.
c. Assess vital signs every hour for 8 hours after catheter removal.
d. Apply heat to the insertion site for 24 hours after catheter removal.
5. During the assessment, the nurse notes fresh bloody drainage on the epidural dressing. Mr. Smith states his pain intensity has increased to 8 in the last hour. The nurse suspects Mr. Smith's epidural catheter has been dislodged. What action should the nurse take first?
a. Contact the anesthesia provider.
b. Stop the infusion.
c. Change the dressing.
d. Administer an oral analgesic.
Answers with Rationale
1. C--Systemic infection is a contraindication for epidural analgesia (Wilkinson, Treas, Barnett, & Smith, 2015). Urinary catheterization, high pain tolerance, and thoracic incision are not contraindicated conditions.
2. C--Pruritus, sedation, and urinary retention are common side effects of opioids (Cason, 2019; Kennedy, 2016; Polomano et al., 2017). Orthopnea is not a side effect of opioids.
3. B--Thorough respiratory assessment reduces the patient's risk for respiratory depression (Menez, 2016; Polomano et al., 2017). Capillary refill, bowel sounds, and visual acuity are not signs related to complications of epidural anesthesia.
4. A--Heparin or low-molecular-weight heparin is held on the day an epidural is to be discontinued (Horlocker et al., 2018). NPO status and increased vital signs monitoring are not needed. Applying heat is incorrect as it could lead to the development of a hematoma over the insertion site.
5. B--If the nurse suspects any complication related to epidural analgesia, he or she should stop the infusion then contact the anesthesia provider (Cason, 2016).
Cason, L. (2019). Pain management. In P.A. Potter, A.G. Perry, P.A. Stockert, & A.M. Hall (Eds.), Essentials for nursing practice (9th ed.) (pp. 939-971). St. Louis, MO: Elsevier.
Horlocker, T.T., Vandermeuelen, E., Kopp, S.L.., Gogarten, W., Leffert, L.R., & Benzon, H.T. (2018). Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (4th ed.). Regional Anesthesia and Pain Medicine, 43(3), 263-309.
Kennedy, J. (2016). Pain. In H. Craven (Ed.), Core curriculum for medical-surgical nursing (5th ed.) (pp. 109-126). Pitman, NJ: Academy of Medical-Surgical Nurses.
Menez, J.A. (2016). Perioperative nursing care. In H. Craven (Ed.), Core curriculum for medical-surgical nursing (5th ed.) (pp. 171-189). Pitman, NJ: Academy of Medical-Surgical Nurses.
Polomano, R.C., Fillman, M., Giordano, N.A., Vallerand, A.H., Nicely, K.L.W., & Jungquist, C.R. (2017). Multimodal analgesia for acute postoperative and trauma-related pain. American Journal of Nursing, 117(3), 12-26.
Wilkinson, J.M., Treas, L.S., Barnett, K.L., & Smith, M.H. (Eds). (2015). Pain. In Fundamentals of nursing (3rd ed., vol. 2) (pp. 610-620). Philadelphia, PA: F.A. Davis.
Wendy G. Woodall, MSN, CMSRN[R], CNE, is Deputy Commander for Nursing and Chief Nursing Officer, Kirk U.S. Army Health Clinic, Aberdeen Proving Ground, MD; and CMSRN[R] Test Development Committee Member.
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|Title Annotation:||Preparing for CMSRN[R] Certification|
|Author:||Woodall, Wendy G.|
|Date:||May 1, 2019|
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