Our post-ops usually come back with an epidural, PCEA (pt controlled epidural anesthesia), PCA (pt controlled anesthesia through peripheral or central line), or some combination of both. If the pt has a combo, the PCA will contain the narcotic & the epidural will contain a numbing agent only (like bupivacaine) -- we never "double narcotize", or send narcotics through both routes at the same time. Sometimes pts are on oral narcotics in addition to any of the above, however.
Monitoring epidurals: first 4 hrs post-op, check bp/hr/rr/temp/level of sedation/ and pulse ox. Then q2h X4, check all of the same. The q8h check bp/hr/temp, while continuing to check rr/level of sedation & pulse ox q4h while the epidural is in place.
We also check for "level of block" each time, desiring for the pt to have sensation below T10 (If they can't feel their legs or abdomen, obviously there is a problem; if the diaphragm is blocked, obviously the person could stop breathing!). Finally, we check for "straight leg raises", asking the pt to raise each leg off the bed separately while holding it straight. Often pts on epidurals cannot do this. If they can't do leg raises & report numbness, they may be getting a dose that's too large!
Danger signs: decr hr/bp, decr rr (10 or below is serious), pin-prick pupils (overdose), incr sedation (dangerous if very drowsy, falls asleep during conversation/questioning), low pulse ox (needs oxygen if below 92%; almost all our epi pts are kept on oxygen 2L by nasal cannula), and any severe allergic/adverse response to the medications (hives, respiratory distress, circ collapse, severe headache indicating dural tear, or hallucinations/delusions). Urinary retention can be a problem, so after foley removal we must I/O cath pt if they do not urinate on their own in a 6-hr time frame. Many pts have nausea (treated c metoclopramide or ondansetron) or itching (treated c benadryl first). There are standing orders for nausea, itching, and urinary retention, but we report any other adverse experiences. We also have standing orders for administering boluses, increasing epidural rates, or decreasing lock-out times for PCAs/PCEAs.
No, there is no change in our pt assignments based on whether someone has an epidural or PCA. These are very routine on our floor (ortho/oncology/med overflow). Our nurse
t ratio is ALWAYS good, 1:3 or 1:4. Pts are usually high acuity. No special electrical monitoring. In our hospital (teaching institution), the anesthesia residents usually place the epidurals and remove them; nurses can "cap" them before their removal (ie. we disconnect them from the medication, and cap in case the epidural needs to be turned back on).