Epidural bolusing by RN's

  1. Was asked to bolus a new epidural(for post op pain control) and declined to do so as I did not feel qualified and was not sure if it was approved by our Board of Nursing. Is this something that most RN's are doing now?

    CaronRN58
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  2. 11 Comments

  3. by   lv2ski
    Using epidurals for pain control is becoming more common. at my facility they are used almost as much as PCA pumps for post- ops.
    We give alot of intermittent doses/? boluses. It probably depends alot on your facilities policies. I am not crazy about epidurals myself, alot of itching and stuff.....narcan
    Last edit by lv2ski on Dec 22, '01
  4. by   doliveri
    Caron,
    In northern California in the hospitals that I have worked at, anesthesia does epidural bolusing. The RN may help prepare the injection for the anesthesiologist, but that is the extent of it. Again, I think it would depend on the policy of the institution where you are employed. But I do applaud you not doing something you did not comfortable or sure about. I think sometimes nurses need to do this more often, and I think administration needs to be more supportive of nursing by making sure that any new procedures which may be done by nursing staff are covered in some form of orientation on the unit or more formal if needed. All too often, nurses are asked to do some procedure for which there is no policy nor any orientation.
    Hope this helps,
  5. by   snickers
    Many of our post-ops have epidurals placed intraoperatively for post-op pain control and Marcaine and Fentanyl is infused via pump. We have standing orders and the gas man writes in the amount of bolus required(Range) and bolus amount. We have strict policies and procedures inplace and in fact have a workbook that we have to complete and annual recertification(it is considered a transfer of function) in our institution.Pts have to lie flat after a bolus and vitals are done q15minutes p0st bolus, we use flow sheets to documentlevels of sensation vitals and response. This is done q1h for 24 hrs after insertion and then q4h until removal.We have standing orders for pruritis, nausea,and narcan!!!
    Would NEVER bolus without strict guidelines in place.

    sj.
  6. by   Dyno
    Like snickers we use a lot of epis on our ward for thoracic surgery.
    We also have standing orders for boluses & rate increases with strict guidlines in place regarding observations, positioning, always do ice-test first to check positioning & orders for naloxone, etc, etc.

    Yes nausea, urinary retention & hypotension are issues. When an epidural works well it is wonderful for the patient & relatively easy for management but when there are problems (ie: pain & catheter positioning) then they are a headache!!!

    The Anaesthetic Registrar on call loves getting woken in the middle of the night by a nurse (I think not!) regarding pain issues

    We also have a pain management workbook (4 modules) in place for each nurse to complete and very good communication with Acute Pain Services (RN plus Anaesthetists)

    Does anyone else use IV ondansetron (Zofran) for pruritis (as well as nausea)? it works well.
  7. by   sharann
    Please tell me what the "ice test" refers to Dyno. Thanks.
  8. by   Dyno
    Hi Shar, the 'ice test' is a test used to assess the nerve block of the epidural. By placing an ice cube on the pt's skin, the extent of the nerve block from an epidural can be assessed.
    For example, it is pointless giving a bolus of analgesia if the catheter is not in position so first the nurse (or anaethetist) needs to assess the block. Using cold sensation is one simple way to assess block.
    The ice cube is touched onto skin that is not within the block (eg: the forearm) and the pt is asked to note the 'coldness' of the sensation.
    The cube is then placed over the area that is supposed to be within the block (eg: thoracic region T4-5, this will be according to the anaethetist's notes).
    The pt is asked to state whether the sensation is as cold as the arm or less. Continue assessing anterior & posterior areas. Often a pt may have 'less coldness' on one side meaning the block is more to one side, if this is the opposite side than where the surgery was performed, then the pt can be repositioned to try to allow gravity to move the pain medication to the least-blocked side.
    Like I said, if an epidural works well, the pt is very comfortable (until it is removed) but if it doesn't work well, it is alot of work for everyone. Hope this helps.
  9. by   sharann
    Thanks so much for the explanation Dyno. I see many epidurals inserted and we start infusions (we hook up the bag and set the pump up, anesthesia hooks the pt up in PACU) but I have never heard of this. I will ask about it next work.
  10. by   mother/babyRN
    At our facility, in labor and delivery, since we most often have to recover patients after c/sections, we do bolus within a prescribed protocol ( so man mgs) per anesthesia...THEY have to actually intiate the epidural and the recovery phase is usually the only time boluses are required, though on odd occasions, after a call to anesthesia when someone has complained of inadequate pain alleviation, we do bolus a patient on post partum (or post gyn surgery)...Usually, however, that is confined to the immediate post operative period and only affects us with c/section people, as we do not recover gyn surgery patients immediately post op..
  11. by   Fgr8Out
    RNs in our hospital receive annual recertification for epidural medication administration. We assess the patients insertion site prior to any bolus administration, and q4 hr minimum with continuous infusions (after the initial 24 hr observations, which are more frequent). Before administering the bolus medication, we pull back on the syringe, checking for blood or possible spinal fluid, which would indicate improper positioning of the catheter. If this first check is clear, we then infuse 1/2cc and again pull back on the syringe, checking placement again, in case infusion may have moved the cath tip.

    We also maintain the continuous infusions and monitor for sedation, pain control, numbness, itching. Generally our surgical patients maintain a foley while they receive a continuous infusion, because of the potential for urinary retention.

    Additionally, Anesthesia must round on the patient every single day to do their own assessment. Epidurals don't provide adequate analgesia for all patients, so it's important to continually assess the pain level and determine the most appropriate form of pain control for each individual.

    Peace
  12. by   huggr8
    we are having the same experiance here with mor e epidural usage, does anyone have a form, or have a set way of documenting assessment. also we have an orthopedic surgeon that leaves thes in 3 days on his knee patients, how often is anesthesi required to see these patients??
  13. by   rhellner57
    we are being asked to set up the continuous pump and start epidural infusions once placed by anesthesia, I have been looking for information dealing with the nurse practice act in Iowa . Does this cover me as I am on a compact license from Nebraska? I have never been asked to do this in any of the other facilities that I have traveled to or worked in Nebraska, New Mexico or Colo

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