epidural dosing

[crissrn27, RN]

Hi everyone! I am confused about this. Some of the articles I have read said it is OK for the RN to be rebolusing, changing rates, etc, and some say no way. Also, you guys seem to have different practices regarding this, from some of the post I have read here. I just started L and D (was in nursery) a few weeks ago, and this is what I am being taught to do.

We assist in epidural placement, supporting mom, VS, etc.

We load and set the pumps, most docs order a continuous rate, a PCEA rate, and lock out time.

If BP drops, we have standing orders for ephedrine, that we give IVP, fluid bolus, etc.

If mom has breakthrough pain, we can get orders and rebolus from the pump, change the settings, whatever doc orders.

Should I not be doing this? It seems that some of you guys say never to touch the pump, and at this hospital, the RNs are the only ones to touch the pump (CRNA, or doc, just does initial bolusing with syringe). What does everyone else do?

I did find a single sentence statement, on the louisanna BON page, that says RN can rebolus in NC.

[Elvish, BSN, DNP, RN, NP]

Hey Criss....

Since we work at the same place, :) nurses are allowed to bolus. We get them sometimes on the floor after the c/s and depending on their pain level (and making sure the epi hasn't migrated out) we can get an order to bolus them. I've never had to but we can. I don't know what L/D's specific policy is, but on the floor we can.

If the BON says so, then cool. We can also remove epidurals; it's a category II thing, like cervical exams.

[crissrn27, RN]

Hi Arwen!! I didn't even question it until I started reading a thread on here where all the nurses were saying "no way, no how" about dosing a epidural, or even setting the pump! Kind of through me for a loop. At least a couple of times a day I set a pump, or dose it, or something, and all these people are saying it is out of our scope! Anyway, good to know that it is OK. As you know, the other place I worked at was not so great at keeping things within scope of practice!

[RNLaborNurse4U]

Always refer to your state BON for scope of practice. In my state (PA) RN's may NOT initiate epidurals, change rates (increase or decrease) or give a bolus dose. The only way an RN can do this is if he/she has taken specific courses/education to do this, like as a CRNA.

The only things the RN can do is: monitor the patients appropriately, assess sensation levels, monitor infusion, d/c infusion (after delivery, or for s/s toxicity), d/c catheter.

[Jolie, BSN]

Hi everyone! I am confused about this. Some of the articles I have read said it is OK for the RN to be rebolusing, changing rates, etc, and some say no way. Also, you guys seem to have different practices regarding this, from some of the post I have read here. I just started L and D (was in nursery) a few weeks ago, and this is what I am being taught to do.

We assist in epidural placement, supporting mom, VS, etc.

We load and set the pumps, most docs order a continuous rate, a PCEA rate, and lock out time.

If BP drops, we have standing orders for ephedrine, that we give IVP, fluid bolus, etc.

If mom has breakthrough pain, we can get orders and rebolus from the pump, change the settings, whatever doc orders.

Should I not be doing this? It seems that some of you guys say never to touch the pump, and at this hospital, the RNs are the only ones to touch the pump (CRNA, or doc, just does initial bolusing with syringe). What does everyone else do?

I did find a single sentence statement, on the louisanna BON page, that says RN can rebolus in NC.

I see that you are in NC. I worked in an LDRP unit in Charlotte in the '90's, when our anesthesia department made the switch from dura-morph for C-sections to continuous epidural infusions which included epidural PCA. Most of the functions related to maintaining the epidural infusion post-op were considered to be Category II procedures, meaning that we had to attend a BON-approved education course (ours was 2 days in length), demonstrate competence to our unit educator prior to working with epidurals, then maintain yearly competence. Our care of epidurals was limited to assessing the patient, changing medication cassettes, administering adjunct pain medication (IV or po, which was rarely needed), communicating with the anesthesia team, and discontinuing the catheters with a physician's order. (This required 2RNs to sign that the catheter tip was intact.) We did not bolus epidurals, nor did we change infusion rates. Only the anesthesia team had the pump codes necessary to do so.

It has been 15 years since I worked there, and it is likely that BON regulations have changed in that time, but I strongly encourage you to write or e-mail the BON for an official written opinion on whether additional training beyond your basic unit orientation is needed for you to take on the responsibility you describe in relation to epidurals, especially labor epidurals.

[jenrninmi, MSN, RN]

No, we are not aloud to touch the settings on the pump. Some of the Anesthesiologists will include the PCA button so the patient can bolus, but not all.

[crysobrn]

For labor patients. We do initiate the continuous, but we are not to increase the dose... We have a standing order for ephedrine also. We can turn the pump off or down if the doc/crna orders. Docs come in to rebolus or increase. This creates some issues at times with docs that do not want to come in JUST to increase (whether it's during office or in the middle of the night) but it's their responsibility!

That said, if a patient is delivered and has an epidural (rarely in OB, but more often on the surg floor) then the nurses can titrate up or down and bolus with an order.