Assessment Description You have been asked to clear a patient for an elective procedure. You are seeing the patient in the preoper

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❖ One 18-gauge, -inch (1.3 × 80 mm) epidural needle (pink)

❖ One 0.45 × 0.85–inch epidural catheter

• One introducer stabilizing catheter guide • One screw-cap locking tip catheter • One 0.2-μm screw-cap locking tip catheter connector • One epidural flat filter • Topical skin antiseptic, as prescribed • Sterile towels • Sterile forceps • Sterile gauze, 4 × 4 pads • Face masks with eye shields • Sterile gloves and gowns • 20 mL normal saline solution • 5 to 10 mL local anesthetic as prescribed (e.g., 1% lidocaine; local infiltration) • 5 mL local anesthetic as prescribed to establish the block • Test dose (e.g., 3 mL 2% lidocaine with epinephrine, 1:200,000) • Gauze or transparent dressing to cover the epidural catheter entry site • Tape to secure the epidural catheter to the patient's back and over the patient's shoulder • Labels stating “Epidural only” and “Not for intravenous injection” • Pump for administering analgesia (e.g., volumetric pump, dedicated for epidural use with rate and volume

limited, which has the ability to be locked to prevent tampering and preferably is a color-coded [e.g., yellow] or patient-controlled epidural analgesia pump)

• Dedicated yellow-lined, epidural portless administration set • Prescribed medication analgesics and local anesthetic medications • Equipment for monitoring blood pressure, heart rate, and pulse oximetry

Additional equipment, to have available as needed, includes the following: • Ice or alcohol swabs for demonstrating level of block • Capnography equipment • Emergency medications (e.g., naloxone for respiratory depression, intravenous colloids, and a vasoconstrictor

such as ephedrine for hypotension and Intralipid, a 20% fat emulsion for local anesthetic toxicity) • Bag-valve-mask device and oxygen • Intubation equipment

Patient and Family Education • Review the principles of epidural use with the patient and family members. If the patient's pain needs are not

met, an assessment of the therapy will be completed and the physician, advanced nurse practitioner, or other healthcare professional may change the dosage or therapy to meet those needs. If available, supply easy-to- read written information. Rationale: This information prepares the patient and family for what to expect and may reduce anxiety and preconceptions about epidural use.

• Explain to the patient and family that the insertion procedure can be uncomfortable but that a local anesthetic will be used to facilitate comfort. Rationale: Explanation promotes patient cooperation and comfort, facilitates insertion, and decreases anxiety and fear.

• During insertion and therapy, instruct the patient to immediately report adverse side effects, such as ringing in the ears, a metallic taste in the mouth, or numbness or tingling around the mouth, because these are signs indicative of local anesthetic toxicity.13,30,33 Rationale: Immediate reporting identifies side effects and impending serious complications.

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• Review an appropriate pain rating scale with the patient. The physician, advanced practice nurse, or other healthcare professional and the patient need to establish a mutually agreeable pain level goal. Rationale: Review ensures that the patient understands the pain rating scale and enables the nurse to obtain a baseline assessment. Establishing a pain level goal allows the physician, advanced practice nurse, or other healthcare professional to know an acceptable goal for pain management.

• During insertion and therapy, instruct the patient to report changes in pain management (e.g., suboptimal analgesia), numbness of extremities, loss of motor function of lower extremities, acute onset of back pain, loss of bladder and bowel function, itching, and nausea and vomiting.4,13,14,17 Rationale: Education regarding adverse side effects allows for more rapid assessment and management of potential complications.

• If the epidural infusion is patient-controlled, ensure that patient and family understand that only the patient is to activate the medication release. Rationale: The patient should remain alert enough to administer his or her own dose. A safeguard to oversedation is that a patient cannot administer additional medication doses if he or she is sedated.

Patient Assessment and Preparation P a ti e nt Asse ssm e nt • Assess the patient for local infection and generalized sepsis. Rationale: Assessment decreases the risk for

epidural infection (e.g., epidural abscess).31 Septicemia and bacteremia are contraindications for epidural catheter placement.4,8,23,27

• Assess the patient's concurrent anticoagulation therapy. Rationale: Heparin (unfractionated) or heparinoids (e.g., low-molecular-weight heparin) administered concurrently during epidural catheter placement increases the risk for epidural hematoma and paralysis. Care must be taken with insertion and removal of the epidural catheter when patients have received anticoagulation therapy. Anticoagulant and fibrinolytic medications may increase the risk for epidural hematoma and spinal cord damage and paralysis. If used, anticoagulants must be withheld before insertion and removal of the epidural catheter.21,25,26 Removal of the epidural catheter should be directed by the physician. According to Kleinman and Mikhail,13 aspirin or nonsteroidal antiinflammatory medications (NSAIDs) by themselves do not pose an increased risk for epidural hematoma, assuming the patient's coagulation profile is within normal limits. Therefore aspirin or NSAIDs may be administered while the epidural catheter is in place.13 However, epidural hematomas have been associated with the concurrent administration of the NSAIDs, ketorolac, and anticoagulants.12,21 Assessment of sensory and motor function must be regularly performed during epidural analgesia for all patients.

• Obtain the patient's vital signs. Rationale: Baseline data are provided. • Assess the patient's pain. Rationale: Baseline data are provided. • Review the patient's medication allergies. Rationale: This information may decrease the possibility of an allergic

reaction.

Patient Preparation • Ensure that the patient and family understand preprocedural information. Answer questions as they arise, and

reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.

• Verify that the patient is the correct patient using two identifiers. Rationale: Before performing a procedure, the nurse and team members should ensure the correct identification of the patient for the intended intervention.

• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and makes a competent decision possible for the patient.

• Perform a preprocedure verification and time out including all team members. Rationale: This action ensures patient safety.

• Wash the patient's back with soap and water and open the gown in the back. Rationale: This action cleanses the skin and allows easy access to the patient's back.

• Consider nothing by mouth (NPO), especially if sedation or general anesthesia is to be used. Rationale: NPO status decreases the risk for vomiting and aspiration.

• Establish IV access, or ensure the patency of IV catheters, and administer IV fluids as prescribed before epidural catheter insertion. Rationale: IV access ensures that medications can be given quickly if needed. The administration of IV fluids may decrease hypotension that may occur during epidural infusions.4,13

• Reassure the patient. Rationale: Anxiety and fears may be reduced.

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Procedure for Pain Management: Epidural Catheters (Assisting With Insertion and Initiating Continuous Infusion)

FIGURE 105-2 Patient positioned for catheter placement. This figure shows two positions patients can assume for the epidural catheter placement procedure. (From Pasero C, McCaffery M: Pain assessment and pharmacologic management, St. Louis, 2011, Elsevier.)

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FIGURE 105-3 Dermatomes. Segmental dermatome distribution of spinal nerves to the front, back, and side of the body. Dermatomes are specific skin surface areas innervated by a single spinal nerve or group of spinal nerves. Dermatome assessment is done to determine the level of spinal anesthesia for surgical procedures and postoperative analgesia when epidural local anesthetics are used. C, Cervical segments; T, thoracic segments; L, lumber segments; S, sacral segments; CX, coccygeal segment. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 9, St. Louis, 2016, Elsevier.)

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Steps Rationale Special Considerations

1.

2. Physicians, advanced practice nurses, and other healthcare professionals should apply personal protective equipment (e.g., face masks with eye shields). All physicians, advanced practice nurses, and other healthcare professionals present during epidural insertion should wear a hat and mask. The individual performing the procedure should wear hat, mask, sterile gown, and gloves.

3. Obtain the prescribed epidural medication infusion from the pharmacy.

The medication should be prepared with aseptic technique by the pharmacy with laminar flow or prepared commercially to decrease the risk for an epidural infection.23,27,28

All epidural solutions are preservative-free to avoid neuronal injury.30

4. Connect the epidural tubing to the prepared epidural medication infusion and prime the tubing.

Removes air from the infusion system.

5. Ensure that the patient is in position for catheter placement. Assist with holding the patient in position (lateral decubitus knee-to-chest position or leaning over bedside table) and consider preprocedure analgesia or sedation, if necessary (Fig. 105-2).

Facilitates ease of insertion of the epidural catheter. Both positions open up the interspinous spaces, aiding in epidural catheter insertion (see Fig. 105-2).

Movement of the back may inhibit placement of the catheter.

6. Assist as needed with the antiseptic preparation of the intended insertion site. (Level C*)

Reduces the transmission of microorganisms into the epidural space.

The choice of povidone-iodine or chlorhexidine as an antiseptic agent for neurological procedures is controversial. Both should be allowed to dry completely. Studies suggest chlorhexidine is neurotoxic.10,18,24

7. Assist if needed with draping the patient with exposure only of the insertion site.

Aids in maintaining sterility.

8. Assist the physician or advanced practice nurse as needed as the epidural catheter is placed.

Provides needed assistance.

9. Monitor the patient as the physician or advanced practice nurse administers 2–3 mL of 1% lidocaine containing 1:200,000 epinephrine as a test dose.

To confirm proper placement of the epidural catheter

An immediate increase in heart rate indicates the catheter has inadvertently penetrated an epidural vein. If this occurs the physician, advanced practice nurse, or other healthcare professional inserting the catheter should

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withdraw the catheter slightly or remove it and insert a new catheter.29

10. After the epidural catheter is inserted, assist as needed with application of a sterile, occlusive dressing.

Reduces the incidence of infection.

Use of a transparent dressing allows for ongoing assessment of the insertion site for infection, leakage, or dislodgment.

11. Secure the epidural filter to the patient's shoulder with gauze padding.

Avoids disconnection between the epidural catheter and filter. Gauze padding prevents discomfort and skin pressure from the filter.

12. The physician or advanced practice nurse administers a bolus dose of medication.

Facilitates a therapeutic level of analgesia and confirms correct catheter position.9

If a local anesthetic is used for the bolus, monitor the blood pressure frequently, with assessment for possible hypotension. Some analgesia medications (e.g., morphine) may take up to 1 hour to be effective.13,14,30

13. Connect the prescribed medication infusion system.

Prepares the infusion system.

14. Initiate therapy:

A. Place the system in the epidural pump or PCEA pump and set the rate and volume to be infused.

No other solution or medication (e.g., antibiotic or total parenteral nutrition) should be given through the epidural catheter.33

Responses to epidural analgesia vary individually, and epidural analgesia is tailored according to individual responses.

B. Attach an “Epidural only” label to the epidural tubing. Use a portless system.4,33 (Level E*)

Inadvertent intravenous administration of some epidural solutions can cause serious adverse reactions, including hypotension and cardiovascular collapse.11,28

C. Lock the key pad on the epidural or PCEA pump.

This is an important safety feature.

15. Assess the effectiveness of the analgesia. Follow institutional standards for assessing pain.

Identifies the need for additional pain medication and interventions.

A. Determine the pain score. Tolerable pain scores should be reported at rest, and very little pain should be

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experienced with deep breathing, coughing, and movement.

B. Assess the level of the epidural block with ice or an alcohol swab.6

The ideal epidural block should be just above and just below the surgical incision or the trauma site (see the dermatomes described in Fig. 105-3).

16. Remove and sterile equipment and discard used supplies in an appropriate receptacle.

Removes and safely discards used supplies.

17. *Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. *Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Procedure for Epidural Catheter (Bolus Dose Administration) Without a Continuous Infusion

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Steps Rationale Special Considerations

1.

2.

3. Boldly label the epidural catheter used for intermittent bolus dosing (suggest color coding).4,33 (Level E*)

Reduces the risk for administration of medication into intravenous lines.

4. Verify the correct medication with the five rights of medication administration.

Before performing a procedure, the nurse should ensure that the correct medication is being administered.

5. Prepare the bolus dose as prescribed.

Use only preservative-free solution to dilute assuring a decreased risk of neuronal injury.4,13

Do not use multidose vials because they increase the risk for contamination and the risk for an epidural infection.4,14

6. Prepare and cleanse the epidural port with an antiseptic agent. (Level C*)

Do not use an alcohol-based preparation. Use aqueous chlorhexidine or povidone-iodine.

Preparations with alcohol are neurotoxic to the epidural space. The choice of povidone- iodine or chlorhexidine as an antiseptic agent is controversial. Both should be allowed to dry completely. Studies suggest chlorhexidine is neurotoxic.10,18,14

7. Use aseptic technique to administer the epidural bolus:

A. Connect an empty syringe to the catheter port.

Administers the medication for injection.

Follow state and institutional guidelines as to who is able to provide bolus doses.

B. Aspirate the epidural catheter, limited by the amount allowed by institutional policy. If blood is aspirated, do not reinject the aspirate. Do not inject the medication. Notify the physician or advanced practice nurse. If clear fluid is obtained, it may be CSF. Do not reinject the aspirate. Do not inject the medication. Notify the physician or advanced practice nurse.6,9,19,30

If blood is obtained, the epidural catheter may have migrated into an epidural vessel. An amount of only 1–2 mL of blood may be inconclusive because any blood from an epidural vein may have mixed with blood from the trauma of inserting the catheter. If more than 3 mL is aspirated, the catheter is most likely in an epidural vein.30

If 5 mL or more of CSF is obtained, the catheter may have migrated into the subarachnoid space.30

Administration of epidural medications into the epidural vein or into the subarachnoid space may result in increased sedation, respiratory depression, hypotension, and bradycardia.

C. Connect the syringe with the bolus medication to the catheter port.

Prepares for the injection.

D. Administer the medication slowly. Note: If excessive pressure occurs, assess for kinks in the catheter or reposition the patient.

Some resistance will be felt because the diameter of the epidural space is small and the epidural filter is in place.

Excessive pressure may be more pronounced if the epidural catheter is

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placed at the lumbar dermatome as opposed to the thoracic dermatome.

If resistance continues to impair administration of a bolus dose, contact the physician or advanced practice nurse.

8. Assess the effectiveness of the medication. Follow institutional standards for assessing pain.

Identifies need for pain interventions. Pain should be relieved or decreased.

Report continued pain despite pain interventions.

9. Monitor vital signs. An epidural bolus may cause hypotension, bradycardia, respiratory depression, or increased sedation.11,28

Report untoward decreases in blood pressure, heart rate, respirations, oxygen saturation, and sedation.

10. Monitor for increased motor and or sensory block, and signs and symptoms of local toxicity related to the epidural medications.

Allows for the early identification of signs and symptoms of local anesthetic toxicity which include lightheadedness, tinnitus, metallic taste, visual disturbances, perioral numbness loss of consciousness, seizure, arrhythmia, and asystole.4

11. Remove and discard used supplies.

12. *Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. *Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Procedure for Assisting With Removal of the Epidural Catheter

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Steps Rationale Special Considerations

1.

2. Physicians, advanced practice nurses, and other healthcare professionals should apply personal protective gear (e.g., face masks with eye shields), and sterile gloves may be worn by the physician, advanced practice nurse, or other healthcare professional removing the catheter.

3. Assist the physician or advanced practice nurse as needed with removal of the catheter.

Facilitates catheter removal.

4. Assist if needed with applying a sterile occlusive dressing.

Reduces contamination by microorganisms.

5. Remove personal protective equipment and discard used supplies in an appropriate receptacle.

Removes and safely discards used supplies.

6. Assess neurological status, pain, and insertion site after removal of the epidural catheter.

Motor or sensory loss in the extremities may be an early warning sign of an epidural abscess or hematoma or may indicate an excessive dose of a local anesthetic.26,27

An epidural hematoma is a rare but serious complication; if undetected, it may result in permanent paralysis.14,16,22,32

Assess for a change in sensory or motor function in extremities, sudden onset of back pain with increasing motor weakness, and loss in bladder and bowel function.

A. Monitor sensory and motor status of lower extremities and ability to void up to 24 hours after removal of the catheter (see Fig. 105-3).2,8,14,16

Identifies potential adverse effects of epidural analgesia.

B. Monitor insertion site for drainage or infection.

Identifies adverse effects of epidural analgesia such as infection.

C. Continue to assess pain.

Identifies need for ongoing interventions to manage pain.

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7.

Expected Outcomes • The epidural catheter is inserted into the epidural space • Pain is decreased and maintained at a tolerable level • The patient experiences minimal sedation • The patient experiences minimal numbness and no motor loss in the limbs • Hemodynamically stable • No opioid-related respiratory depression or decreased respiratory blockade from local anesthetic affecting the

diaphragm or ancillary muscles required for inspiration and expiration

Unexpected Outcomes • Inability to insert the epidural catheter • Suboptimal pain relief13

• Oversedation or drowsiness11,28

• Opioid-induced respiratory depression or hypoxia11,28

• Hypotension14,19,30

• Motor blockade of limbs; lower extremity weakness13,19,30

• Sensory loss in the limbs13,19,30

• Patchy block (e.g., uneven pain relief)13

• Unilateral block (e.g., pain relief on the contralateral side of the body only)13

• Nausea and vomiting8,14,17,28

• Pruritus1,8,14,17,28

• Urinary retention1,8,14,16,28

• Accidental dural puncture into the subarachnoid space13,33

• Dural puncture headache13,33

• Epidural catheter tip migration into a vessel or adjacent structure13

• Redness or signs of skin breakdown at pressure area sites (e.g., sacrum, heels) from decreased sensation • High epidural block— epidural local anesthetic block above the thoracic fourth vertebrae (T4)14

• Total spinal blockade13

• Occlusion of epidural catheter13

• Accidental epidural catheter dislodgment13

• Dressing disruption exposing insertion site • Leakage from the epidural catheter insertion site13,33

• Cracked epidural filter • Local anesthetic toxicity13

• Anaphylaxis14

• Epidural hematoma8,25,26,28

• Epidural abscess8,25,27,28

• Local erythema or drainage at insertion site32

• Nerve or spinal cord injury13

• Accidental connection of the epidural solution to the intravenous fluids33

• Accidental connection of intravenous fluids to the epidural catheter. • Local anesthetic toxicity13,14

• Cardiopulmonary arrest13

Patient Monitoring and Care

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Steps Rationale Reportable Conditions

These conditions should be reported if they persist despite nursing interventions.

1. Assess the patient's level of pain with use of a pain scale.9,14,30 The frequency of assessments is determined by institutional standards. Record the patient's subjective level of pain, with use of the institution's standard pain assessment tool.

Describes patient response to pain therapy. A low pain score is expected both at rest and during movement.

Analgesic goal is safe, steady pain control at a low level that is acceptable to the patient.

• Moderate to severe pain scores

2. Assess the patient's level of sedation9,14,30 with use of the institution's standard assessment scale and frequency standard.

Sedation precedes opioid-related respiratory depression. A sudden change in sedation scale may indicate that the epidural catheter has migrated into an epidural blood vessel or the intrathecal space.11

• Increasing sedation and drowsiness or sudden change in sedation scale

3. Assess respiratory rate the first 20 minutes after administration of the epidural medication, and/or bolus then every 1–2 hours and as needed (prn).11,14,28 (Level D*)

Provides data for diagnosis of respiratory depression.

• Increasing respiratory depression or sudden change in respiratory rate combined with increasing somnolence

4. Assess heart rate14,28 with vital signs every 2 hours, then every 4 hours when stable.

Tachycardia may indicate a condition such as shock. Bradycardia may indicate opioid overmedication and sympathetic blockade by the local anesthetic.13,19

• Change in heart rate

• Abnormal heart rate

• Abnormal cardiac rhythm

5. Assess blood pressure with vital signs every 2 hours, then every 4 hours when stable. If hypotension occurs:

A. Turn off the epidural infusion; notify the physician, advanced practice nurse, pain relief service.

B. Place the patient in a supine, flat position.

C. Administer IV fluids as prescribed or according to protocol.

D. Administer vasopressor medications as prescribed.14,28

Epidural solutions that contain a local anesthetic may cause peripheral and venous dilation, providing a “sympathectomy.”14 The hypotensive effect of a local anesthetic is most common when a patient's fluid status is decreased. Epidural analgesia may not be the sole cause of hypotension but may reveal hypovolemia.

• Hypotension

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E. Use caution when raising patient from lying to sitting or sitting to standing positions.31

6. Monitor the infusion rate with vital signs. Ensure that the control panel is locked if using the volumetric infuser or ensure that the PCEA program is locked in via key or code access.

Ensures that the medication is administered safely.

7. Monitor oxygen saturation and end- tidal carbon dioxide if prescribed or continuously as per institutional policy.11,14 (Level E*)

Assesses oxygenation. A decrease in oxygen saturation is a late sign of opioid oversedation and should not be solely relied on to detect oversedation.

• Oxygen saturation <93% or a decreasing trend in oxygenation

• Note: Decreased oxygen saturation is a late sign of opioid oversedation and should not be solely relied on to detect oversedation .

8. Obtain the patient's temperature11,14 every 4 hours; assess more often if febrile. (Level E*)

Fever may signify an epidural space infection or systemic infection that is a potential risk when an epidural catheter is in place.14,17,27,32

• Temperature >101.3°F (38.5°C)

9. Assess the epidural catheter site every 4 hours or according to established institutional standards.14,32

Identifies site complications and infection. An epidural abscess is a rare but serious complication. Patient recovery without neurological injury depends largely on early recognition.14,17,27,32

• Redness • Tenderness

or increasing diffuse back pain

• Pain or paresthesia during epidural injection induration

• Swelling or presence of exudate

10. Monitor ability to void and ability to completely empty bladder.1,8,14 (Level E*)

Provides data regarding urinary retention and possible early signs of epidural abscess or epidural hematoma.8,14,26,27,32

• Urinary retention

• Change in bladder function

• Lack of urination for >6–8 hours

11. Monitor for sensory and or motor loss (e.g., leg numbness or inability to bend knees) at least every 4 hours and prn (see Fig. 105-3).2,8,14,16 (Level E*)

Motor or sensory loss in the extremities may be an early warning sign of an epidural abscess or hematoma or may indicate an excessive dose of a local

• Change in sensory or motor

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anesthetic.26,27 An epidural hematoma is a rare but serious complication; if undetected, it may result in permanent paralysis.14,16,17,32

function in extremities

• Sudden onset of back pain with decreasing motor weakness

• Loss in bladder and bowel function (e.g., incontinence )

12. Assess for ringing in the ears, tingling around lips, or a metallic taste.5,13,14 (Level E*)

If a local anesthetic is used in the epidural solution, ringing in the ears, tingling around the lips, or a metallic taste may indicate impending local anesthetic toxicity.5,13,14

• Ringing in the ears, tingling around the lips, or a metallic taste

13. Monitor and check skin integrity of the sacrum and the heels every 2 hours and as needed. Change the patient's position as needed.

If a local anesthetic is used in the epidural solution, check for pressure points and decubitus ulceration (patient may have sensory loss in lower limbs).13,19,30

• Altered skin integrity

• Increasing redness or blistering of the skin on the sacrum or heels

14. Change the epidural catheter insertion site dressing as prescribed or if soiled, wet, or loose. Call physician or advanced practice nurse if catheter site is exposed. Follow institutional standards.

Provides an opportunity to cleanse the area around the catheter and to assess for signs and symptoms of infection that may indicate early signs of an epidural abscess.14,27

• Swelling • Site pain • Redness • Leakage of

epidural solution or drainage

15. Assess for the presence of nausea or vomiting.8

Antiemetics may need to be administered; the medication may need adjustment (e.g., opiates may need to be decreased or stopped if nausea and vomiting are not well controlled).

• Unrelieved nausea and vomiting

• Note: Nausea and vomiting may be a sign of severe hypotension.

16. Assess for the presence of pruritus.2,8 Epidural opiates may cause itching. Medications such as antihistamines

may cause sedation and are ineffective for spinally mediated itching. Low-dose opioid antagonists may be necessary to relieve pruritus. Small doses of naloxone (e.g., 0.04 mg) are

• Itching • Redness • Rashes

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effective for pruritus without reversing the analgesia.13,19

Diphenhydramine or hydroxyzine can also be effective for itching associated with dehydration but may cause increased sedation.13,19

17. Label the epidural pump and tubing33 and consider placing the ep

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