Epidural Assessment

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Epidural Assessment

• Rebecca M Humphreys, BSN, RN
• Unit Based Educator, 5 East
• St. Lukes Health System, Boise

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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.

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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

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Epidural Insertion
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Epidural Catheter Placement
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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.

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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.

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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.

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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?
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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.

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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)

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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.

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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
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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.

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What if you see this?
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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.

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What would you do?

• Stimulate
• Turn off continuous infusion
• Check O2 saturation
• Call RT
• Start oxygen
• Give Narcan 0.4 IVP

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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?

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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

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Questions?

• ?