Epidural & post-op pain management

  1. 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?
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  2. 20 Comments

  3. by   meownsmile
    We never see anyone come back to the floor with epidurals in place. We have them come back still numb, but not in place. Occasionally, anethesiology will do nerve blocks before the patient is brought back to the floor to keep them comfortable longer.
  4. by   Sadie04
    Some of our trauma patients are on the regular floor with epidurals; we don't do any electronic monitoring though. We do vital signs and sensory checks Q4.
  5. by   jackieliz
    We have patients with epidurals on my floor (general surgical). They all have apnea monitors and q4 vs.
  6. by   adidas99
    .....
    Last edit by adidas99 on Jan 30, '07
  7. by   sharann
    Quote from jackieliz
    We have patients with epidurals on my floor (general surgical). They all have apnea monitors and q4 vs.
    There is one med floor that cant take pts with epidurals but the ones that can have them on apnea monitors. Even when the pt receives Duramorph the must have an apnea monitor (due to the long acting nature). Insist on apnea monitors unless you have really great staffing(ha).
  8. by   RN-PA
    We have continuous epidurals mainly on the orthopedic/med-surg unit, but we sometimes have them on our general med-surg unit. We have q1h VS x 12 hrs., then q2h. If the dosage gets increased, we have to go back to q 15 min x 4, q 30 min x 4, then back to the q1h etc. etc. They are monitored with continuous pulse oximetry, so that's helpful... Personally, I can't stand epidurals. I have rarely had a patient whose pain was adequately controlled (i'm frequently on the phone with Anesthesia getting new orders, giving MSO4 for breakthrough pain way too often), dealing with the side effects-- itching, and numbness that gets too extensive. :stone Bleh! Staffing is no different if you have an epidural patient either. No reduction in your patient assignment, so we could easily have a total of 6 patients and still have to deal with LPN patient problems as well, and the poor PCT's seem to constantly be taking vital signs in the beginning. No meds are given prior to D/Cing the epidural.
    (I'm editing to add another "con' for epidurals and that's urinary retention-- big time! One of our surgeons who does all our gastric bypass patients used to send the patients up post-op with an NG tube, continous epidural, and NO FOLEY CATH! Of course he had orders to insert foley if unable to void-- well DUH! Now the patients go to ICU post-op and come to our floor with a foley cath.)
    Last edit by RN-PA on Mar 13, '04
  9. by   suzanne4
    I personally love epidurals. If you are needing to call for coverage all of the time, perhaps that has to do with the way that your anesthesia dept is ordering their meds. And what they are putting in the drip, is it only duramorph? They usually have some type of "caine" agent mixed in. I personally had a 5 hour surgery with an epidural placed by a CRNA, and it was fabulous. The catheter was taken out later that day, but it was wonderful.
  10. by   RN-PA
    Quote from suzanne4
    I personally love epidurals. If you are needing to call for coverage all of the time, perhaps that has to do with the way that your anesthesia dept is ordering their meds. And what they are putting in the drip, is it only duramorph? They usually have some type of "caine" agent mixed in. I personally had a 5 hour surgery with an epidural placed by a CRNA, and it was fabulous. The catheter was taken out later that day, but it was wonderful.
    I'm glad you love them-- maybe it does have to do with Anesthesia's dosing and/or placement. Maybe I've just been unlucky with the patients and problems they've had. When my mom went in for a hysterctomy and bladder "sling", the Anesthesiologist wanted her to consider the Epidural but we'd talked about it beforehand and asked for a PCA MSO4 which worked out great for her. I also feel bad for the patients who have to have their VS taken so frequently with continuous epidural. Just as they're faling asleep, there's the PCT to take their BP again.

    Our continuous epidurals are fentanyl-bupivacaine, by the way.
  11. by   alli
    On my unit (General surgery) we have epidurals all the time. q4h VS and sensory checks. No need for other monitoring. With an epidural they always come up with a foley.
    Alli
  12. by   lady_jezebel
    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 nurset 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).
  13. by   lady_jezebel
    Oh, forgot to mention anticoagulants -- these can cause epidural hematomas, leading to disability/death. We have very strict guidelines about the use/doses of heparin or lovenox given with an epidural. If an MD orders an epidural but has a pt on anticoagulants, we DO NOT give the anticoag unless we've called the doc & clarified that the dose/drug meets our protocol. Docs often forget this.
  14. by   maythen
    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.

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