Epidurals: to Dose, or Not to Dose?

Specialties Ob/Gyn

Published

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 facility policy? I will refrain, at this time, from giving any particulars as not to "sway the jury". Any and all comments would be appreciated.

Thank you in advance

God bless your hands at work

4Blessings

Specializes in LTC, assisted living, med-surg, psych.

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. :)

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

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

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
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.

I think this says it right. I would not be messing w/dosing or changing meds in epidural anesthesia as an RN. And AWHONN is a good org to join if you are a professional RN in any capacity regarding labor/delivery/newborn/GYN nursing. There, you will get info regarding safe practices, and NATIONAL standards to which we ARE ALL HELD. Best wishes, to all.

Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
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. :)

Bad deal.I would reallllly research this more and bring this up in your staff meetings. I think you are out scope doing this, esp with the lack of additional training. Dangerous.

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.

I appreciate you advise and I like how your facility handles the safety and documentation issues. I must clarify that I am never expected to medicate with a syringe or such to bolus. When my clients start hurting again or get those bothersome "hot spots", our docs tell us to give a bolus of 8-10mls using the pump. My state says that I am not allowed to do that. Arkansas' position statement was very muddy as written so that is why I got verbal explanition from them. They are putting it writting for me so I can present it to my committee members. I am re-writting poilicy and proceedures at my institution. My biggest challenge will be changing the practices of our drs. Many of my co-workers have never felt to comfortable with dosing, but were ignorant in their knowledge of their scope of practice. I came to this facility 7 months ago and was shoked at what I was expected to do. Needless to say, I've been "rocking the boat" quite a bit lately but this may completely capsize the whole ship by the time it is said and done......

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.

Please make sure that you and "that nurse along for the ride" aren't practicing outside your scope!!!! My institution was doing "inservices", although I never got one, but my state clarified that this was not acceptable! All I can do as an RN is to monitor the client and the pump and turn it off. That's it! You are doing things that only a CRNA, Anesthesiologist, or Physician should do. We did not go to school to deal with the many complications that could arise SUDDENLY. At that moment, your clints life and the life of that baby can't wait while you call the doc........Be very careful

It's actually AWHONN--Association of Womens' Health, Obstetric and Neonatal Nurses

http://www.awhonn.org

Thanks for that clarification for me....brain clitch...sorry

Specializes in ER, Oncology, MS.
Hello to All,

Can any one give me some information regarding the use of Coumadin with the use of a Duramorph epidural.. Recently had a pt on our unit that was on the epidural and her primary came along and started the patient on Coumadin. The med order went thru pharmacy and sent to the floor. I gave med as ordered and am now told how wrong that was!

Thank you :imbar undefined

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