Epidural & post-op pain management

maythen · May 7, 2004

I'm a relatively new grad and have only had a handful of pateints with epidurals. But in my facility they come with a foley in place and continuouse pulse ox. Vitals are every fifteen for the first two hours, every 30 for two hours, every hour for two hours, then every four thereafter. There's also two flow sheets, one like a PCA flowsheet which is supposed to be filled out every four hours and every time there is a dosage change, and the other which is just an oxygen saturation reading and a respiration count that is done every hour.

It gets a little crazy since having an epidural patient doesn't change the nurses patient load so it's not unusual for us to have a couple of tele patients, high acuity patients, and to admit as well. I work nights and my facility has decided to cut costs by having only one tech for the entire hospital and no other support staff at night. If our tech calls in sick they just tell us to suck it up.

The epidural seems to control pain relatively well, it just involves a lot of titration and additional meds. But I have to say my personal preference is for the patient to have a PCA. The PCA seems to do just as good a job for pain coverage without all the extra fiddling the epidurals need. But that may be partly infulenced by my small amount of experience.

Lysa · May 18, 2004

On my unit we have a step down unit with three beds and one nurse. This is where our epidural pts go post-op. They are monitered here for at least the first 24 hrs. VS are as follows: post-op-B/P, P, R, and T, sedation level, SpO2 q 1h x8h then B/P, P, R, T q4h (R q1h-SpO2 q2h). The main complication has been over sedation(R @5-6/min). Ok after narcan.

SurgRN · May 23, 2004

How are others caring for post-op patients with epidurals? Nurse to patient ratio? Are patients on any electronic monitoring? Are these patient on the general surgical floors? Before removal of epidural, are others getting Duramorph? Any complications?

The nurse-patient ratio on our 21 bed Surgical floor is 1:5(occassionally 1:6). Epidurals must be check by PACU and surgical RN upon arrival to our floor. According to our policy the RN checks the epidural settings, level of sedation, patient's pain level, Resp. rate, blood pressure, and SaO2 q 2 hours. 2 RNs are required when settings are changed or when the erpidural medication needs to be changed. At our facility, the patients are not receiving duramorph at the time of the epidurals removal... however usually PO pain medication is started before the removal of the epidural. At most we have had 4 patients with epidurals on the floor at the same time, occassionally(but seldom) one RN may have 2 epidurals,

As far as complication: It seems that the elderly can get confused if the epidural contains a narcotic(sometimes the epidural are bupivacaine only). Also in some indviduals hypotension can be an ongoing battle. In order to minimize over medication in these patients, hospital policy states that patients with epidurals can only get other narcotics or sedatives if ordered by anesthesia.

Long Term Care Columnist / Guide · May 23, 2004

Where I work, patients with epidurals get VS taken Q 1 hour X 24 hrs., plus Q 5 mins. X 3 after ANY change is made to the dosage. It's a royal PITA for the nurse, especially when you don't have a CNA to do vitals and you're having trouble with a) pain control, b) keeping BP/RR/O2 sats up, c) loss of sensation that doesn't resolve when the dosage is decreased, or d) all of the above. On top of that, the hassles of dealing with epidurals are never figured into "the numbers" when making assignments. Personally, I hate total knees anyway......between the epidurals, the pain-control issues, and the back-breaking physical work of getting the patients in and out of the friggin' CPM machines, it's sheer hell when our ortho docs schedule a batch of them all at once. :angryfire

jett01 · Jun 7, 2004

On our 37 bed med-surg/ortho floor RN's can have 4-6 patients of their own and responsibility for an LPN's patient group for a combined total of 10-12 patients. Two RNs must verify initial settings. VS q1h x 8 hrs, q 2 X 16 hrs, then q 4 until dc'd. Any dosage change reverts to q 1h. LPNs can get vs but RN has to verify settings at shift beginning and clear pump at shift end and give any iv pushes of supplemental meds. We generally use fentanyl/bupivicaine. No tele or apnea monitors are used. Settings tend to run from 8-12 cc/hr although they seem to be drifting higher. Toradol or morphine IV tend to be supplemental meds of choice. It seems the more teaching I do with patients about possible epidural side effects the more often these patients develop them. :) We begin weaning TKR pts off epidural on 3-11 shift of day two and pull it in the AM of day three. No duramorph used, just PO meds.

barefootlady, ADN, RN · Jun 7, 2004

Great post jezebel and jett. What you describe jezebel is what I am used to when having an epidural patient. Apnea monitor for at least 24 hours.

gwenith, BSN, RN · Jun 7, 2004

Is anyone doing cold/ice tests for defining level of pain relief???

One complication that is never mentioned but I can report on from a person perspective is back pain. In some patients - especially pregancy where weight has been shifted off the spinal column the epidural causes relaxation of the back muscles and therefor causes massive back pain - believe me - I spent a horrific night attempting to lie on a new suture line because the pain in my back was so severe!!!

leemacaz · Jul 7, 2008

Please excuse an ignorant question I guess..but are Foley's an automatic with an epidural?..I did not know until recently that many (if not all) general anesthesia pts get one while under.

lovetoride · Jul 10, 2008

an epidural for a hyst and a sling? That's a little much. We do pca or im/po depending on the doc. I've never seen and epi with a hyst. That's strange that anesth. would ever offer that!