Epidurals: to Dose, or Not to Dose? - page 3

Hello to All, Am in a bit of a tiff at work concerning the dosing of continuous epidural infusions. Is this practice widely accepted, is it within an RN's scope of practice, what are your... Read More

  1. by   begalli
    Quote from 4Blessings
    What training have you aquired to preform such a task?
    We complete an "Intraspinal (epidural and intrathecal) Analgesic Administration Module." This is a class (or as I called it, an inservice) that lasts about 30 minutes complete with anatomy, policies, procedures, and rationales. It could be (and probably is) longer, it's been a long time since my initial class. It's part of the 12 week orientation to the unit.

    We then complete a written post-test and must pass with 90% or better. After the test, we demonstrate skill in epidural drug administration by administering an epidural opiate dose to a patient or simulated patient situation such as a teaching manikin.

    Every year we must recertify by demoinstrating the skill and taking the test. Many RN's on our unit choose to specialize or be an "expert" or resource in something that requires certification before an RN can work with a particular treatment or piece of equipment (epidural, cvvh, iabp, vads, etc) for their staff nurse level. An "epidural RN" will make sure everyone is renewed when it's time. This certification enables us to administer medication to the epidural space through implantable ports or pumps.

    I have never seen a patient with an intrathecal catheter, but this applies to intrathecal as well.

    Gosh, ya know, we can even repair a catheter connector or adapter if it is found to be disconnected for whatever reason or breaks. We call the doc immediately and he/she determines any risks for infection and if all is well, we, the RNs replace the connector by snipping about 1 1/2 inches of catheter with sterile scissors (after prepping it with betadine), and replace the connector. It's much like repairing a broken picc connector.

    I hope no one gets the impression that I or the nurses I work with take this as just another task. We don't. We know the seriousness of what we are doing, and we know what we're doing. Even some of the most experienced nurses still have another RN along for the ride just to be sure when we have to manipulate an epidural for whatever reason.
    Last edit by begalli on Jan 4, '05
  2. by   begalli
    Quote from SmilingBluEyes
    Additional meds MUST be either on PCA for the patient to self- administer--- or bolused BY the MDA, NOT EVER A NURSE! that is NOT in our scope of practice. Be really careful where you tread!
    I don't think the hospital that I work for would allow us to do such a thing if it was not within our scope. I'm looking for info online to back this up but there's so much to go through.

    When I find something I will share it.

    btw, 4Blessings, what is AWON?
  3. by   palesarah
    Quote from SmilingBluEyes
    As nurses, We are allowed only to TURN DOWN the rate, if ordered by anesthesiologist. Additional meds MUST be either on PCA for the patient to self- administer--- or bolused BY the MDA, NOT EVER A NURSE! that is NOT in our scope of practice. Be really careful where you tread!
    It is allowed within the RN scope of practice in my state (NH) to adjust (increase or decrease) the rate on a pump, but not to inject medication directly into the line.
  4. by   stevierae
    Quote from begalli

    btw, 4Blessings, what is AWON?
    It's actually AWHONN--Association of Womens' Health, Obstetric and Neonatal Nurses

    www.awhonn.org
  5. by   jwk
    Quote from stevierae
    In fact, isn't anesthesia required to be in house at all times in hospitals that have OB units--or does that vary?
    Anesthesia needs to be in-house if they have epidurals in place. Otherwise there is no such requirement.

    There's a lot of smaller rural hospitals that really shouldn't be doing labor and delivery, and limited anesthesia services is one of many reasons. It's hard to maintain competency when you're only doing 10 deliveries a month.
  6. by   jwk
    Here's how our hospital does it.

    All patients with labor epidurals are placed on a constant epidural infusion with Ropivicaine via syringe pump (no bag to run dry and pump air in). We have standardized programming for all patients with pre-printed anesthesia orders that all our nurses are very familiar with. RN's can give the patient a bolus using the PCA function of the syringe pump. If the patient's remain uncomfortable, the anesthesiologist is called, and they'll either order another bolus through the pump, or the anesthesiologist or anesthetist will go by and give a bolus of lidocaine or bupivicaine. If they don't get comfortable after that, anesthesia will usually reposition the catheter before further boluses. If they don't get comfortable after that, the epidural is replaced. Anesthesia handles any catheter disconnects and will troubleshoot pumps as needed.

    We do 18,000 deliveries a year - most of the moms get an epidural. We have a minimum of three anesthesia providers available for OB at all times. Our OB nurses are great - we trust them, they trust us, and we all work great together. We have to with that many deliveries.
  7. by   scooterRN52
    Quote from 4Blessings
    Well, I got my defining ansewer today. I got a response from my state board that sealed the deal. Must be a CRNA to dose an epidural. We are being asked to do something that is out of our scope of practice. My advise is to check with your own state boards and find out their stance. Now I'm in for an up hill battle to change policy in my institution.
    Hi, just read your note about dosing w/ epidural infusions, we Rn's are not allowed to inject anything into an epidural infusion. We are trained to monitor epidural infusions via PCEA infusion pumps. We are allowed to change the RX on the pump if ordered by the MD. We then have 2 nurses check the infusion pump to make sure THe RX is correct, we also change infusion bags and tubing PRN. This too is checked and signed off by 2 nurses.
    My sister is a CRNA, their of practice is under medical boards of licensure.
    The scope of CRNA is totally different than an RN.
    If your institution is asking nurses to inject anything into an epidural line, they are out of compliance w/ state board rules and regulations.
    You can refuse to comply stating that it is out of your scope of practice, if something goes wrong w/ pt. hospital, nurse and doctor are responsible.
    Last edit by scooterRN52 on Jan 4, '05
  8. by   begalli
    Something occurs to me as I search for info about bolusing an epidural and the rules and laws that govern that activity in my nursing practice in California.

    I work in an adult ICU. This is an OB/GYN message board. Two completely different areas of practice in nursing.

    So as I was looking for something to back me up in my state's practice act (CA), I came across a couple of other states that do back up what I've been saying, but I can't seem to locate CA's. A couple of the states I found clearly make a distinction between L&D and other areas of nursing when it comes to what the RN can do with an epidural.

    This is VERY interesting. OF COURSE it's different for us because what we do is different. I can't even begin to understand OB/GYN nursing, I have absolutely NO experience with the field (except birthing my own 3 kids and having been the RN for only several patients who needed ICU care following delivery). I didn't mean to stir up any controversy, this really is interesting to me how different we are even within the same profession!! It's great and I appreciate ya'lls knowledge in the area that you work!!

    Here are a couple of links on the subject of epidurals and nurses--who can and cannot do what in at least two states and the CRNA's position:

    Mississippi BON
    Oklahoma BON
    American Association of Nurse Anesthetists

    Thanks for this very informative chat!
    Last edit by begalli on Jan 4, '05
  9. by   JaneyW
    [QUOTE=begalli]Something occurs to me as I search for info about bolusing an epidural and the rules and laws that govern that activity in my nursing practice in California.

    I work in an adult ICU. This is an OB/GYN message board. Two completely different areas of practice in nursing.

    So as I was looking for something to back me up in my state's practice act (CA), I came across a couple of other states that do back up what I've been saying, but I can't seem to locate CA's. A couple of the states I found clearly make a distinction between L&D and other areas of nursing when it comes to what the RN can do with an epidural.

    I am also in Ca and would love for you to share what you find. This is a real bone of contention in our unit. We don't have 24 hour OB anaesthesia--they can go home but must come in if called. The MDs are always trying to get us to do things in the middle of the night and none of us are too clear on what we really can and cannot do. The docs don't seem to know or care. I am unwilling to do much of anything I don't have very specific training for as it is such a huge liability area and I love my career.

    I have also appreciated this thread. It's nice to know what others are doing!
  10. by   begalli
    Whoops!!

    I was continuing to search for CA's regulations (I know they're there somewhere!!) and I came across these couple of gems. Seems the American Society of Anesthesiologists (ASA) and the AWHONN can't agree.

    [font=Trebuchet MS]'With "dueling statements" by physician (ASA) and nurse (AWHONN) organizations on the role of the registered nurse caring for patients with labor epidurals, no one wins and patients become the "damsels in distress."'
    [font=Trebuchet MS]
    [font=Trebuchet MS]This newsletter from the California Board of Anesthesiologists is in regard to the ASA statement that is in the ASA link below.

    This is the American Society of Anesthesiologists Statement on the Role of Registered Nurses in the Management of Continuous Regional Analgesia.

    Very interesting, but I still wish I could find a position statement from the CA NPA on epidurals.
  11. by   VivaLasViejas
    This is an interesting thread..........On all three of the units I work on (M/S, OB-GYN and ICU), RN's are allowed to give boluses through an epidural pump, as well as adjust the dose up or down within parameters set by the anesthesiologist or CRNA. It's pretty labor-intensive, as we have to take VS every 5 minutes X 5 every time we give a bolus or adjust the rate; however, like most of nursing, one has to use some common sense......you don't bolus somebody with respirations of 10/min, or increase the dose when the pt's systolic is below 100 :stone

    Where I work, there's no special training for this; we're expected to know how to deal with epidurals and to call the surgeon and the anesthesia provider when a problem is beyond our skills and our scope of practice, e.g., we can't inject anything into an epidural or intrathecal catheter, and we don't manipulate the catheter itself, except of course to pull it when the MD orders it discontinued.
  12. by   4Blessings
    Quote from SmilingBluEyes
    To dose or not to dose.....I VOTE NOT!

    If at ALL possible: Get your anethesia team on board with PCA-dosing epidural delivery. It keeps US out of that loop and is the ONLY way to go. Patients are happier and so are our anethesiologists; they don't have to come in nearly as often to "bolus" the patients, cause their pain is well-controlled.

    As nurses, We are allowed only to TURN DOWN the rate, if ordered by anesthesiologist. Additional meds MUST be either on PCA for the patient to self- administer--- or bolused BY the MDA, NOT EVER A NURSE! that is NOT in our scope of practice. Be really careful where you tread!
    good to know we're on the samr team........thanks
  13. by   4Blessings
    mjlrn97 _____ Thank you for your post but I am scared for you. I strongly encourage you to Find out if your state board of nursing supports your hospitol policy. What really concerns me is that you said that there was no formal training for the things that you do to the cath. Remember that it is "your" licence on the line if anything were to go wrong. Make sure you have our governing bodies behind you.......good luck

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