Download Care for a patient receiving epidural analgesia in the perianesthesia

Care for a patient receiving epidural analgesia
Care for a patient receiving epidural analgesia in the perianesthesia setting
Completing the skills that make up this competency provide you
with the basic skills you need to manage a patient receiving
epidural analgesia.
Competency appropriate for Perianesthesia Department.
This lesson contains exercises on the following topics:
Assist with insertion of epidural
Correctly set up and initiate the epidural infusion
Assess patient's dermatome level
Monitor for adverse effects of medications administered for
epidural analgesia and symptoms of severe complications
Printed on: Wednesday, August 17, 2011
Version 1.1 (September, 2010)
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Care for a patient receiving epidural analgesia
Critical thinking skills that apply to caring for a patient receiving epidural analgesia
Before you begin performing the hands-on portion of the learning
as it applies to caring for a patient receiving epidural analgesia,
you need to learn a number of key principles that you’ll use every
day as you work with patients.
Besides this fundamental knowledge, you also need to learn the
critical thinking process as it applies to caring for a patient
receiving epidural analgesia.
This lesson focuses on that background information and critical
thinking. After successfully completing this lesson, you’ll be ready
to begin the hands-on portion of learning this competency.
Learning Exercise
Orientee Practice
Assessment Description
Method: Discussion
KEY POINT: Be sure you can answer WHY something is done.
Knowledge Checks:
KEY POINT: How would you retrieve the information you need?
Correctly answer each of the
One aspect of pain treatment involves the administration of
analgesics/local anesthetics via an epidural route. Intraspinal
analgesia (either epidural or intrathecal) offers some benefits
that systemic medications do not. For many patients, intraspinal
analgesia provides better pain relief with fewer side effects.
The use of epidural opioids allows for a high local concentration
of a drug at the desired spinal cord receptors with a minimal
amount of opioid entering the systemic circulation where the
opioid can cause undesired side effects. The epidural route also
allows for selective analgesia depending on the location of the
catheter.
KEY POINT: How would you document your actions?
What are the misconceptions of intraspinal analgesia?
questions in the Orientee
Practice.
What are the benefits of intraspinal analgesia?
What is the difference between epidural and intrathecal routes of
analgesia?
Method: Learning Resources
•
Epidural Resource
•
ASPAN 2008-2010 Standards of Perianesthesia Nursing
Practice, Resource 7: ANA Position Statement on the Role
of the Registered Nurse in the Management of Analgesia by
Catheter Techniques
•
ASPAN 2008-2010 Standards of Perianesthesia Nursing
Practice, Resource 7A: AWHONN Position Statement on
Role of the Registered Nurse (RN) in the Care of the
Pregnant Woman Receiving Analgesia/Anesthesia by
Catheter Technique
Text book
•
Drain & Odom-Forren. (2009). PeriAnesthesia Nursing: A
th
Critical Care Approach, 5 Edition, Chapter 25: Regional
Anesthesia
Printed on: Wednesday, August 17, 2011
Version 1.1 (September, 2010)
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Care for a patient receiving epidural analgesia
Skill 1: Assist with insertion of epidural
Orientee Practice
Assessment Description
Method: Discussion
KEY POINT: Be sure you can answer WHY something is done.
Knowledge Checks:
KEY POINT: How would you retrieve the information you need?
Correctly answer each of the
Epidural anesthesia is accomplished by injecting local anesthetic
in to the epidural space at the lumbar or thoracic level. The level
and duration of epidural anesthesia depends on the location of
the block, as well as the volume and concentration of the local
anesthetic, and the presence or absence of a vasoconstrictor. A
catheter is usually left in place for continuous medication infusion
when epidural anesthesia is used.
Anesthesiologists at the University of Minnesota Medical Center,
Fairview and University of Minnesota Amplatz Children’s
Hospital initiate epidural anesthesia preoperatively,
intraoperatively, and sometimes postoperatively.
The regional anesthesia time out process must be followed.
KEY POINT: How would you document your actions?
Who marks the site prior to placing an epidural? How is the site
marked?
How would you prepare a patient for an epidural?
What monitoring equipment should be placed on the patient prior
to the placement of an epidural?
questions in the Orientee
Practice.
Performance Checks:
Correctly demonstrate each
performance item in the
Orientee Practice.
Demonstrate administering sedation/analgesia for the placement
of an epidural, if ordered.
What elements must the RN, assisting with the insertion of an
epidural, read out loud when the time out is conducted?
Method: Policies
•
Sedation and Analgesia for Procedures
Universal Protocol (including Site Marking and Verification):
•
UMMC Perioperative Services
Demonstrate keeping the patient in a motionless position during
Method: eLearning Resources
Mosby’s Nursing Skills
•
Epidural Catheter Insertion
•
Epidural Catheter: Assisting with Insertion (Pediatric)
How would you provide reassurance to the patient throughout
the placement of an epidural.
What needs to be documented during the procedure? How often
are assessments done and documented?
the procedure?
Method: Learning Resources
•
Regional Anesthesia (Peripheral Nerve Blocks) Resource
Epidural Resource
•
•
A Competency Based Orientation and Credentialing
Program for the Registered Nurse in the Perianesthesia
Setting, 2009 Edition, Ch 9c: Regional Anesthesia
•
A Competency Based Orientation and Credentialing
Program for the Registered Nurse in the Perianesthesia
Setting, 2009 Edition, Chapter 11: Pain and Comfort
Management
Printed on: Wednesday, August 17, 2011
Version 1.1 (September, 2010)
Page 3 of 6
Care for a patient receiving epidural analgesia
Skill 2: Correctly set up and initiate the epidural infusion
Orientee Practice
Assessment Description
Method: Discussion
KEY POINT: Be sure you can answer WHY something is done.
Knowledge Checks:
KEY POINT: How would you retrieve the information you need?
Correctly answer each of the
Prior to initiating an epidural infusion it is necessary to assess
the epidural insertion site by directly viewing the site, turning the
patient if necessary. The site assessment should also be
performed during transfer of care, and may be incorporated while
performing other patient assessments.
When obtaining the medication to be administered for epidural
infusion, ensure that it is preservative-free.
The tubing that is used for epidural infusions should not have
any injection ports.
The characteristic of a drug affects its ability to diffuse through
the dura mater. Drugs that are lipid soluble are less likely to
cause delayed respiratory depression. Drugs that are more
water soluble have a greater potential to spread in the CSF to
those brain centers that control respiration and vomiting.
KEY POINT: How would you document your actions?
What are common complications that may be present at an
epidural insertion site?
Demonstrate an assessment of the insertion site, looking for
complications at insertion site.
Determine if epidural is intact and document your assessment.
Who should be contacted if you find an abnormality at the site?
Demonstrate obtaining the appropriate tubing for the epidural
questions in the Orientee
Practice.
Performance Checks:
Correctly demonstrate each
performance item in the
Orientee Practice.
pump.
Demonstrate comparing the medication that was dispensed from
pharmacy with the order for the epidural infusion.
Demonstrate the setup, dose change, and discontinuing the use
Method: Policy
•
Epidural and Intrathecal Medications for Management
of Pain
of a PCEA pump.
What are the characteristics of drugs administered during
epidural analgesia?
Demonstrate appropriate use of monitoring equipment during
epidural administration.
Method: Learning Resources
•
Epidural Resource
•
A Competency Based Orientation and Credentialing
Program for the Registered Nurse in the Perianesthesia
Setting, 2009 Edition, Ch 9c: Regional Anesthesia
•
A Competency Based Orientation and Credentialing
Program for the Registered Nurse in the Perianesthesia
Setting, 2009 Edition, Chapter 11: Pain and Comfort
Management
Order Set
•
Post-Anesthesia Orders ADULT: Epidural Infusions or
Intrathecal Opioids
Printed on: Wednesday, August 17, 2011
Version 1.1 (September, 2010)
Page 4 of 6
Care for a patient receiving epidural analgesia
Skill 3: Assess patient's dermatome level
Orientee Practice
Assessment Description
Method: Discussion
KEY POINT: Be sure you can answer WHY something is done.
Knowledge Checks:
KEY POINT: How would you retrieve the information you need?
Correctly answer each of the
Dermatome is the segmental distribution of the spinal nerves.
Nurses test dermatomes to establish the level of block by using
cold test items to identify the level.
The therapeutic level required for each patient is dependent on
the location of surgical procedure.
KEY POINT: How would you document your actions?
Demonstrate obtaining and documenting the dermatome level on
a patient receiving an epidural infusion.
Demonstrates identifying the therapeutic level that is necessary
to meet the needs of the patient.
Method: Learning Resources
•
Epidural Resource
•
A Competency Based Orientation and Credentialing
Program for the Registered Nurse in the Perianesthesia
Setting, 2009 Edition, Ch 9c: Regional Anesthesia
•
A Competency Based Orientation and Credentialing
Program for the Registered Nurse in the Perianesthesia
Setting, 2009 Edition, Chapter 11: Pain and Comfort
Management
Printed on: Wednesday, August 17, 2011
Who do you notify if the epidural level is insufficient?
Version 1.1 (September, 2010)
questions in the Orientee
Practice.
Performance Checks:
Correctly demonstrate each
performance item in the
Orientee Practice.
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Care for a patient receiving epidural analgesia
Skill 4: Monitor for adverse effects of medications
administered for epidural analgesia and symptoms of
severe complications
Method: Discussion
Potential adverse effects of medications administered during
epidural analgesia include:
•
Respiratory depression
•
Pruritus
•
Urinary retention
•
Hypotension
Potential complications associated with epidural analgesia
include:
•
Total or high spinal blockade
•
Intravenous injection
•
Dural puncture resulting in a dural puncture headache
•
Bleeding resulting in an epidural hematoma
•
Catheter problems including migration of the epidural
catheter
Orientee Practice
Assessment Description
KEY POINT: Be sure you can answer WHY something is done.
Knowledge Checks:
KEY POINT: How would you retrieve the information you need?
Correctly answer each of the
KEY POINT: How would you document your actions?
What complications necessitate a notification to the physician?
Demonstrate notifying the appropriate people of adverse effects
from epidural anesthesia.
What emergency treatment measures are taken if there is a
severe complication from the administration of the epidural
analgesia?
questions in the Orientee
Practice.
Performance Checks:
Correctly demonstrate each
performance item in the
Orientee Practice.
Method: Learning Resources
•
Epidural Resource
•
A Competency Based Orientation and Credentialing
Program for the Registered Nurse in the Perianesthesia
Setting, 2009 Edition, Ch 9c: Regional Anesthesia
•
A Competency Based Orientation and Credentialing
Program for the Registered Nurse in the Perianesthesia
Setting, 2009 Edition, Chapter 11: Pain and Comfort
Management
Article
•
Clark, M.K. (2008). Lipid emulsion as rescue for local
anesthetic-related cardiotoxicity. Journal of PeriAnesthesia
Nursing, 111 - 121.
Printed on: Wednesday, August 17, 2011
Version 1.1 (September, 2010)
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